Partnerships in Primary and Behavioral Health Care ACO Survival Integrated Care

Size: px
Start display at page:

Download "Partnerships in Primary and Behavioral Health Care ACO Survival Integrated Care"

Transcription

1 Partnerships in Primary and Behavioral Health Care ACO Survival Integrated Care Ensuring Success for ACOs September Joyce Wale LCSW Vice President, Institute for Behavioral Healthcare Improvement

2 Pursuing the Triple Aim through ACO s ACO s: A healthcare delivery and payment system that ties together provider reimbursement through incentives, and quality metrics, connected to a specific patient population. 2

3 The Model Differs Based on Partnership Structure Health Plan Developed ACO Jointly Developed ACO between Health Plan and Employer, Health plan and physician group, insurers, hospital system etc. Outcomes are all about the same 3

4 An ACO should support Patient-centered and coordinated care A high preforming network of providers Transparency Health information technology Patient Engagement Outcomes-oriented measurement 4

5 Evidence of the Need for Mental Health Care Overwhelming evidence that treatment works National studies: Over 1-year period up to 30% of US adults meet criteria for one or more mental health conditions Mental health conditions are 2-3 times more common in patients with chronic diseases (Diabetes, Heart disease, chronic pain, Arthritis) Many problems patients bring to primary care have no recognized medical etiology or course of treatment 5

6 Opportunities for ACO s to Integrate Care Mental and Substance Use disorders are leading causes of disability worldwide, are associated with increased medical care and employer costs and lead to premature mortality Primary care is the de-facto source of care due to stigma and limited access to BH providers Providers can improve efficiency with on-site behavioral health support 6

7 A high preforming network of providers should use integrated care delivery models Chronic Care Model Patient Centered Medical Home Integrated Co-located care 7

8 Chronic Care Model (CCM) Promotes: Enhanced access and continuity through delivery system design Care planning and management through decision support guidelines, self-management, linkages to community resources, tracking and coordination of care, measurement and performance improvement 8

9 Patient Centered Medical Home Transition from a clinic to a comprehensive service model with focus on o Access o Accountability o Comprehensive Person o Coordination of care Designed to produce higher quality, reduce costs in a team approach 9

10 Integrated Co Location of Care Bringing care to the patient o Within PCMH Team Care Embedded behavioral health (Psychiatrist, NP, Social worker, etc. o Within BH Clinic Internist, Family Practice, NP, PH, etc. 10

11 Components of Integrated Care Cultural shifts o Mind / Body connection Role of PCP o Diagnostic Assessment o Development of Care Plan o Monitoring and Follow-up Redesigning workflows to allow BH Care Integrated Care o 15 minute scheduling / psychotherapy 11

12 Components continued Care Management: The Glue o Opportunities to integrate o Social work & nursing o Mind / body responsibility o Competence / skills, health & BH o Ongoing screening o Roles change with matching patient need and staff competency 12

13 Range of tasks Communications broker / feedback loops Gate keeper for implementation of Care Plan Patient engagement agent Addressing basic and social needs Medication management and compliance Wellness coaching Navigator for the complex system 13

14 Patient Centered Consumer Driven Care Using people with lived experience through Peer Support creates hope Peers provide opportunities for improved patient engagement Member satisfaction is enhanced 14

15 Timing Is Everything Transitions of care Readmission (all cause) Screening of members o Who o What o When o Where 15

16 Behavioral Health Providers are taking steps to get involved with ACO s How do you currently operate? Is the delivery system integrated? Do you know your BH providers? Can you tell who does a good job? Do you manage your high utilizers and what % have BH conditions? 16

17 17

18 Key Points Integrating care is critical Evidence supports it Lot s of opportunities Transforming PCMH & Co-Location of Services Care coordination vital Using data to understand needs Effective integration of behavioral health can save money 18

Integrating Behavioral Health and Primary Health Care: Development, Maintenance, and Sustainability Cici Conti Schoenberger, LCSW, CAS Behavioral

Integrating Behavioral Health and Primary Health Care: Development, Maintenance, and Sustainability Cici Conti Schoenberger, LCSW, CAS Behavioral Integrating Behavioral Health and Primary Health Care: Development, Maintenance, and Sustainability Cici Conti Schoenberger, LCSW, CAS Behavioral Health Provider Sunshine Community Health Center Why Integrate?

More information

Day 1 Follow-Up: Panelist Suggestions and Final Topic Ranking. IHS Advisory Panel Meeting April 20, 2013 (Day 2) Chad Boult, MD, MPH, MBA Director

Day 1 Follow-Up: Panelist Suggestions and Final Topic Ranking. IHS Advisory Panel Meeting April 20, 2013 (Day 2) Chad Boult, MD, MPH, MBA Director Day 1 Follow-Up: Panelist Suggestions and Final Topic Ranking IHS Advisory Panel Meeting April 20, 2013 (Day 2) Chad Boult, MD, MPH, MBA Director 1 Suggestions From Panelists 2 Use One Care Management

More information

Consolidated Project Information Project 3.a.i Integration of Primary Care and Behavioral Health Services

