HCIA Complex Care Care Coordination Update

Transcription

1 HCIA Complex Care Care Coordination Update July 26 th, 2013

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3 Patients to be Care Coordinated ~500 have a tube in place and meet all criteria for care coordination ~165 (33%) are seen by a service line that tries to provide global care coordination ~30 (6%) are seen by clinics with BCMH service coordination ~40+ (8%) are on the Top 1% list and require care coordination as prescribed by the managed care plans & the state ~265 children remaining 3

4 Its contents Challenges are solely the responsibility of the authors and with do not necessarily Patient represent Acquisition Some service lines already provide care coordination services Are we supplementing these services? How are we accounting for them in our metrics? Families who need it the most are not always interested in care coordination Convenience sample vs. outreach based on need Appropriate case load? 4

5 Care Coordination Process HCIA Care Coordination PFK Care Coordination Global Care Coordination 5

6 Care Coordination Workflow Patients identified as tube fed with a neuro dx and Medicaid Potential sources of patient acquisition Schedule OP Clinic Visit Current Inpatient Census Physician referral ED Discharges Inpatient Discharges New tube insertions High Utilizers (ED/IP Days/Specialty Clinics) 6

7 Complexity Scale Wisconsin Complexity Score CM Triggers Score Medical Specialists Medical Fragility None OP Clinic Visits None 1-8 per year 9-16 per year per year per year 41+ per year ED/UC Utilizations None 1-4 per year 5-8 per year 9-12 per year per year 17+ per year Hospitalizations None 1-4 per year 5-8 per year 9-12 per year per year 17+ per year Outpatient Procedures/Day Surgeries Hospital Days Technology Needs Medications None 1-4 per year 5-8 per year 9-12 per year per year 17+ per year None Mobility Assistance & Orthotics <10 Enteral Medications 1-16 days per year Pulmonary, Cardiorespiratory monitoring, Home Oxygen, Subcutaneous Infusion Devices >10 Enteral Medications days per year Ostomy, Feeding Tubes, Implanted Devices, TPN, Non-invasive Ventilation Enteral Vasoactive Medications days per year Central Vascular Lines, Trach IV Medications 85+ per year Trach with Invasive Ventilation, Peritoneal Dialysis IV Vasoactive Medications 7

8 Complexity Scale Care Coordination Complexity PCP Involvement PCP assists with care coordination PCP provides primary care only No PCP OR change in PCP Health Care Adherence or Seeking Behaviors None Adherence Issues: 1-8 per year Adherence Issues: 9-24 per year Adherence Issues: >24 per year Home Health Care None Needed Have it and it works Have it but problems with service OR need it Transition Child/Family is Experiencing None Transitions (family, school related, specialties) Needs Transportation Help to Access Services None Needs assistance with transportation Chronic transportation issues/transportati on is a barrier Distance from NCH (based on county of residence) Franklin, Delaware, Licking, Fairfield, Pickaway, Madison, Union All other counties Language English Other Non- English TOTAL SCORE DATE COMPLETED 8

9 Care Coordination Workflow Patients identified as tube fed with a neuro dx and Medicaid Potential sources of patient acquisition Schedule OP Clinic Visit Current Inpatient Census Physician referral ED Discharges Inpatient Discharges New tube insertions High Utilizers (ED/IP Days/Specialty Clinics) 9

10 Health Risk Assessment Review medical record Problem List Past Medical Hx, Past Surgical Hx Medication Reconciliation (when necessary) ADL s Cognitive Functioning Life Planning Cultural/Religious Preferences Parental Concerns PCP Medical Supply Companies Therapies School Medical Devices GI Behavioral Health Resources Barriers Family Support Communication Preferences 10

11 Care Coordination Workflow Patients identified as tube fed with a neuro dx and Medicaid Potential sources of patient acquisition Schedule OP Clinic Visit Current Inpatient Census Physician referral ED Discharges Inpatient Discharges New tube insertions High Utilizers (ED/IP Days/Specialty Clinics) 11

12 Care Plan Care Team Upcoming Appointments Goals Self Management Plan 12

13 Metrics Program Aim for June 30, 2015 Baseline Results as of June 30 th, 2013 Goal Proactive Care Coordination will be provided for 85% of children 22% 0% 85% with a feeding tube and neurodevelopment disorder(s). (100/461 kids*) Cumulative Total of Patients Engaged in Care Coordination Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Kids Flagged for Care Navigation Cumulative Total of Patients Engaged in Care Coordination *Complex Care Patients defined as 0-18 years, with tube-fed related visit in last 12 months and a neurodevelopmental disorder (excludes all NICU); Numerator: # New Care Assessments; Denominator: # Kids Flagged for Care Navigation in Complex Care Patient Registry which has been vetted by chart review and also includes a small number (8 for June 2013) of new patients not yet reviewed 13

14 Monthly Total Care Coordination the official views of HHS Patient or any of its Touches agencies. and Assessments Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Telephone Face-to-Face New Assessments Reassessments 14

15 Care Coordination Metrics New measures currently under development Cohort Analysis for children with an HCIA Care Coordinator Reduction in ED visits Reduction in unplanned admissions Increase in PCP visits Reduction in no show rates Reduction in 90 day readmission rates Increased satisfaction/efficacy scores 15

16 Care Coordination Metrics New Care Coordination Process Measures % of care coordinated children with an IP discharge in July whose care plans were modified within 14 days of discharge. (Goal = 85%) % of care coordinated children with an ED discharge in July whose care plans were modified within 14 days of discharge. (Goal = 85%) % of care coordinated children who have not been assessed in the past 6 months (Goal = 0%) 16