About CCMCN BACKGROUND AREAS S OF FOCU CUS Colorados Health - - PowerPoint PPT Presentation

BACKGROUND

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Colorado’s Health Center Controlled Network (HCCN)

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Composed of 20 Colorado Health Centers (BOD)

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Non-Profit

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Founded in 1994

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Sister company of CCHN (Colorado’s Primary Care Association)

AREAS S OF FOCU CUS

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Data Management

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Health Information Technology

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Performance Improvement

About CCMCN

CCMCN’s Mission

To provide services that enable its members and their community partners to succeed as efficient, effective and accountable systems of care.

CCMCN Strategic Plan Goals

Requirements of the Colorado Data Strategy

• 1. Empower us with data.
• 2. Figure it out from there.

As Colorado’s HCCN…

Prot

• tect and

and Empower FQHC’s and and the their Co Communit ity Partners wi with Infor

• rmatio

ion Systems

Population Health Tool Common Features

Azara Healthcare Application

SDOH Dashboards

Success Stories using Azara only

• HCCN value and appreciation from health center

members

• HCCN, PCA and FQHC credibility and empowerment for

having a centralized data strategy

• More advanced functionality than HIEs, Medicaid and

Public Health

• Centralized UDS and other quality measure reporting

(Medicaid, Medicare, SIM, other)

• Common tools for collaboration and best practices
• