Developing Our Service Package(s) Florida Neighborhood Networks Shirley, Sandra, Gabriel, Maria and Anna

Service packages Major services/service packages that will meet our customers’ needs: Save money – referred by care transition team, physician – we will do wellness and prevention assessment (nurse or clinical social worker EnhancedWellness working for the collaborative Patient-centered assessment – Coordinated model Major services/service packages that will meet our contracting organization’s needs: Patient-centered assessment Access to Evidence-based programs – person is connected to community health worker Access to aging network services PMPM to cover services 2

Network capacity Current network partners, capacity and strengths Organization nameService competenciesStrengths ADRC in 3 countiesHistory, EBP program delivery, knowledge, information and access to entire service systems Network of providers with deep penetration FQHCsMedical home expertise, experience with EBPs, providing clinical services, becoming geriatric center of excellence HRSA mandate, Health IT, Medicare billing capacity Embedded in high risk communities, building services to older adults, attracting people who need services VA health systemMOVE program – weight reduction system, hope to have VA support as benefit Use to refer veterans to community programs YMCAEBP delivery capacity, embedded in community, Core strength in fitness and wellness programs, 100% retention Embedded in high risk community, capacity to influence, 60 community partners, Aging networkMTS and network of facilitators, 30 MOAs with community partners Deliver programs in day care centers, and deliver other programs, access to large condos, name recognition Parks and Recreation HospitalsLink via ADRCs, id older adults

Network capacity New network partners to be added Medicaid opportunities, what can network partners bring Physician groups (family practitioners), Prestige – build relationships, Large clinics (Medicare Advantage) internal structure Rand eye institute, hospital systems - current CCTP hospital partners 4

Service value definition Result(s) we commit to deliver 7% Reduction in ambulatory emergency room in target population of 2+ chronic conditions at end of year one 7% ambulatory-sensitive admissions at end of yr one Achieve 25% reduction in 30-day all cause readmissions Achieve 7% reduction in overall medication cost How we will measure Partner with health plan to determine claims utilization, control and intervention population Part D medication claims 5

Service value definition Level of satisfaction we commit to deliver 90% customer satisfaction rate based on service package How we will measure Entry assessment Assessment of goals achieved (6 months) Satisfaction survey (6 months) 6

Service value definition Early thoughts on possible pricing for your service package Pilot is funded by health foundation. Researcher will assist with cost analysis and identify actual savings. This will help in developing a pm/pm fee Health plan – no cost, but needs to assist with recruitment of 600 participants and 600 control and provide access to data via secure HIT 7

Insights Our biggest insight(s) from this session on Developing Service Packages is/are… We are on the right track (Broward and Dade) Way of conceptualizing the pilot is moving in the direction of expanding CCTP To date, no one has evaluated integrated package of EBPs and cost savings 8

Action Steps The action step(s) we will take in the next month to develop our service package(s) are: Create a community road map (MI concept) Meet with potential health plan partners to test out service package to determine their perception of the value Projected cost for one pilot (600 people in 6 months and follow up for 6 months) builds in evaluation and delivery 6-month intervention and 6-month follow-up 9

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