Consolidated Project Information Project 3.a.i Integration of Primary Care and Behavioral Health Services Consolidated Information 3.a.i Integration of Primary Care and Behavioral Services Contents 3.a.i Integration of Primary Care and Behavioral Services... 3 3.a.i Objective & Requirements... 3 3.a.i Requirements

More information

Proven Innovations in Primary Care Practice

Proven Innovations in Primary Care Practice Proven Innovations in Primary Care Practice October 14, 2014 The opinions expressed are those of the presenter and do not necessarily state or reflect the views of SHSMD or the AHA. 2014 Society for Healthcare

More information

6/26/2014. What if air travel worked like healthcare? EMERGING SYSTEM DELIVERY MODELS FOR INTEGRATED CARE

6/26/2014. What if air travel worked like healthcare? EMERGING SYSTEM DELIVERY MODELS FOR INTEGRATED CARE EMERGING SYSTEM DELIVERY MODELS FOR INTEGRATED CARE SUMMER INSTITUTE PRESENTERS With 20+ years experience as a clinician and administrator, Zohreh leads Inter-Growth s team of experts and works with clients

More information

Implementation of SBIRT onto Electronic Health Records: From Documentation to Data

Implementation of SBIRT onto Electronic Health Records: From Documentation to Data Implementation of SBIRT onto Electronic Health Records: From Documentation to Data John R. McAteer, LCSW-R New York City Department of Health and Mental Hygiene Bureau of Alcohol and Drug Use Prevention,

More information

Game Changer at the Primary Care Practice Embedded Care Management. Ruth Clark, RN, BSN, MPA Integrated Health Partners October 30, 2012

Game Changer at the Primary Care Practice Embedded Care Management. Ruth Clark, RN, BSN, MPA Integrated Health Partners October 30, 2012 Game Changer at the Primary Care Practice Embedded Care Management Ruth Clark, RN, BSN, MPA Integrated Health Partners October 30, 2012 Objectives To describe the recent evolution of care management at

More information

Lessons on the Integration of Medicine and Psychiatry

Lessons on the Integration of Medicine and Psychiatry Lessons on the Integration of Medicine and Psychiatry Edward Post, MD, PhD Associate Professor of Internal Medicine, University of Michigan VA Health Services Research & Development Center of Excellence,

More information

Integrated Health Care Models and Practices

Integrated Health Care Models and Practices Integrated Health Care Models and Practices The Greater Houston Behav io r al Health Affordable Care Act Initiative S e c o n d C o m m u n i t y E d u c a t i o n E v e n t I n t e g r a t e d H e a l

More information

Project Objective: Integration of mental health and substance abuse with primary care services to ensure coordination of care for both services.

Project Objective: Integration of mental health and substance abuse with primary care services to ensure coordination of care for both services. Domain 3 Projects 3.a.i Integration of Primary Care and Behavioral Health Services Project Objective: Integration of mental health and substance abuse with primary care services to ensure coordination

More information

Health Home Program (Section 2703) Iowa Medicaid Enterprise. Marni Bussell Project Manager December 13, 2013

Health Home Program (Section 2703) Iowa Medicaid Enterprise. Marni Bussell Project Manager December 13, 2013 Health Home Program (Section 2703) Iowa Medicaid Enterprise Marni Bussell Project Manager December 13, 2013 1 Two Health Home Programs: Same Triple Aim Goals Chronic Condition Health Home: Primary Care

More information

Degree of Integration

Degree of Integration Integrated Primary Care and Behavioral Health Services at Community Clinics and Health Centers: RESULTS OF THE 2012 BEHAVIORAL HEALTH SERVICES ADVOCACY AND NETWORKING SURVEY FACT SHEET: Integrated Behavioral

More information

Bi-Directional Integration: What Degree of Integration is Needed for Success Linking Indiana Integration Principles to National Models

Bi-Directional Integration: What Degree of Integration is Needed for Success Linking Indiana Integration Principles to National Models Bi-Directional Integration: What Degree of Integration is Needed for Success Linking Indiana Integration Principles to National Models What Degree of Success is Needed from the Affordable Care Act Perspective?

More information

Care Coordination and Community Case Management Partner Meeting

Care Coordination and Community Case Management Partner Meeting Care Coordination and Community Case Management Partner Meeting To ensure the right care, in the right order, at the right time, in the right setting 1 Today s Objectives What is Integrated Community Health

More information

Ohio Medicaid Health Homes. The Future for Providers and Patients

Ohio Medicaid Health Homes. The Future for Providers and Patients Ohio Medicaid Health Homes The Future for Providers and Patients Understand Prepare Provide 2012 Annual Conference on Aging Ohio Association of Area Agencies on Aging Making History Medical Reintegration

More information

STATE PUBLIC HEALTH ACTIONS FOR PREVENTION GRANT OVERVIEW

STATE PUBLIC HEALTH ACTIONS FOR PREVENTION GRANT OVERVIEW STATE PUBLIC HEALTH ACTIONS FOR PREVENTION GRANT OVERVIEW December 5, 2014 Kari Majors, Health Systems and Disease Management Program Manager Chronic Disease Prevention and Control Programs DHHS, Division

