1. Care Coordination Work Group Meeting April 24th, 2018

2. Welcome and Introductions
Introduce yourself: Name, organization, and county
WELCOME

3. Review Desired Meeting Outcomes
Review Logic Model
Begin to operationalize target population
Discuss issues related to Health Homes
Discuss relation of Peer Support to the Pathways workforce

4. 1.) Project Implementation Plans Due 10/31/18
Project 2B – Community Based Care Coordination
Goal: Establish a regional system for care coordination that measurably improves population health outcomes and provides sustainable funding
Please see for additional information about this project
1.) Project Implementation Plans Due 10/31/18
2.) Start HUB Services by 12/31/18
2.) Scale & Build Sustainability through 12/31/21
CPAA Investments/Inputs
Care Coordination Agencies
Pathways Community HUB
Cross Project Elements
Outcomes
Pathways Community HUB Operation
Staffing & management
Data services
Training/Technical Assistance/Workforce
Training for Care Coordinators & Supervisors
TA from Healthy Gen., PCHI, and CCS
Incentives for care coordinator workforce expansion
Population Health Management
CCS Software Platform
Pathways HUB staffing and infrastructure
Financial Sustainability
Braided funding for HUB outcome based payments
Care Coordination Services
Outreach & engagement
Client assessment for needed Pathways
Education
Client advocacy
Referral and warm hand-off to services
Peer support and/or motivational interviewing
(transportation support)
Monitoring, encouraging, and reporting on client progress
(participate in wrap-around case conferencing for clients, as needed)
HUB Services Start-up
Up to six CCAs will hire…
… about 12 care coordinators…
… serving around 400 clients across the CPAA region…
… leading to 4,000 – 7,000 outcome based units
80+ hours of training in the model and software
Test and improve referral system with HUB and referral providers
Implement CCS Software Platform into agency’s workflow
HUB Services Expansion
Add additional CCAs
Increase to 100 or more care coordinators…
… serving around 4,000 clients…
… creating more than 120,000 outcome based units during the Transformation period
Coordinating Care Coordination
Provide all CCAs with resources, training, and support to implement the Pathways model of care coordination
Ensure accurate and timely reporting
Administer outcome based payments
Develop and manage the referral system for Pathways services
Develop and ensure adherence to standards of practice for Pathways care coordination in the CPAA region
Develop and maintain standard tools and resources to be utilized by care coordinators
Provide and manage a CQI process with all CCAs
Population Health Management
Provide regular reports on performance and outcomes to HUB members and the CPAA Council
Incorporate multiple data sources into analysis that informs continuous HUB planning and improvement
Provide recommendations, grounded in Pathways HUB data, regarding opportunities to strengthen the overall delivery system, fill gaps in services, and for coordinating to target additional populations
Outcome Based Marketplace
Convene payers and other partners to develop outcome based payment methodology for the CPAA region
Use evaluation data of HUB Services Start-up period to clarify valuation of outcome based units as it relates to the CPAA implementation of the Pathways model
Establish a marketplace for the exchange of outcome based units that will provide sustainable funding for Pathways Community HUB services
Bi-Directional Integration
Integrate referrals for Pathways
Pathways supports patient engagement in own care
HUB data informs systems improvement
Transitional Care
Opioid Response
Reproduction & Maternal/Child Health
Chronic Disease Prevention & Control
Individual
4,000 people get support navigating systems of care and increasing engagement in own care
120,000 needed outcomes are achieved through 20 standardized Pathways
Communities
Target populations realize a gradual reduction in health disparities
Service providers are better able to understand and connect with the needs of patients
Decision makers have more information about the strengths and challenges of their local systems of care
Systems
Care coordination services are increasingly standardized
Quality and effectiveness of tools and resources used for care coordination is improved
Increased effectiveness of population health surveillance
Partner Inputs
CCAs
Participate in HUB planning and learning activities
Provide care coordination services using Pathways model
Rigorous reporting to HUB
Participation in CQI with HUB
Referral Providers
Refer clients to the HUB
Incorporate Pathways Care Coordinators into workflows when appropriate
Payers
Purchase outcome based units from the HUB
Identify potential HUB clients
Target Populations
2B Pay for Performance Metrics
Initial Target Population
Behavioral Health: Mental Health or Substance Use Disorder diagnosis
… and a chronic disease or high risk pregnancy
… and one or more risk factors set by the HUB (e.g. Homeless, high risk pregnancy, frequent EMS use, etc.)
The HUB will continue to add target populations through a data driven process as capacity is increased
Outpatient ED visits per 1000 MM
Depression screening and follow-up for adolescents and adults
Inpatient hospitalization
Follow-up after discharge from ED for mental health, alcohol or other drug dependence
Mental health treatment penetration (broad)
Follow-up after hospitalization for MI
Percent homeless
Plan all-cause readmission rate (30 days)
SUD treatment penetration

5. Operationalizing target population
Definitions from data sources
How do agencies identify referrals?
Ease of use for referrals vs. accuracy for evaluation

6. Health Homes Discussion
Health Homes & Pathways target populations
Health Care Authority Guidance
Developing effective workflows

7. Bi-Directional Referral Process

8. Peer Support and Pathways
Value of lived experience shared with target population
Certification and licensing of Peers
Pathways workforce development needs
Discussion

9. Environmental Scan (3)
Nurses (13) and Social Workers (12) are the most commonly employed coordinators
11 employ coordinators with lower credentials than Nurse or Social Worker
About 320 care coordinators
9 Community Health Workers
28 Peer Counselors
146 Social Workers
68 Nurses
69 Other
Almost all employees are full time
Large variability in case loads, (average 65)
All but one agency have less than 20 open slots

10. Summary and Next Steps Next Steps: Next Meeting:
Schedule 2-day deep dive w/Planning Team for early June
Continue analysis and operationalization of target population
Begin development of HUB referral coordination guidelines
Begin development of workforce recommendations or standards for CCAs
Next Meeting:
Tuesday May 29th, 2018
3:15-4:45pm