Work Smarter, Not Harder:

Care Coordination Made Easy

Michelle Duplantier, LCSW-BACSPatti Barovechio DNP, RN, CCMSBHA 23rd Annual ConferenceMonday April 8, 2019

• Define care coordination (CC)

• Assess clinic care coordination strengths

• Explore evidence-based QI tools

• Identify 3 easy to implement strategies which improve care coordination services

Objectives

Bureau of Family Health

Partners for Family Health

Bureau of Family Health –

Children’s Special Health

Services

• Increase medical home capacity in Louisiana

• Improve youth health transition services and supports

www.ldh.la.gov/cshs

Care Coordination (CC) Defined

• CC is the collaborative organization of patient care activities across all practice domains, designed to facilitate delivery of appropriate, patient centered health care services.

• In pediatric/adolescent populations CC addresses interrelated medical, social, developmental, behavioral, educational and financial needs to achieve optimal health and wellness outcomes.

Poorly Coordinated Care

• Unsafe

• Financially inefficient

• Inferior quality

Safety: Missing Clinical Data

• Lab Results

• Consults

• Radiology

• H & P Exam

• Current Medications

• Pathology Reports

• Immunization Records

• Procedure Reports

Missing clinical information during primary care visits.

Smith, Araya-Guerra, Bublitz, et al. JAMA 2005

E. C. Schneider, D. O. Sarnak, D. Squires, A. Shah, and M. M. Doty, Mirror, Mirror: How the U.S. Health Care System Compares

Internationally at a Time of Radical Change, The Commonwealth Fund, July 2017.

Financially InefficientHealth Care Spending as a Percentage of GDP, 1980–2014

GDP refers to gross domestic product. Data in legend are for 2014.

Source: OECD Health Data 2016. Data are for current spending only, and exclude spending on capital formation of health care providers.

Percent

header AUS CAN FRA GER NETH NZ NOR SWE SWIZ UK US

OVERALL RANKING 2 9 10 8 3 4 4 6 6 1 11

Care Process+

2 6 9 8 4 3 10 11 7 1 5

Access+ 4 10 9 2 1 7 5 6 8 3 11

Administrative Efficiency+

1 6 11 6 9 2 4 5 8 3 10

Equity+ 7 9 10 6 2 8 5 3 4 1 11

Health Care Outcomes+

1 9 5 8 6 7 3 2 4 10 11

U.S. Health QualityHealth Care System Performance Rankings

U.S. Ranks 11th out of 11 countries in overall quality,

spending over double of the top ranked UK!

July 2017 “Mirror ” report by the Commonwealth Fund analysis

Triple Aim & Care Coordination

•Improving the patient

experience of care

(including quality and

satisfaction)

•Improving the health

of populations

•Reducing the per capita

cost of health care

Care Coordination in a Medical Home in Post-Katrina New Orleans: Lessons Learned

Berry S, Soltau E, Richmond NE, Kieltyka RL, Tran T, Williams AMaternal and Child Health Journal (2011) 15(6):782-793.

Enhancing State Medical Home Capacity through a Care Coordination Technical Assistance Model

Berry S, Barovechio P, Mabile E, Tran TMaternal and Child Health Journal (2017) 21; 1949-1960.

Testing a Care Coordination Model

CSHS Care Coordination (CC) Model

Practice Based CC Model

• Designated care coordinator

• Community referrals

• CSHCN Screener (CMHI 2006)– SBHC screens

– Risk assessments

– Depression screens PHQ-9

• CYSHCN Stratification

• Actionable care plans for high

need CYSHCN

• Quality Improvement

• Measurement

• Assessment driven process

• Partnership between patient/family, Specialist, Therapist, Nurse, and PCP

• Conduit for community services

• Facilitates internal and external communications

• Ongoing follow-up

• Closed referral loop

CSHS Care Coordination

Medical Home Index- Short Version Indicators (MHI-SV)

Cultural Competence

Care coordinator/role definition

Community assessment of needs for CSHCN

Family feedback

Quality Standards

Identification of children in the practice with SHCN

Care continuity

Assessment of needs/plans of care

Supporting the transition to adulthood

Cooperative management between PCP and specialistSHCN: Special health care needs

CSHCN: Children with special health care needs

(MHI-SV, Center for Medical Home Improvement (CMHI) 2006)

Medical Home Index-SV

Study Measurement

Medical Home Index-Short Version (MHI-SV)

2.08 2.13

1.76 1.74 1.831.96

2.181.95

1.82

2.25

3.53 3.62

3.33

2.983.21

4.11

3.413.64

2.83

3.48

1

2

3

4

5

Cultural

competence*

Care

coordination/

role

definition*

Community

assessment of

needs for

children with

special

healthcare

needs*

Family

feedback*

Quality

standards*

Identification

of children in

the practice

with special

health care

needs*

Care

continuity*

Assessment of

needs/ plans of

care*

Supporting the

transition to

adulthood*

Cooperative

management

between

primary care

physician and

specialist*

MH

I-S

V I

nd

ica

tor

Sco

re (

Ra

ng

e 1

-5)

MHI-SV Indicator

Baseline Last follow-up

Mean MHI-SV Score by Indicator in Ten Clinics at Baseline and Last Follow-up after Care Coordination Intervention

*Statistically significant difference (p<.05) between baseline and last follow-up MHI-SV score

SBHCs & SDOH

SBHCs provide access to physicaland mental health care for students confronted with financial, geographic, & cultural barriers to care!

