AN EVOLVING SUCCESS STORY THE INTEGRATION OF CARE COORDINATION :

 Began 35+ years ago as an ‘Independent Practice Association’ (IPA) for Lane County physicians  Grew to become ‘Lane Independent Practice Association’ (LIPA) to provide management of the Medicaid State Health Plan, now with 58,000 members  Continued growth resulted in formation of ’Trillium Community Health Plan’; developed to serve the Medicare eligible members in Lane County; currently with 3,500 members  Added a small membership of 150 with the Healthy Kids program  Integrated Medical and Behavioral Health services January, 2012  Awarded CCO status by State in August, 2012 and combined all lines of business under Trillium Community Health Plan name 2

3 RN Care Coordinators & 3 Care Coordination Assistants working together to provide very high- level/high-touch care coordination services for: 3200Medicare/Medicaid members 300Medicare Advantage members 3 RN Exceptional-Needs Care Coordinators for: 65,000 Medicaid members 3

The birth of the Trillium Coordinated Care Organization

Integration brings together physical healthcare coordination and behavioral healthcare coordination staff into a cohesive, functional team.

Integration of Community Health Workers into the Care Coordination Team begins. Lane United CareConnect (LUCC) and Trillium Community Health Plan (TCHP) partnered together in providing additional care coordination services within the Trillium Coordinated Care Organization (CCO) 6

Formerly, employees of Lane United CareConnect (LUCC); now employees of Trillium Dedicated people with a desire to help improve healthcare in Lane County Specially trained to provide a unique service to the Medicaid, Medicare, & dual-eligible members of our CCO community 7

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Changed our model of CC to multi-level care coordination teams working together with all Medicaid, Medicare, and Medicaid/Medicare members:  RN Care Coordinators Care Coordinators Behavioral Health Care Coordinators Medical Social Worker Community Health Workers

Development and deployment of community-wide consistency with THW education and scope of practice Metrics and evaluation of current CHW program Expansion of Perinatal Program to include greater integration of CHWs Involvement of CHWs with high-risk cardiac members Involvement of CHWs in Readmissions Program Integration of CHWs into ED transitions 10

Recently restructured Care Coordination Teams are now working together with their groups of specific Primary Care Clinics to: Implement the movement of communication of CC information to & from the Interdisciplinary Care Team (ICT) via our new web-based communication tool (CareTeamConnect). Proactively coordinate care based on member’s level of risk. Actively enroll identified members into special Care Programs for additional Disease Management. 11

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13 Trillium Member PCP; Care Coordination; Other Providers; CHW Social Services; Other Agencies

Trillium’s Definition of Coordination of Care: Care Coordination is a community-wide team based approach to address the healthcare needs of the Trillium membership. Care Coordination incorporates physical health, behavioral health and community- based services, providers, and practitioners, to identify needs and ensure the provision of the right care at the right time, for our members. 14

15 Provider/TCHP identifies patient with complex needs. External Provider makes referral of patient to Trillium Care Coordination. Trillium Care Coordination triages patient referral to determine if CHW is needed. Trillium Care Coordination Team identified to work with CHW and patient Trillium Care Coordination Team meets every 2 weeks with LUCC CHWs Ongoing training Complex Case Review Updates on referred patients Continued ongoing communication LUCC receives triaged CHW referrals Care Plan issues for CHW assistance are identified on referral Internal Hot Spot List Risk Stratification Hospital Readmissions CC/UM Identification referrals

Service Provider initiates a referral of their patient to the Trillium Care Coordination Team 16

18 Trillium Behavioral Health, Medical, and CHW Care Coordination Team Meeting

Cardiac/Million Hearts Tobacco Cessation in Pregnancy Diabetes Disease Management COPD/Asthma Disease Management Pilot project-’Top 40’ Heart Failure Disease Management High-Risk IP Discharge Restructure of Complex Case Management into stand-alone teams 19

GOALMETRICQUESTIONDATA Improved access to and experience of care Improved member self- perception of quality of care and health status Satisfaction with program?Survey Improved self-perceived health status?Member short-form assessment results Care Coordination ensures access Referrals to social service agencies and/or health education resources? CTC: referrals by entity Increased use of primary care and/or behavioral health services? Claims: utilization per 1000 Improved health status and quality of care Improved member self- management of chronic conditions Fewer hospital readmissions?Claims: utilization per 1000 Decreased use of emergency room and urgent care services? Claims: utilization per 1000 Fewer cancellations, missed appointments?Survey Goals achieved?CTC Improved medication management and compliance with treatment regimens Prescriptions filled?CTC and claims:  Medications  Prescribers Lower costs long-term Program efficiencyWhat are the characteristics of the members who use the program? CTC and claims:  members by demographics, condition, risk factor  Member willingness and ability to engage Are we reaching those most in need?CTC:  TAT from referral to acceptance/ denial  TAT to first contact with CHW  Smoking cessation rates Program sustainabilityWhich members are being served most efficiently with the best outcomes? CTC:  Members referred, offered, accepted  Referral sources, by internal vs. external  Reasons not accepted  Type, duration of contact  Duration of program  Calls and visits by CHW  Goals achieved What are the conditions best managed by the program? CTC; Claims:  Cost and utilization Health care costsDid costs decrease or increase; for what types of services? Claims: pre-and post; comparison with members not enrolled with CHW 20

Trillium ‘All Care’ Care Coordination meetings bring the entire team together to coordinate ALL care for the member: Physical Health CC Behavioral Health CC Community Health Workers Utilization Review Nurses Pharmacy DME ISNP CC

Last month we held our 1st Community-wide Care Coordination Meeting to introduce the Trillium CC Teams to their community counter-parts. We are hopeful through shared experiences to learn more about creating Community Care Coordination Meetings that are successful for all.

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THANK YOU FOR YOUR TIME AND ATTENTION Dr Holly Jo Hodges Medical Director, Trillium Community Health Plan