Developing Our Service Package(s) (insert network name and/or location)

Service packages Major services/service packages that will meet our customers’ needs: EBP – need targeting & outreach Psychosocial Transportation Food Safety – physical & social ADRC/information – connecting with coach Reinforcement for good habits DME/assistive devices Training about accessibility Caregiver Major services/service packages that will meet our contracting org’s needs: Eyes & ears in the home (they don’t ask/don’t listen) – 10-day post-discharge Identify & have solutions for modifiable risk factors Med Rec/HomeMeds ( Star Rating) – Review after next visits – specialist vs. PCP – PharmD Caregiver support – spouses are on same health plan – NYUCI for spousal caregivers Coaching – Navigation of LTSS Fall prevention

Network capacity SoCAL MULTI-SPECIALTY COMMUNITY CARE GROUP Organization nameService competenciesStrengths SeniorServMeals, ADHC, Care Mgt., CT AAAs (Ventura, S. Diego)OAA, CM, CT, transportation AltaMedFQHC, LTSS, Vendor Mgt., PACE, CT St. BarnabasKorean, PartnersLTSS, Vendor Mgt, CM, CT, research/evaluation, EBP Jewish HomeHospice/Home, CT, housing

Network capacity New network partners to be added St. Barnabas San Bernardino/Riverside Mental health services – Didi Hirsch, Winstone Define opportunities – invite gap-fillers – primarily evolutionary We need definition on our roles Branding: Describing ourselves in materials/handouts Scalability

Service value definition Result(s) we commit to deliver 20% reduction in Medicare FFS readmissions – MCO/ACO – Medicaid Reduce ED use Reduce falls Reduce SNF Reduce hospitalizations/days Reduce adverse drug effects More advance directives Fewer 911 calls – more calls to call center Member retention How we will measure Data from MCO/physician group – ED use – Hospital use – SNF/rehab; SNF/LTC – Treatment for falls – 911/Ambulance Data from paramedic systems Data from HomeMeds Client/Patient Reassessment Pre/post vs. comparison group  % deaths in hospital

Service value definition Level of satisfaction we commit to deliver 75% accept home visit 90% satisfaction? Don’t know. Ask for current level of satisfaction & set bar higher Payer satisfaction Post-discharge hospital satisfaction How we will measure CAHPS IFC/Research lead development of measures 6

Service value definition Early thoughts on possible pricing for your service package? Cost plus shared savings Fully loaded cost 7

Insights Our biggest insight(s) from Developing Service Packages is/are… Building from shared current interest and building toward shared future interests – Sharing best practices – still getting our CCTPs off the ground – Proving the value of the collaborative – Building trust; building relationships – Buying services from each other We need to move forward with a work group to define and formalize this – we each have visions & intentions, assumptions Different collaborative members will bring different opportunities to the table – as a network, at least members have right of first refusal

Action Steps Thursday meeting with hospitals Refine marketing materials - Reframe CCTP into SNF diversion Define services each member provides or can access through their networks/collaboratives – December 6 or separate call with team leads – using slides from Kathy Greenlee, June & Lynn Kellogg Longer term – Convene IT workgroup to come up with data sharing strategy – Pricing strategies – contract floor levels – Define geographies – Gap analysis and other members to be invited

Parking Lot (Issues for later, additional questions for speakers) List here 10