More information

Implementing CDSMP in an integrated health care system

Implementing CDSMP in an integrated health care system Implementing CDSMP in an integrated health care system The Group Health experience October 2, 2009 Kimberly Wicklund, MPH Group Health Overview Consumer-governed, non-profit financing and care delivery

More information

1115 Medicaid Waiver Programs Section1115 of the Social Security Act allows CMS the authority to approve state demonstration projects that improve care, increase efficiency, and reduce costs related to

More information

Building an Accountable Care Organization. Jean Malouin, MD MPH University of Michigan Health System September 21, 2012

Building an Accountable Care Organization. Jean Malouin, MD MPH University of Michigan Health System September 21, 2012 Building an Accountable Care Organization Jean Malouin, MD MPH University of Michigan Health System September 21, 2012 Agenda UMHS overview PGP demo ACO precursor Current efforts underway Role of primary

More information

Collaborative Care Tips for Sustainability. Virna Little, PsyD, LCSW r, SAP The Institute for Family Health NYS Collaborative Care Initiative

Collaborative Care Tips for Sustainability. Virna Little, PsyD, LCSW r, SAP The Institute for Family Health NYS Collaborative Care Initiative Collaborative Care Tips for Sustainability Virna Little, PsyD, LCSW r, SAP The Institute for Family Health NYS Collaborative Care Initiative Teamwork Applies to Billing Too!!! Combine with other initiatives

More information

CCNC Care Management

CCNC Care Management CCNC Care Management Community Care of North Carolina (CCNC) is a statewide population management and care coordination infrastructure founded on the primary care medical home model. CCNC incorporates

More information

July 20, 2015. Dear Colleague:

July 20, 2015. Dear Colleague: July 20, 2015 Dear Colleague: On May 29, 2015, the Department of Human Services released a request for information (RFI) to help guide us as we plan for the release of a new procurement for the provision

More information

Evolving with the System: The Changing Role of Medical Assistants in the Delivery of Team-Based Care

Evolving with the System: The Changing Role of Medical Assistants in the Delivery of Team-Based Care Evolving with the System: The Changing Role of Medical Assistants in the Delivery of Team-Based Care Background Geneia brings innovation to health care by helping hospitals, physicians and all types of

More information

Person-Centered Nurse Care Management in Home Based Care: Impact on Well-Being and Cost Containment

Person-Centered Nurse Care Management in Home Based Care: Impact on Well-Being and Cost Containment Person-Centered Nurse Care Management in Home Based Care: Impact on Well-Being and Cost Containment Donna Zazworsky, RN, MS, CCM, FAAN Vice President: Community Health and Continuum Care Carondelet Health

More information

POPULATION HEALTH MANAGEMENT The Lynchpin of Emerging Healthcare Delivery Improve Patient Outcomes, Engage Physicians, and Manage Risk

POPULATION HEALTH MANAGEMENT The Lynchpin of Emerging Healthcare Delivery Improve Patient Outcomes, Engage Physicians, and Manage Risk POPULATION HEALTH MANAGEMENT The Lynchpin of Emerging Healthcare Delivery Improve Patient Outcomes, Engage Physicians, and Manage Risk Julia Andrieni, MD, FACP Vice President, Population Health and Primary

More information

Behavioral Health Integration into Primary Care. Hackley Community Care Center (HCCC) Community Mental Health of Muskegon County

Behavioral Health Integration into Primary Care. Hackley Community Care Center (HCCC) Community Mental Health of Muskegon County Behavioral Health Integration into Primary Care Hackley Community Care Center (HCCC) Community Mental Health of Muskegon County Integrated Health Care In essence integrated health care is the systematic

More information

Benefit Design and ACOs: How Will Private Employers and Health Plans Proceed?

Benefit Design and ACOs: How Will Private Employers and Health Plans Proceed? Benefit Design and ACOs: How Will Private Employers and Health Plans Proceed? Accountable Care Organizations: Implications for Consumers October 14, 2010 Washington, DC Sam Nussbaum, M.D. Executive Vice

More information

DSRIP Domain 2-4 Projects for FQHCs

DSRIP Domain 2-4 Projects for FQHCs In this document, CHCANYS presents information on select DSRIP projects from Domains 2, 3, and 4. These are projects that FQHCs should or could play a leadership or central role in designing and implementing.

More information

Payment Reform in Massachusetts: Impact and Opportunities for the Health Care Workforce

Payment Reform in Massachusetts: Impact and Opportunities for the Health Care Workforce Payment Reform in Massachusetts: Impact and Opportunities for the Health Care Workforce Jessica Larochelle July 9, 2014 Overview Forces driving payment and delivery system reform Overview of payment and

More information

Note: This is an authorized excerpt from 57 Population Health Management Metrics. To download the entire report, go to

Note: This is an authorized excerpt from 57 Population Health Management Metrics. To download the entire report, go to Note: This is an authorized excerpt from 57 Population Health Management Metrics. To download the entire report, go to http://store.hin.com/product.asp?itemid=4817 or call 888-446-3530. 57 Population Health

More information

Pushing the Envelope of Population Health

Pushing the Envelope of Population Health Pushing the Envelope of Population Health Timothy Ferris, MD, MPH Senior Vice President, Population Health Management, Partners HealthCare May 15, 2014 DISCLAIMER: The views and opinions expressed in this

More information

Designing the Role of the Embedded Care Manager

Designing the Role of the Embedded Care Manager Designing the Role of the Embedded By Patricia Hines, Ph.D., RN and Marge Mercury, RN, MS, CMCE The Embedded The use of an Embedded ( ECM ) to coordinate within the complex delivery system is sharply increasing.

