1. Disclosures
Successful completion of this continuing education activity includes the following:
Signing into the conference and providing your address
Attending the entire CE activity
Completing the evaluation
You will receive an ed copy of your certificate
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Institute for Medical Quality/California Medical Association (IMQ/CMA) through the joint providership of Cardea and the Washington Chapter of the American Academy of Pediatrics. Cardea is accredited by the IMQ/CMA to provide continuing medical education for physicians.
Cardea designates this live activity for a maximum of 5.5 AMA PRA Category 1 Credits™. Physicians should claim credit commensurate with the extent of their participation in the activity.

2. Disclosures
Faculty: Paula Holmes, RN, MPH; Alexis Koutlas, RN, BSN, CHWC, PPIC and Sheryl Morelli, MD, FAAP
CME Committee: David Couch; Kathleen Clanon, MD; Johanna Rosenthal, MPH; Pat Blackburn, MPH; Richard Fischer, MD; Sharon Adler, MD.
Richard Fischer, MD is a member of an Organon speaker’s bureau.
Dr. Fischer does not participate in planning in which he has a conflict of interest, and he ensures that any content or speakers he suggests will be free of commercial bias.
None of the other planners and presenters of this CE activity have disclosed any conflict of interest including no relevant financial relationships with any commercial companies pertaining to this CE activity.
There is no commercial support for this presentation.

3. Disclosures
This conference was supported by: Amerigroup, Coordinated Care, Mary Bridge Children’s Hospital, Molina Healthcare, Seattle Children’s, Swedish Pediatrics, and United Healthcare Community Plan

4. Disclosures
Following completion of this session, learners should be able to:
Identify opportunities for improving patient care through empanelment.
Discuss the process of moving a medical practice toward team-based care.
Explain how value based payment supports empanelment and team-based care.

5. Questions?
If you have any questions about this CE activity, contact Margaret Stahl at or (206)

6. Pediatric Partners in Care: Care Coordination for Medically and Socially Complex Patients
November 4, 2017
Paula Holmes, RN
Alexis Koutlas, RN
Sheryl Morelli, MD

7. Session Objectives
Identify opportunities for improving patient care through empanelment
Discuss the process of moving a medical practice toward team-based care
Explain how value-based payment supports empanelment and team-based care

8. Pediatric Partners in Care (PPIC)
CMMI Demonstration Grant
August 2014– August Care Coordination intervention
August 2016 – May 2018 Payment model development and testing
Population
18 years or younger
Molina, CHPW, Coordinated Care or Amerigroup Medicaid client
Live in King/Snoh County, on SSI
Prism score > 1.0 are eligible for the intervention
Total Lives
4,000 lives, 809 enrolled in care coordination intervention
Hypothesis
Providing care coordination via an RN/Community Care Coordinator team to a targeted population within an SSI cohort will reduce their total cost of care by 9%. These shared savings will sustain the intervention.

9. PPIC Intervention: Overview
4 Care Coordination Teams (RN and Community Care Coordinator):
Social Determinants assessment and assistance (eg DDA applications, transportation resources, appointment logistics)
PCP/Specialty plan of care
Caregiver clinical escalation plan
Other support as needed (eg School IEP, ABA therapy application, wrap around service communication)
Other intervention as appropriate (eg Asthma home environment assessment and mitigation)

10. PPIC Intervention: Targeted Populations
PRISM
Only “common denominator” risk score within WA Medicaid. > 1.0 is a proxy for higher cost.
Not particularly pediatric sensitive or timely
Doesn’t identify ‘rising’ risk
SSI
65% have a PRISM score <1.0
Predominance of behavioral health
Community Care Coordinator navigation
Transitions of Care
Most ED/IP utilization is unavoidable/intentional
Long LOS often due to system barriers
Issues arise long after discharge

11. Partnering with Primary Care Lessons Learned
Case Manager Cohort Review
Approximately 200 patients
receiving longitudinal care
management support
Short term 30 day intervention arm yielded consistent findings
Clinical Support
13, 6.5%
No needs identified
45, 23%
Combined
13, 6.5%
Social Services
Support
127, 64%
Considerations
Resource allocation
Many needs are non-clinical in nature
Important to direct appropriate resources to need
Team-based care is essential

12. Partnering with Primary Care Lessons Learned
Targeting Enrollment Population – Beyond PRISM
Provider Referrals (Internal & External)
Effective for:
Connecting clinical and social resources to population needs
Supported provider-patient partnerships
Barriers to effectiveness
Caregiver/Patient engagement
Caregiver/Patient priority
Caregiver/Patient mental health
Limited resources HEDIS Measures

13. Partnering with Primary Care Lessons Learned
Summary Considerations
Patient identification and stratification
Opportunity to identify patient cohorts and appropriate personnel resource.
Screening
Huddles
Panel list
Driving efficiency in care coordination
Poor engagement results in a barrier to effective care coordination
Address family priorities
State or readiness

