The Child Health Accountable Care Collaborative (CHACC):

Strengthening the Bond Between the Pediatric

Subspecialist and the Patient-Centered Medical Home

Mary Jones, RN, CHACC Coordinator

Disclosures

I have no conflicts of interest or financial disclosures

Goals

• Briefly describe Community Care of North Carolina (CCNC) & Medicaid

• Describe the program goals for the Children’s Health Accountable Care Collaborative

• Discuss the challenges of care for children with chronic and complex diseases and the role of care coordination

• Discuss the creation and use of specific treatment and referral guidelines in the care of children with special healthcare needs

Community Care of NC

Statewide primary care medical home & care management system

Rests on foundation of Carolina Access in which Medicaid patients are linked to a primary care home

Provides resources to improve access to, quality of and coordination of care across the different segments of the local health care system and decrease cost of care

Private-public partnership (all savings stay in NC)

Provides ready access to data

Community based, locally driven, provider led

CCNC Goals

Evolving towards “Wellness” based case versus “Illness” based care.

Consolidation of hospitals, practices, and health care systems into larger integrated systems (shared responsibility of care by physicians and hospitals) is now the norm

Health care is evolving toward patient-centered using medical home (a single site or home for coordination of a patient’s health care) as the focus of the care structure

Technology allows access to and new approaches to data

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What is a “Medical Home?”

A medical home is defined as primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective. (American Academy of Pediatrics)

“My doctor is….”

Childhood Accountable Care Collaborative

How it started..

Started in 2013 as Federal CMMI Award for 2 years to improve care for children with Medicaid & complex medical conditions ($9.3 million over 3 years)

Statewide initiative involving local CCNC network primary care homes, 5 academic medical centers, 7 tertiary hospitals, and Pediatric Subspecialists- 7/2015 has been continued in local areas by Community Care Plan of NC or Hospitals

Program Goals Engage primary care providers and pediatric subspecialists across the

state to share responsibility and accountability for pediatric primary, subspecialty, and hospital care.

Primary care providers and peds subspecialists jointly develop and utilize evidence-based guidelines of care for pediatric chronic illnesses and high volume referrals to peds subspecialists. Actively engage in co-management of these children.

Provide active care management to children under the care of pediatric subspecialists through embedded care managers and patient coordinators at tertiary hospitals and provide a warm hand-off to CCNC network care managers.

Reduce costs of care for this patient population (target is 2%)

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Outcome Targets of Program

Provide a model for medical home-medical center collaboration in care of children with special health care needs

Develop statewide evidence based management schemes for complex and chronic illnesses in children

Establish referral guidelines to streamline consultation

Reduce cost of care for children with special health care needs

Improved access to necessary pediatric subspecialty care in a timely and efficient way

Who are the NC children with Chronic or Complex illnesses and what are the challenges in their care?

Background

FACT: 5% of Children under 18 incur 54% of the cost for children’s care in Medicaid

Who are these children and what can be saved on cost while maintaining or improving quality of care?

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Issues for Children with Chronic and Complex Illness in NC

Location of and Access to the subspecialists (long waits for appointments-up to 4 months or more)

Communication with PCPs and co-management Where is the Medical Home? Family confusion (My

doctor is….) Coordination of access to services

CHACC vs C5

Who is a C5 patient? Medically complex, often requiring technology (trach/vent), needing active care coordination. C5 makes home visits and hosts patients in a weekly referral clinic with link back to primary care medical home

Who is a CHACC patient? High cost, chronically ill patient seen in a specialty clinic, needing care coordination and link to primary care medical home; often various social concerns

CHACC goals

Provide continuity of care for patients who see our subspecialists

Enhance what is done in the primary care setting at the time of referral before the patient sees the subspecialist

Improve communication with the family and the medical home after the visit- CHACC Care plans

Better meet the needs of the PCMHs and the subspecialists

Decrease unnecessary referrals and return visits to subspecialists to reduce wait time for new referrals

CHACC goals cont.

Reduce hospitalizations and ED visits

Help with medication compliance and education

Ensure community f/u in the home (HV in Pitt County)

Care Coordination & Case Management

CHACC embeds pediatric specialty care managers in specialist clinics

Develop the “CHACC Care Plan” to facilitate collaboration between pediatric sub-specialists and primary care physician

Support families with Co-Management.

CHACC Care Plan

CHACC Care Plan pg2

CHACC Care Plan pg3

CHACC care plan pg4

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Case Management at Subspecialty Care location

Case Manager Role: coordinate care and medical needs of patients with CCNC case manager, subspecialty providers, and PCP.

Patient Advocate Role: provide assistance for family with social needs, appts, and transportation; assist case manager

Who are we?

Our Vidant based Center for Children with Complex and Chronic Conditions (C5): Medical directors from BSOM (Drs Willson and Zepeda), A Nurse Practioner (Clay Parker, NP), and 3 care coordinators (Kathy, Tieranny,and Rhonda)

Our CHACC program is supported through the Community Care Plan of Eastern Carolina (CCPEC) and Vidant Medical Center: Medical champion (Dr. Willson), 2 care coordinators (Mary, Cierra), and 2 patient navigators (Michael, Davey Ann)

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Co-Management Guidelines for Primary Care Physicians and Subspecialists

Develop CME for PCPs and Subspecialists about the guidelines

Track outcomes by ED and hospital utilization Repeat cycles with appropriate “expert panels” to cover

a series of diseases and disorders where co-management is needed.