More information

UW Medicine Integrated Mental Health Care. Laura Collins MSW, Darcy Jaffe ARNP Jürgen Unützer, MD, MPH, MA

UW Medicine Integrated Mental Health Care. Laura Collins MSW, Darcy Jaffe ARNP Jürgen Unützer, MD, MPH, MA UW Medicine Integrated Mental Health Care Laura Collins MSW, Darcy Jaffe ARNP Jürgen Unützer, MD, MPH, MA Why Behavioral Health Care in Primary Care? 1. Access to care: Serve patients where they are 2.

More information

Our Patient-Centered Medical Home a Process, not a Click

Our Patient-Centered Medical Home a Process, not a Click Our Patient-Centered Medical Home a Process, not a Click Richard Johnston, M.D. President, Medical Clinic of North Texas, P.A. Medical Clinic of North Texas, P.A. MCNT Physician Owned Primary Care Medical

More information

Nuts and Bolts Accountable Care Organizations: A New Care Delivery Model for New Expectations

Nuts and Bolts Accountable Care Organizations: A New Care Delivery Model for New Expectations Nuts and Bolts Accountable Care Organizations: A New Care Delivery Model for New Expectations Presented to The American College of Cardiology October 27, 2012 1 Franciscan Alliance Overview Franciscan

More information

Care Coordination among DSRIP Partners

Care Coordination among DSRIP Partners Care Coordination among DSRIP Partners John F. Skip Williams, Jr., MD, EdD, MPH Maureen Fahey, RN, MBA Thursday, June 25, 2015 3:00-3:30 pm OVERVIEW OF PRESENTATION New York State DSRIP Overview Brooklyn

More information

WellSpan Health Care Management Strategy. October, 2013

WellSpan Health Care Management Strategy. October, 2013 WellSpan Health Care Management Strategy October, 2013 We will realize a fundamental, yet gradual, shift in how we deliver and receive payment for care From: A system that treats people mostly when they

More information

How Health Reform Will Affect Health Care Quality and the Delivery of Services

How Health Reform Will Affect Health Care Quality and the Delivery of Services Fact Sheet AARP Public Policy Institute How Health Reform Will Affect Health Care Quality and the Delivery of Services The recently enacted Affordable Care Act contains provisions to improve health care

More information

Population Health Management For Behavioral Health. MHA s 2015 Annual Conference June 3, 2015

Population Health Management For Behavioral Health. MHA s 2015 Annual Conference June 3, 2015 Population Health Management For Behavioral Health MHA s 2015 Annual Conference June 3, 2015 Goals of the Affordable Care Act Improve the health of populations Lower per capita costs Improve the patient

More information

Health Enterprise Zones Dashboard, Data Dictionary of Key Terms

Health Enterprise Zones Dashboard, Data Dictionary of Key Terms Health Enterprise Zones Dashboard, Data Dictionary of Key Terms HOSPITAL UTILIZATION: UPPER LEFT CORNER Description: Hospitalization rate (per 1,000 population) and readmission rate are provided for the

More information

Population Health Solutions for Employers MEDIA RESOURCES

Population Health Solutions for Employers MEDIA RESOURCES Population Health Solutions for Employers MEDIA RESOURCES ABOUT MISSIONPOINT MissionPoint s mission is to make healthcare more affordable, accessible and improve the quality of care for our members. MissionPoint

More information

1) What would it take to get four or five FQHCs to implement ECHO, and how many patients can we serve?

1) What would it take to get four or five FQHCs to implement ECHO, and how many patients can we serve? RI Mental Health Summit Lightning Round Q&A s June 8, 2015 Opiate Addiction Epidemic 1) What would it take to get four or five FQHCs to implement ECHO, and how many patients can we serve? 2) What would

More information

Value-based Health Care Models. TASC 90 Webinar May 2015

Value-based Health Care Models. TASC 90 Webinar May 2015 Value-based Health Care Models TASC 90 Webinar May 2015 Definitions Accountable Care Organization (ACO) Coordinated Care Organization (CCO) Patient Centered Medical Home (PCMH) Population Health 2 Accountable

More information

HOW CARE MANAGEMENT EVOLVES WITH POPULATION MANAGEMENT

HOW CARE MANAGEMENT EVOLVES WITH POPULATION MANAGEMENT Reform and rising costs continue to push the importance of care management systems to the forefront. With the growing prominence of population health for provider organizations, provider-based care management

More information

Key Strategic and Tactical Steps to Excel as Community Hospital May 2011

Key Strategic and Tactical Steps to Excel as Community Hospital May 2011 Key Strategic and Tactical Steps to Excel as Community Hospital May 2011 1 2 3 Pillars of Excellence 4 Transformation from Hospital-Centric to Community-Centric with Triple Aim as Framework 5 Objectives

More information

Realizing ACO Success with ICW Solutions

Realizing ACO Success with ICW Solutions Realizing ACO Success with ICW Solutions A Pathway to Collaborative Care Coordination and Care Management Decrease Healthcare Costs Improve Population Health Enhance Care for the Individual connect. manage.