Health Equity & Health Outcomes

(County Health Rankings Model, 2014)

County Health Rankings is a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute

– SBHCs care for many students that receive services in a variety of provider settings (potential for fragmented care)

– SBHCs have a multidisciplinary health team – capacity to address physical, mental, and behavioral health needs

– SBHCs collocated within educational institutions supports active coordination of IEP and health transition plans

– SBHCs can support linkage to community and specialty services

– Some SBHCs function as the patients medical home

SBHC Ecosystem

Care access for students

confronted with financial,

geographic, & cultural barriers

to care

Unique contact point

for school-aged children

& youth

Activities of Care Coordination

Appointments

Acute Care

Follow-up

Annual-Wellness

Mental Health

Sports Physicals

Referrals

Specialist

Diagnostics

Therapy

Dietician

Pharmacist

Patient Educator

Treatments

Medications

DME

Technology Supports

Care Coordination Processes

Stratify Population

Work Smarter-Not Harder

• Quality improvement/QI is key

• QI is assessment and data driven

• Process improvement first used in manufacturing industry

• Used to build effective and efficient workflows

• Using QI frameworks maximizes effect (evidence-based)

Process Improvement/Service Implementation

CC Discussion

At my school based health clinic we…

What did you find?

QI and Health Care

• QI should be embedded into any health care organization

• Process approaches targets efficiency and effectiveness

• A patient focus is elemental, don’t just collect feedback – use it to drive improvement

• QI necessary to reach the Triple Aim

QI Frameworks

IHI Model for Improvement

https://www.youtube.com/watch?v=szLduqP7u-k

Model for Improvement, Institute for Healthcare Improvement (IHI); IHI QI Essentials Toolkit 2017.

The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real work setting —by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method adapted for action-oriented learning.

Process Improvement

• Know some tests will fail, much is learned from failed cycles - document

• Start small n=1, n=3• Over time retest under

varied conditions - ramps (days, times, situations)

• Keep staff up to date on QI activities

• Formalize processes only when effective workflows established

Plan-Do-Study-Act Worksheet

Easy to Implement CC Strategies

Use population health methods• Screen • Identify high risk population

– Conduct needs assessment

• Stratify by level of need– Actionable care plans for high

need patients– Ongoing follow-up– Address SDH through community

referrals

Care Coordination Strategies

• Utilize resource organizations like Families Helping Families, CSHS Family Resource Centers (NOLA), Exceptional Lives Louisiana (web-based)

• Partner with public health programs (free resources, TA, and services like home visiting)

• Engage entire team around CC services– Identify staff roles– Establish efficient workflows to support consistency of services – Promote accountability

• Implement easy access resources– Condition specific– Community programs/services– Web-based, rack cards, print on demand– Form letters

SmoothMovesYHT.org

An Education Intervention

• Evidenced based education intervention

• Youth friendly materials

• Library of YHT tools developed by expert workgroups across US and Canada

Bureau of Family Health’s

Louisiana YHT Toolkit

Regional Resource Guides

Work Smarter-Not Harder

• Establish effective/efficient workflows for CC services

• Use population health methods

• Build partnerships with resource orgs

• Establish consistent paths for CC documentation

Michelle Noah Duplantier LCSW-BACS Michelle.Duplantier@la.gov

Patti Barovechio DNP MN CCMpatti.Barovechio@la.gov

Bureau of Family Health 504-568-5055

• Agency for Healthcare Research and Quality, Care Coordination Measures Atlas. https://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/atlas2014/index.html

• Berry S, Soltau E, Richmond NE, Kieltyka RL, Tran T, Williams A. Care Coordination in a Medical Home in Post-Katrina New Orleans: Lessons Learned. Maternal and Child Health Journal (2011) 15(6):782-793.

• Berry S, Barovechio P, Mabile E, Tran T. Enhancing State Medical Home Capacity through a Care Coordination Technical Assistance Model. Maternal and Child Health Journal (2017) 21; 1949-1960.

• Center for Medical Improvement. The medical home index - short version: Measuring the organization and delivery of primary care for children with special health care needs. 2006.

• Cooley WC, McAllister JW, Sherrieb K, Clark RE. The medical home index: Development and validation of a new practice-level measure of implementation of the medical home model. Ambulatory Pediatrics. 2003;3(4):173-180.

• Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee. Patient- and family-centered care coordination: A framework for integrating care for children and youth across multiple systems. Pediatrics. 2014;133(5):e1451-60.

• Craig C, Eby D, Whittington J.. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011.

• Institute for Healthcare Improvement. Triple Aim for Populations and Model for Improvement. http://www.ihi.org

References