1. Evolution of Care Coordination Tara Costello MSW,CASAC Vice President of Behavioral Health Jillian Gross, MSW CNY Operations Manager Debra Juidiciani, RN, CCM, RN RN Supervisor

2. L EARNING O BJECTIVES History of Behavioral and Primary Care Co-location Brief overview of Learning Collaborative Overview of Systems Implemented Process and Clinical Outcomes Opportunities and Challenges

3. H ISTORY In 1974, Community Health Services became a licensed diagnostic and treatment center providing neurological, orthopedic, pediatric and psychological screenings that were necessary for UCP residential programs. The clinic is now classified as an independent out patient health center, providing services to the surrounding community. In 1977, Community Behavioral Services became a licensed Mental Health Program and began to promote mental health care and the role it played in a person’s overall wellness. Central New York Health Home, LLC established themselves in 2012, serving Oneida, Herkimer, Madison, Cayuga, St. Lawrence, Jefferson and Lewis Counties. Central New York Health Home became Incorporated in October 2014.

4. L EARNING C OLLABORATIVE P ROJECT Purpose Facilitate the development and implementation of systems that support collaboration and integrated care planning between clinicians, social and behavioral health providers and care management staff within across a variety of safety-net healthcare organizations. Pilot Site Community Health and Behavioral Services Outpatient Clinic located at 1427 Genesee Street, Utica. Change Team: Project Lead: Tara Costello, Vice President of Behavioral Services Clinical Champion: Dr. James Fredrick, MD Primary Care Administrator: Debra Juidiciani, CCM, RN Supervisor Care Management: Jillian Gross, Operations Manager Central New York Health Home Behavioral Health Administrator: Gordon Dunham, Associate Vice President of Clinical

5. P ROJECT D ESCRIPTION Team Goals: Sample size of 40 Embed Central New York Health Home Care Manager within outpatient practice Establish workflows for referral and Care Management caseload Increase referrals to care management from primary care and behavioral health. Establish a process to increase multidisciplinary case conferences for care management patients who mutually receive primary care and behavioral health services at pilot site. Increase the number of Health Home patients with an integrated care plan (integrated with input from PC, BH, and HHCM) Establish a process for Health Homes to track and act on hospital alert information.

8. C O - LOCATION C OLLABORATION Checking the Resource Schedule daily Access RHIO daily Outreach patient contact Developed and enhanced collaboration with primary and behavioral Documentation in a specific EHR sites Coordinated Care Management welfare checks

9. G OALS I DENTIFIED Baseline Data: # of referrals made to HH program from Primary Care and Behavioral # of Health Home referrals resulting in patients opting in # of Health Home referrals resulting in patients opting out Process Measures: # Patients with a Multidiscipline Case Conference # of Patient with Integrated Care Plan Clinical Outcome Measures : Patient Activation Measurements (PAM) # Received or scheduled Annual Primary Care Visits

10. O UTCOMES Primary Care ‘no show rate’ decreased from 45% to 32% (13%) over 11 months ‘attendance rate’ increased from 48% to 50% (2%) over 11 months Behavioral Health ‘no show rate’ decreased from 50% to 25% (25% decrease) ‘attendance rate’ increased from 46% to 52% (6% increase) ***please note this data is based on n=40 sample size

11. P ROCESS AND C LINICAL O UTCOMES

12. P ERFORMANCE O UTCOMES

13. O PPORTUNITIES Allowed us to develop and test solutions that we commonly face related to an integrated care planning process Bi-weekly “PCDC meetings” enhanced communication efforts with change team Developed monthly “integrated care conference” meetings Weekly huddles with primary and behavioral Developed risk stratification toolrisk stratification tool Development of workflow processworkflow Explored ways to integrated care plans Opened up conversations with local hospitals, outpatient clinics, shelters, etc… for future collaborations Helped get us prepared for DSRIP initiatives Establish methods to identify HARP eligible clients

14. C HALLENGES Electronic Health Record all agents utilize different systems GSI, Clinic Tracker, EcW Updating care plans and having all team members involved RHIO Healthy Connections – having access to up to date health information, alerts, etc Physical Space needs Supply/Demand (high caseload) Staff Turnover and re-education on process both internally and to outside agencies Health Status

15. Q UESTIONS