More information

2019 Healthcare That Works for All

2019 Healthcare That Works for All 2019 Healthcare That Works for All This paper is one of a series describing what a decade of successful change in healthcare could look like in 2019. Each paper focuses on one aspect of healthcare. To

More information

Idaho Health Home State Plan Amendment Matrix: Summary Overview. Overview of Approved Health Home SPAs

Idaho Health Home State Plan Amendment Matrix: Summary Overview. Overview of Approved Health Home SPAs Idaho Health Home State Plan Amendment Matrix: Summary Overview This matrix outlines key program design features from health home State Plan Amendments (SPAs) approved by the Centers for Medicare & Medicaid

More information

caresy caresync Chronic Care Management

caresy caresync Chronic Care Management caresy Chronic Care Management THE PROBLEM Chronic diseases and conditions, including heart disease, diabetes, COPD and obesity, are among the most common, expensive, and preventable health problems in

More information

CHAPTER 535 HEALTH HOMES. Background... 2. Policy... 2. 535.1 Member Eligibility and Enrollment... 2. 535.2 Health Home Required Functions...

CHAPTER 535 HEALTH HOMES. Background... 2. Policy... 2. 535.1 Member Eligibility and Enrollment... 2. 535.2 Health Home Required Functions... TABLE OF CONTENTS SECTION PAGE NUMBER Background... 2 Policy... 2 535.1 Member Eligibility and Enrollment... 2 535.2 Health Home Required Functions... 3 535.3 Health Home Coordination Role... 4 535.4 Health

More information

Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Summit Health Plan of Florida

Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Summit Health Plan of Florida Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Summit Health Plan of Florida Medicare Quality Management Program Overview Quality Improvement (QI) Overview At Coventry, we

More information

Care Coordination. The Embedded Care Manager. Presented by Thomas Decker, MD Mary Finnegan, BSN, M.Ed

Care Coordination. The Embedded Care Manager. Presented by Thomas Decker, MD Mary Finnegan, BSN, M.Ed Care Coordination The Embedded Care Manager Presented by Thomas Decker, MD Mary Finnegan, BSN, M.Ed Goals of Care Management The goals of care Management are consistent with the Triple Aim: Improve population

More information

Care Coordination: Case managers connect the dots in new delivery models

Care Coordination: Case managers connect the dots in new delivery models The Pathway to Certfication is CCMC IssueBrief VOLUME 1, ISSUE 2 Care Coordination: Case managers connect the dots in new delivery models Well before health reform was signed into law, new models for health

More information

Future of Health Care: How Do You Fit In? Physician Leadership Institute February 28, 2015 Brian M. McCook, CPA

Future of Health Care: How Do You Fit In? Physician Leadership Institute February 28, 2015 Brian M. McCook, CPA Future of Health Care: How Do You Fit In? Physician Leadership Institute February 28, 2015 Brian M. McCook, CPA Learning Objectives Industry Transitions Challenges and Changes ACO s Look at the Future

More information

The Montefiore ACO and Behavioral Health Integration: A Work in Progress. Henry Chung, MD Bruce Schwartz, MD

The Montefiore ACO and Behavioral Health Integration: A Work in Progress. Henry Chung, MD Bruce Schwartz, MD The Montefiore ACO and Behavioral Health Integration: A Work in Progress Henry Chung, MD Bruce Schwartz, MD Agenda Describe the Montefiore Medical Center delivery system and experience in managing vulnerable

More information

Telehealth Solutions Enhance Health Outcomes and Reduce Healthcare Costs

Telehealth Solutions Enhance Health Outcomes and Reduce Healthcare Costs Text for a pull out can go heretext for a pull out can go heretext for a pull out can go Text for a pull out can go here Text for a pull out can go here Telehealth Solutions Enhance Health Outcomes and

More information

Achieving Success through Innovative Partnerships

Achieving Success through Innovative Partnerships Achieving Success through Innovative Partnerships Rosanne DiStefano, Executive Director Joan Hatem-Roy, LICSW, Assistant Executive Director Jennifer Raymond, MBA, Hebrew Senior Life Common Goals for the

More information

Senate Special Committee on Aging

Senate Special Committee on Aging Senate Special Committee on Aging Field Hearing July 31, 2015 Five Star Senior Center, St. Louis, Missouri Testimony Delivered by Sandra Van Trease Group President, BJC HealthCare Introduction Members

More information

Community Health Worker Led Diabetes Coaching within the Medical Home

Community Health Worker Led Diabetes Coaching within the Medical Home Community Health Worker Led Diabetes Coaching within the Medical Home Christine Snead, RN Erin Kane, MD Baylor Scott & White Health www.alliancefordiabetes.org Objectives Identify tools, resources and

