1. SAFETY NET NETWORK LEADERSHIP AND ADVISORY GROUP MEETING Wednesday, June 19, 2013

2. Community Care Coordination  Need to invest in infrastructure to support primary care and patients  Rural, independent, safety net  Need for care coordination among providers and with other community resources  Model developed based on experience of other states  Address risk profile and social determinants of health

3. Community Care Coordination  Vision: To develop regional community care coordination entities across Iowa to coordinate care for high-risk patients and to support primary care providers, regardless of the presence of Accountable Care Organizations.  Guiding Principles  Use experience from other states to guide the model in Iowa (North Carolina, Alabama, New Jersey, Oregon, Vermont, Colorado, Maine, etc.)  Regions should develop based on local partners coming together to address identified needs Public health and hospital Community Health Needs Assessments and Health Improvement Plans

4. Community Care Coordination  Guiding Principles (cont.)  Community-based, clinician-led medical homes  Clinician leadership and engagement  Reduce health care costs by delivering greater quality and efficiency (i.e. reduction in inappropriate emergency room visits and hospital readmissions)  Providers expected to improve care must have ownership of the improvement process

5. Community Care Coordination  Guiding Principles (cont.)  State level accountability and leadership combined with local autonomy  Focus on high-risk/high-need patient populations  Link to existing community services and supports to address social determinants  Use of informatics and incorporating social determinant of health data going forward  Focus on patient-centered and directed care patient in mind – patient focused

6. Community Care Coordination  Goals  Provide assistance to local primary care providers to meet the unique needs of their highest risk patients  Deploy care coordinators to help support practices in providing services for their highest need patients, including, but not limited to targeted disease and care management interventions, addressing gaps in care, education, self-management support, transitional care, connection to community resources, pharmacy management, and behavioral health management  Improve quality, population health, cost at local level

7. Community Care Coordination  Goals (cont.)  Regional community care coordination entities become extension of primary care team Care coordination of high risk patients Support diabetes, heart failure, asthma, COPD, self management, etc.  Engage practices in quality improvement initiatives Practice support and coaching Feedback of quality data  Establish connections with other community resources so patients can be linked to supports that which address social/behavioral needs of patients

8. Community Care Coordination  Goals (cont.)  Demonstrate value of community care coordination and linkages to community resource approaches to payors in meeting the goals of the Triple Aim goals  Foster community innovation and response by building upon local champions and early adopters

9. Partners in Community Care Coordination Model  Primary care providers  Public health departments  Maternal/child health providers, inc. CHSCs  Area Agencies on Aging  Family planning agencies  Community action organizations  Patient/family advocates  Specialists/hospitals  Legal aid services  Organ/cancer associations  Behavioral health providers  Oral health providers  Long-term care providers  HCBS providers

10. State Entity Work  Support the regional community care coordination teams.  The infrastructure built at the state level is a more efficient use of resources and will provide practices with:  Behavioral health consultative support  Pharmaceutical support  Support to share information among all of the partners, i.e. case management software

11. Implementation Steps  Conduct community outreach and education sessions in partnership with an outside technical assistance provider from a state already engaged in building this type of infrastructure.  Bring together partners  Identify clinician champions  Execute and monitor contracts for at least two and no more than three developmental regional community care coordination entities.

12. RFP Development  Timeline of Key Dates  Background  Eligible Applicants and Entity Qualifications  Scope of Work  Data and Reporting Requirements  Alignment with key state initiatives already in place  Plan for Partnerships  Provider Champions  Anticipated Challenges and Technical Assistance Needs  Budget and Budget Narrative  Financial Documents  Plan for Sustainability  Evaluation and Selection Process  Appendices

13. Implementation Steps, cont.  Develop state-level infrastructure to support regional community care coordination entities and local practices based on community outreach and education sessions and barriers identified through the RFA process.  Develop an evaluation plan for the regional community care coordination entities and statewide entity.