Available now are guidelines for GERD management Constipation, Sickle Cell, and Abdominal Pain

http://www.communitycarenc.com/emerging-initiatives/child-health-accountable-care-collaborative/chacc-gi/

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Co-Management Guidelines for Primary Care Physicians and Subspecialists

Joint development of co-management guidelines with PCPs and Subspecialists

Process: Evidence-based review of literature around the subject and published guidelines for referral, pediatric endocrinologists, obesity center directors, and PCPs from CCNC invited to attend, discussion of the review, development of consensus on management by PCP and Subspecialists-web site initiated with NC Medicaid to publish the guidelines

Referral Sources

Pediatric Specialists

Hospital NICU

PICU

Pediatric Floor

Primary Care Providers

CDSA

CC4C

ECU Clinics Where CHACC Patients Are Followed

Nephrology

Gastrointestinal

Healthy Weight

Endocrine

Surgery

Behavior/Develop.

Neurosurgery

Hematology

Cardiac

Physical Medicine & Rehab

Pulmonary

Infectious Disease

Neurology

Adult Transition Clinic

CHACC Referral Sources

Referral Source Quantity %age

ECU Peds Nephro 89 24.58%Vidant-NICU 27 9.32%Vidant-SW 25 8.47%List-CHACC ADT 15 8.47%ECU Peds Specialty-SW 12 8.47%List-TCP 13 10 5.93%List-Vidant Hospital 8 5.93%CC4C CM 7 5.93%

CCPEC CM 7 5.08%

List-ECU Peds Specialty 6 2.54%ECU Neurology 4 2.54%ECU Peds Endo 4 1.69%ECU Peds Cardiolgy 3 1.69%ECU APHC 2 1.69%ECU Peds Pulmonary 2 0.85%ECU Peds Surgery 2 0.85%C5 1 0.85%CHACC- Duke 1 0.85%CHACC- UNC 1 0.85%

CHACC-CCWJC 1 0.85%Cumberland Hospital-VA 1 0.85%ECU Peds ID 1 0.85%Total 218 100.00%

Specialist Referrals

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ECU/Vidant CHACC Referral Source

Quantity

Sou

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Quantity

PCP ReferralsPCP Quantity %ageECU Pediatrics 49 21.19%Eastern Carolina Pediatrics 15 11.02%Kinston Pediatrics 14 7.63%Goldsboro Pediatrics 12 5.93%ECU APHC 11 5.93%Washington Pediatrics 10 5.08%Boice Willis Clinic 9 5.08%Greenville Pediatric Services 8 4.24%Jacksonville Children's Clinic 8 3.39%MTW County Health Dept 8 3.39%Mt Olive Pediatrics 7 2.54%Benson Area Medical Center 5 2.54%Kinston Community Health Center 5 2.54%Vidant Chowan Pediatrics 5 1.69%Carolina East IM Pediatrics 4 1.69%Children's Health Services 4 1.69%Park Avenue Pediatrics 4 0.85%Halifax Pediatrics 4 0.85%Coastal Childrens Clinic 3 0.85%Craven County Health Dept 3 0.85%Vidant MultiSpecialty Clinic Tarboro 3 0.85%Goshen Medical Center 3 0.85%Vidant Chowan Family Practice 3 0.85%Kate B Reynolds 2 0.85%Our Childrens Clinic 2 0.85%ECU Family Medicine 2 0.85%ECU Firetower Clinic 2 0.85%Kinston Medical Specialist Pink Hill 2 0.85%Vidant Family Medicine Allen Street 2 0.85%Carolina Pediatrics 1 0.85%Eastern North Carolina Medical Group 1 0.85%KidsCare Pediatrics 1 0.85%Vidant Pediatrics Kenansville 1 0.85%Total 100.00%

PCP Referrals

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ECU/Vidant CHACC Patient PCP Clinics

Quantity

Primary Care Physician Clinics

Qua

ntity

CHACC/CCPEC Co-Management Process

CHACC Care ManagerCCNC Care Managers

Patient Coordinators

CCNC Networks--Medical Home/Primary Care Providers

Children with complex, chronic Illnesses

Co-management

Specialty CarePrim

ary C

are

CC4C Care Managers

Case Studies

Patient A-Chronic kidney disease, abnormal GU anatomy, recurrent UTIs, significant social barriers

Hospital visits 2014:14, then 2015:5

CHACC involvement has been crucial in coordination of patient’s care as family is hesitant to work with new providers.

CHACC assistance with medical supplies, appt coordination, and compliance

Case Studies cont.

Patient B-nephrotic syndrome, HTN, extreme social barriers (language, compliance, literacy)

Hospital visits increased due to condition over time

CHACC has arranged for medications delivered to home, medication calendars in Spanish, home visits set up with CCNC-all have increased compliance and kept patient in remission for longer bursts

Case Studies cont.

Patient C-diabetes insipidus, Gtube, social concerns

Hospital visits 2013:3, to present-0

CHACC has assisted with getting Gtube feeds done at patient’s school and daycare; patient has gained weight appropriately and labs have normalized