More information

Pamela Tropiano, RN, CCM, BSN, MPA. CareSource

Pamela Tropiano, RN, CCM, BSN, MPA. CareSource Annual Education Conference September 30 October 3, 2012 Orlando, FL 1.7 Creative Case Management Pamela Tropiano, RN, CCM, BSN, MPA Senior Vice President, Health hservices CareSource Mission: The CareSource

More information

Kim Olmedo, LCSW, CCM CSW-G Social Work Manager, Silverback Care Management

Kim Olmedo, LCSW, CCM CSW-G Social Work Manager, Silverback Care Management Kim Olmedo, LCSW, CCM CSW-G Social Work Manager, Silverback Care Management According to AARP, about 8000 people turn 65 every day The Medicare Trustees have estimated that Medicare will run out of money

More information

Health Disparities in H.R. 3590 (Merged Senate Bill)

Health Disparities in H.R. 3590 (Merged Senate Bill) Health Disparities in H.R. 3590 (Merged Senate Bill) Definitions: Health disparity population is defined in the bill as defined in Section 485E (Sec. 931) Current Law: a population is a health disparity

More information

Transitional Care Management

Transitional Care Management Transitional Care Management HE ALTH SOLUTIONS consulting technology innovation A DIVISION OF AVASTONE TECHNOLOGIES, LLC I avastonetech.com/healthsolutions transitional care management I Avastone Health

More information

Integrating Behavioral Health and Primary Care. Overview

Integrating Behavioral Health and Primary Care. Overview Integrating Behavioral Health and Primary Care Department of Family Medicine & Public Health Sciences Overview 1) Healthcare system & spending 2) Why behavioral health? 3) Patient-Centered Medical Home

More information

REWRITING PAYER/PROVIDER COLLABORATION July 24, 2015. MIKE FAY Vice President, Health Networks

REWRITING PAYER/PROVIDER COLLABORATION July 24, 2015. MIKE FAY Vice President, Health Networks REWRITING PAYER/PROVIDER COLLABORATION July 24, 2015 MIKE FAY Vice President, Health Networks AGENDA ACO Overview ACO Financial Performance ACO Quality Performance Observations 2 AGENDA ACO OVERVIEW ACO

More information

Behavioral Health: Creating Effective Interdisciplinary Teamwork through EHR Technology

Behavioral Health: Creating Effective Interdisciplinary Teamwork through EHR Technology Behavioral Health: Creating Effective Interdisciplinary Teamwork through EHR Technology Executive Summary To achieve higher quality care, better patient outcomes and lower costs, the healthcare industry

More information

SoonerCare Health Management Program. Mike Herndon, D.O. Medical Director, Health Care Management

SoonerCare Health Management Program. Mike Herndon, D.O. Medical Director, Health Care Management SoonerCare Health Management Program Mike Herndon, D.O. Medical Director, Health Care Management SoonerCare Health Management Program Existing Health Management Program, mandated by OK legislature in 2006

More information

State Innovation Model

State Innovation Model State Innovation Model P a t i e n t C e n t e r e d M e d i c a l H o m e W e b i n a r M a y 1 1, 2 0 1 6 1 Agenda SIM Overview & Updates Patient Centered Medical Home Overview Questions 2 1 SIM Overview

More information

Accountable Care Organization Workgroup Glossary

Accountable Care Organization Workgroup Glossary Accountable Care Organization Workgroup Glossary Accountable care organization (ACO) a group of coordinated health care providers that care for all or some of the health care needs of a defined population.

More information

Advanced Clinical Social Work Practice in Integrated Healthcare Module 1. Marion Becker, PhD School of Social Work University of South Florida

Advanced Clinical Social Work Practice in Integrated Healthcare Module 1. Marion Becker, PhD School of Social Work University of South Florida Advanced Clinical Social Work Practice in Integrated Healthcare Module 1 Marion Becker, PhD School of Social Work University of South Florida Introduction to Integrated Healthcare and the Culture of Health

More information

With New Models of Value-Based Care. September 1, 2015

With New Models of Value-Based Care. September 1, 2015 With New Models of Value-Based Care September 1, 2015 Using Community Care Coordination and Mobile Technology to Impact Health Outcomes and Reduce Avoidable Hospital Encounters Presenters: Chris Parsons,

More information

10/21/2014. Clinical Innovations in the Patient Centered Medical Home to Improve Diabetes Care

10/21/2014. Clinical Innovations in the Patient Centered Medical Home to Improve Diabetes Care Clinical Innovations in the Patient Centered Medical Home to Improve Diabetes Care Robert A. Gabbay, MD, PhD, FACP Chief Medical Officer & Senior Vice President Joslin Diabetes Center Harvard Medical School

More information

Patient-Centered. Medical Home

Patient-Centered. Medical Home Patient-Centered Medical Home PROTECT PROMOTE IMPROVE Healthcare Transformation in Ohio Ted Wymyslo, MD Director Ohio Department of Health Adherence Summit II Continuing Medical Educators Nov. 14,

More information

Planning Effective. Workflows & Payment Models

Planning Effective. Workflows & Payment Models Planning Effective Collaborative Care Workflows & Payment Models Virna Little, PsyD, LCSW r, SAP TWO PROCESSES 1. Systematic diagnosis and outcomes tracking e.g., PHQ 9 to facilitate diagnosis and track

More information

Community Care Collaborative Integrated Behavioral Health Intervention for Chronic Disease Management 307459301.2.3 Pass 3

Community Care Collaborative Integrated Behavioral Health Intervention for Chronic Disease Management 307459301.2.3 Pass 3 Community Care Collaborative Integrated Behavioral Health Intervention for Chronic Disease Management 307459301.2.3 Pass 3 Provider: The Community Care Collaborative (CCC) is a new multi-institution, multi-provider,

More information

What is an Accountable Care Organization & Why is it Important to Your Home Infusion Company?

