1. Care Coordination What is it? How Do We Get Started?

2. Care Coordination: What Is It?
The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When the CIO (Clinically Integrated Organization) succeeds both in delivering high-quality care and spending health care dollars wisely, the quality of life of the patient improves and health care dollars are saved.

3. Care Coordination
AIM - effectively identify, manage and track results of PCMH’s high risk patient population through care coordination, patient coaching and education, application of Evidence Based Medicine, and population data analysis & reporting
Interventions – Embed Care Coordination Teams in Primary Care offices; identify high risk patients and provide high touch to these patients.

4. Care Coordination
Oversee care coordination for the primary care practice’s patients
Continue to develop and monitor care coordination processes and support primary clinical teams with these efforts
Identify high-acuity patient population and working to ensure care coordination for this patient population

5. Care Coordination - Improved Outcomes
Success Measures and Improved Outcomes
Lower HgbA1c
Lower LDL
Rx Compliance
Lower Utilization (ER and Admission Rates)
Reduce Cost of Care
ROI for Employers/Payors

6. Care Coordination Pilot – Results
HgbA1c (181 participants)
Overall improvement of 4.20% in HgbA1c levels
33% progress out of the High A1c range
68% of participants remained or progress toward goal
LDL (217 participants)
Overall improvement of 1.83%
10% increase in LDL frequency adherence to EBM guidelines
6.5% improvement into the Ideal LDL Range
Smoking Status
12% of participant smokers progressed to goal of not smoking

7. Care Coordination – Utilization Results
Admissions
51% decrease
Readmissions
35.2% decrease
ER Utilization
37.3 decrease

8. Care Coordination – Cost Savings
Projected ROI for Cincinnati Mercy/CHP Employees if Nurse Care Coordinators implemented across all owned PCPs:
Approximately 150 high-risk, high cost patients impacted
RN Staffing: 1 RN/150 patients
Cost of Nurse =$100,00
Projected Health Plan Savings = $558,000
ROI = 5:1

9. Care Coordination - Medicare Savings
Projected Savings for Medicare Fee-For-Service Beneficiaries if Nurse Care Coordinators Implemented Across all Owned PCPs in the Greater Cincinnati area:
Approximately 1,900 high-risk, high-cost patients impacted
RN Staffing: 12.5 RNs
Cost of Nurses = $1,250,000
Projected Medicare Savings = $5,400,000
ROI = 5:1

10. Care Coordination – Success Stories
Patient had 4 hospital admissions for 36 hospital day in the 12 months prior to the pilot for respiratory and cardiac failure. No hospital admissions during the pilot year
Patient had HgbA1c of 10.4 prior to participation. Interventions include; Care Coordinator visits, weekly diet & exercise coaching phone calls. HgbA1c is currently at 6.5.
Medication reconciliation before the patient left the hospital

11. Care Coordination – Patient Satisfaction
Patients Satisfaction Survey
1. You are receiving the highest quality medical care at the primary care office - Improved 10%
2. You have a positive experience with the primary care office - Improved 9%
3. You receive helpful education related to your illness/disease health from the primary care office - Improved 9%
4. You have the necessary access to your physician and care team - Improved 6%
5. You have adequate communication with the primary care office - Improved 6%
6. You receive timely communication concerning; follow-ups, referrals, and test results Improved 1%
Patient and Physicians Comments
“This Care Coordinator role was more successful than I thought it could be. We’d love to have the funding to hire a full-time NCC. Insurance co. will get out way ahead financially if they saw the wisdom of funding this position for PCPs.” - Physician
“ I wish all doctors had this – they would have more satisfied patients.” - Patient
“Expand! It is AMAZING!!” – Physician
“Programs like this one is a big help and the concept of working together to help me find a better way to improve my health issues. Just wish there had been a program set in place before now that I could have followed” - Patient
“Please continue this valuable service for our patients” - Physician

12. Care Coordination - Learning & Challenges
Physician buy-in across entire practice
Develop trigger list to identify patients that can benefit care coordination intervention
Integrating Mental Health services into patient care protocols
Obtaining historical claims data
Managed Care Organization payment for services and access to patient specific historical utilization data

13. How Do We Get Started?
Hire RN Care Coordinator. Good fits include home care, outpatient clinic such as Coumadin or CHF, and PACE program experience. Ability to quickly develop relationships with multiple layers of people and have the confidence to work independently are key.
RN Care Coordinator Orientation (about 4-5 weeks) that includes shadowing several Care Coordinators and the Community Care Worker, education on tools available, motivational interviewing/positive psychology training and EPIC training
Produce Practice Risk Report utilizing InforMed and Explorys .

14. How Do We Get Started cont.
Have introductory meeting with practice providers, practice manager and area manager if appropriate to introduce Care Coordination Team and their role, discuss practice risk report as starting point for patient referrals and provide trigger list for identification of patients appropriate for Care Coordination.
RN Care Coordinator will meet with staff for introductory meeting to describe role and trigger list
Care Coordination Team get started!

15. What Can We Expect The Care Coordination Team is responsible for:
Identifying high‐acuity patients,
Assisting with patient goal setting, coaching, education,
and adherence with national evidence‐based medicine,
Facilitate patient adherence with treatment plan,
medication compliance,
Referral completion and communication between
patient, Primary Care Physician, and other providers.

16. What Are Interventions We Can Expect
The Care Coordination Team will visit with patients before, during and/or after physician office visits, frequent telephonic follow-up, referral management, and make home visits on select patients for visual medication reconciliation, safety assessment, social assessment etc.
The Care Coordination Team can facilitate post discharge calls to optimize compliance with new Transition CPT codes

17. Who Is On The Team?

19. Tying It All Together Integrated elements of a successful ACO
Improved clinical outcomes and patient satisfaction linked to
Care Coordination embedded in
Patient Centered Medical Homes practicing
Improvement Science Methodologies that support
Population Health Management using
Data Analytics across a
Clinically Integrated Organization

20. Questions