14. Coordinating Across the Continuum Lessons Learned
Effective for:
PCP and Specialist Clinical Review
Improved patient outcomes, increased quality
HEDIS Measures
Case Example:
Former 33 ¾ week, now 9 year old, Grade III intraventricular hemorrhage
VP Shunt, Cerebral Palsy, Seizure disorder, G-tube dependence
Admitted 11 times in one year for cyclical vomiting
Utilization and Case Review with PCP & Specialists
Pneumonia

15. Coordinating Across the Continuum Lessons Learned
Effective for:
Early allocation of resources
Reduction in costs, improved patient outcomes
HEDIS Measures
Case Example:
Former 25 2/7 week twin infant, now 22 months. Initial NICU stay approximately 5 months
Discharged X 24 hours and return to hospital with desaturations
Bronchopulmonary dysplasia, Pulmonary Hypertension
Oxygen & G-tube dependence
Single Mother, working full-time. Looking for daycare options
Established Home RN

16. Coordinating Across the Continuum Lessons Learned
Effective for:
PCP and Specialist Coordination of services
Enhanced patient and provider safety
HEDIS Measures
Case Example:
3 y/o child with galactosemia, neonatal kernicterus
Global developmental delays, g-tube dependent
Parents divorced. Dad resides out of state. Mom providing care independently. Concern for untreated mental health issues.
Established Home RN

17. Coordinating Across the Continuum Lessons Learned
Barriers
PCP and Specialist Coordination of services
Poor response despite provision of resources
HEDIS Measures
Case Example:
Former 26 week, now 23 months old, initial NICU stay 11 months.
Global developmental delays, g-j tube dependent, seizure disorder
History of resuscitation during operative procedure. All subsequent anesthesia required encounters resulted in spike in seizure activity.
Single mother with diagnosed mental health issues, untreated.
Daycare
Palliative Care
Referral
Established Home RN

18. Partnering with Primary Care Lessons Learned
Summary Considerations
SCH centralized care coordination clinical support
Improved access to patient information across care continuum
Evaluate real time utilization across organizations (Premanage)
Supported development of a comprehensive plan of care, tracking of information
Improved efficiencies and patient outcomes
Mental health
Resources may not resolve utilization or risks
However the patients general wellbeing may improve

19. Primary Care Provider Strategy
Monthly patient case reviews with primary care team
Providers RN MA SW
Other: Patient Navigators, Dietician, PHN
Effective outcomes
Proactive intervention plan
Timely evaluation and response to changes
Promote team-based care
Leadership support – specifically in mixed practices (adult/pediatrics)
Negotiate appt. time, resources, and responsibilities

20. PPIC: Partnering with Primary Care Summary of Effective Collaboration
Team-based care in PCP setting
Provide resources and services where patients live
Centralized approach for a subset of patients
Improved outcomes, enhanced continuum communication
Not everyone needs it, but those who do, benefit
Observations
Appropriate distribution of responsibilities and resources
The right patient to the right resource
Data driven mechanisms to target the population
Efficiencies
Proactive planning
Monitoring the continuum
Outcome Based
TLC feedback from the PCP

21. Health Home: Care Coordination Payment Strategy
MCOs are lead agencies
Clinics/Hospitals/Agencies apply to be Care Coordinating Organizations
FFS (1x per month per patient) payment model
All children on Medicaid with PRISM >1.5 are eligible
Pediatric Partners in Care within SCH is a Health Home CCO for King and Snohomish Counties
Model developed for adult duals, where cost savings via decreased ED/readmissions were significant

22. PPIC Shared Savings Payment Model

23. PPIC Payment Model: Update
Early Total Cost of Care shared savings results are directionally encouraging
Deeper validation of results in process, including trending against a comparison group and time sequence analysis

24. PPIC Lessons Learned: Value-Based Contracting
Establish minimum baseline measurement period
Understand attribution methodology
Establish robust empanelment process
Negotiate outliers
ESRD, transplant, 150K
Advocate for risk-adjustment
Consider adding PMCA (Pediatric Medical Complexity Algorithm)
Understand risk-adjustment model

25. PPIC Lessons Learned: Value-Based Contracting
Advocate for control comparison group
Identify appropriate control group
state vs regional
Advocate for required PCP designation
Select evidence-based pediatric quality measures
Understand quality measures definitions
HEDIS
Negotiate access to EDIE and Premanage

26. PPIC Lessons Learned: Value-Based Contracting
Establish standard reporting package
High-risk
Gaps in care
Pharmacy
Quality
Patient Centered Medical Home PMPM(Per Member Per Month)
Care Management PMPM

28. Thanks!