What is an Accountable Care Organization & Why is it Important to Your Home Infusion Company? What is an Accountable Care Organization & Why is it Important to Your Home Infusion Company? Lisa Harvey McPherson RN, MBA, MPPM EMHS Vice President Continuum of Care & Chief Advocacy Officer Disclosures

More information

Co-management (Service Line Agreement 2007)

Co-management (Service Line Agreement 2007) Co-management (Service Line Agreement 2007) Orthopedics Neuroscience Cardiology Cardiovascular Surgery Collaboration on a different level Tactical method of increasing alignment and collaboration Agreement

More information

Impact of the 2010 Affordable Care Act on the California Labor Force

Impact of the 2010 Affordable Care Act on the California Labor Force Impact of the 2010 Affordable Care Act on the California Labor Force Linda L. Zorn, RD, MA Sector Navigator Health Workforce Initiative California Community Colleges Chancellor s Office Project Overview

More information

Introduction to the GLPTN Program. Provider Office & Physician Organization Briefing

Introduction to the GLPTN Program. Provider Office & Physician Organization Briefing Introduction to the GLPTN Program Provider Office & Physician Organization Briefing What is the GLPTN? The GLPTN is one of 29 Practice Transformation Networks (PTNs) funded under the brand new CMS Transforming

More information

Second Forum on Health Care Management & Policy November 28 30, 2012. Discussion Report. Care Management

Second Forum on Health Care Management & Policy November 28 30, 2012. Discussion Report. Care Management Second Forum on Health Care Management & Policy November 28 30, 2012 Discussion Report Care Management Thomas G. Rundall Henry J. Kaiser Emeritus Professor of Organized Health Systems School of Public

More information

Arkansas Behavioral Health Home State Plan Amendment. Draft - 03/11/14

Arkansas Behavioral Health Home State Plan Amendment. Draft - 03/11/14 Arkansas Behavioral Health Home State Plan Amendment Draft - 03/11/14 NOTE: Bolded text within document denotes required health home language by the Centers for Medicare and Medicaid Services (CMS) with

More information

What is an Accountable Care Organization & Why is it Important to Your Home Infusion Company? Disclosures. Overview 3/10/2015

What is an Accountable Care Organization & Why is it Important to Your Home Infusion Company? Disclosures. Overview 3/10/2015 What is an Accountable Care Organization & Why is it Important to Your Home Infusion Company? Lisa Harvey McPherson RN, MBA, MPPM EMHS Vice President Continuum of Care & Chief Advocacy Officer Disclosures

More information

Clinical Nurse Specialists Practitioners Contributing to Primary Care: A Briefing Paper

Clinical Nurse Specialists Practitioners Contributing to Primary Care: A Briefing Paper Clinical Nurse Specialists Practitioners Contributing to Primary Care: A Briefing Paper As the need grows for more practitioners of primary care, it is important to recognize the Clinical Nurse Specialist

More information

Collaborative Care in Health Systems

Collaborative Care in Health Systems Collaborative Care in Health Systems Competencies and Skills of Psychosomatic Medicine Psychiatrists James Rundell, MD, FAPM Jürgen Unützer, MD, MPH, MA Wayne Katon, MD, FAPM ACADEMY OF PSYCHOSOMATIC MEDICINE

More information

OHIO CONSUMERS FOR HEALTH COVERAGE POLICY PRIORITIES FY 2012-13. Medicaid Make Improvements to Improve Care and Lower Costs

OHIO CONSUMERS FOR HEALTH COVERAGE POLICY PRIORITIES FY 2012-13. Medicaid Make Improvements to Improve Care and Lower Costs OHIO CONSUMERS FOR HEALTH COVERAGE POLICY PRIORITIES FY 2012-13 Ohio Consumers for Health Coverage supports robust implementation of the Patient Protection and Affordable Care Act (ACA) in Ohio, making

More information

Collaborative Onsite Medical Care in the Workplace

Collaborative Onsite Medical Care in the Workplace Collaborative Onsite Medical Care in the Workplace Sue Dierksen, MPH,RN, COHN-S/CM, CSP Director of Business Health- Aspirus Clinics Holly Bauer, RN BSN Health Services Supervisor, Sentry Insurance Objectives

More information

Addressing Barriers to Integration: Successful Reimbursement Strategies for Behavioral Health Providers in Primary Care

Addressing Barriers to Integration: Successful Reimbursement Strategies for Behavioral Health Providers in Primary Care Addressing Barriers to Integration: Successful Reimbursement Strategies for Behavioral Health Providers in Primary Care Colleen Clemency Cordes, Ph.D. Assistant Director Clinical Associate Professor Nicholas

More information

Oregon Standards for Certified Community Behavioral Health Clinics (CCBHCs)

Oregon Standards for Certified Community Behavioral Health Clinics (CCBHCs) Oregon Standards for Certified Community Behavioral Health Clinics (CCBHCs) Senate Bill 832 directed the Oregon Health Authority (OHA) to develop standards for achieving integration of behavioral health

More information

Who are Parent Navigators?

Who are Parent Navigators? Parent Navigators: A New Care Team Member in Your Medical Home or Specialty Practice Faculty Disclosure: We have no financial relationships to disclose relating to the subject matter of this presentation.

More information

Wellmark s ACO Model and the Value Index Score. Tom Newton, Vice President Network Engagement

Wellmark s ACO Model and the Value Index Score. Tom Newton, Vice President Network Engagement Wellmark s ACO Model and the Value Index Score Tom Newton, Vice President Network Engagement Wellmark s ACO Shared Savings Model 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield

More information

5 A s Behavior Change Model Adapted for Self-Management Support Improvement

5 A s Behavior Change Model Adapted for Self-Management Support Improvement 5 A s Behavior Change Model Adapted for Self-Management Support Improvement Self-Management Model with 5 A s (Glasgow, et al, 2002; Whitlock, et al, 2002) Assess: Beliefs, Behavior & Knowledge Arrange:

More information

The Five Pillars of Population Health Management. Dr. Christopher Mathews Senior Vice President and Chief Medical Officer ZeOmega

The Five Pillars of Population Health Management. Dr. Christopher Mathews Senior Vice President and Chief Medical Officer ZeOmega The Five Pillars of Population Health Management Dr. Christopher Mathews Senior Vice President and Chief Medical Officer ZeOmega ZeOmega a forerunner in Population Health Management Transformation into

More information

Automating Population Health Management to Deliver Sustainable, High-Quality Care. Michael Matthews, CEO MedVirginia / inhealth

Automating Population Health Management to Deliver Sustainable, High-Quality Care. Michael Matthews, CEO MedVirginia / inhealth Automating Population Health Management to Deliver Sustainable, High-Quality Care Michael Matthews, CEO MedVirginia / inhealth Objectives Describe how to use technology to meet the challenges of population

More information

Community Care of North Carolina. Statewide program for managing Carolina Access recipients

Community Care of North Carolina. Statewide program for managing Carolina Access recipients Community Care of North Carolina Statewide program for managing Carolina Access recipients Key Goals Improve access to, quality of, and coordination of care for Carolina Access Medicaid patients. By doing

More information

Integrating Behavioral Health into Primary Care Innovation Community Webinar #7. June 17, 2015

Integrating Behavioral Health into Primary Care Innovation Community Webinar #7. June 17, 2015 Integrating Behavioral Health into Primary Care Innovation Community Webinar #7 June 17, 2015 Today s Agenda 1. Updates, Reminders 2. Guest Speaker: Andrea Auxier, PhD Director of Integration, National

More information

Integrating Primary Care and Behavioral Health Services: A Compass and A Horizon

Integrating Primary Care and Behavioral Health Services: A Compass and A Horizon Integrating Primary Care and Behavioral Health Services: A Compass and A Horizon A curriculum for community health centers Developed for the Bureau of Primary Health Care Managed Care Technical Assistance

More information

Presented by Kathleen S. Wyka, AAS, CRT, THE AFFORDABLE CA ACT AND ITS IMPACT ON THE RESPIRATORY C PROFESSION

Presented by Kathleen S. Wyka, AAS, CRT, THE AFFORDABLE CA ACT AND ITS IMPACT ON THE RESPIRATORY C PROFESSION Presented by Kathleen S. Wyka, AAS, CRT, THE AFFORDABLE CA ACT AND ITS IMPACT ON THE RESPIRATORY C PROFESSION At the end of this session, you will be able to: Identify ways RT skills can be utilized for

More information

Overview and Legal Context

Overview and Legal Context Impact of ACOs on Physician/Provider Membership Decisions 0 Overview and Legal Context Michael R. Callahan Katten Muchin Rosenman LLP Vice Chair, Medical Staff Credentialing and Peer Review Practice Group

More information

69 th Annual Meeting of the Southern Legislative Conference

69 th Annual Meeting of the Southern Legislative Conference 69 th Annual Meeting of the Southern Legislative Conference Medicaid Behavioral Health Homes Integrating Services- Overview and Implementation Advice Savannah, GA July 19, 2015 Michael S. Varadian, JD,

More information

Analytic-Driven Quality Keys Success in Risk-Based Contracts. Ross Gustafson, Vice President Allina Performance Resources, Health Catalyst

Analytic-Driven Quality Keys Success in Risk-Based Contracts. Ross Gustafson, Vice President Allina Performance Resources, Health Catalyst Analytic-Driven Quality Keys Success in Risk-Based Contracts March 2 nd, 2016 Ross Gustafson, Vice President Allina Performance Resources, Health Catalyst Brian Rice, Vice President Network/ACO Integration,

More information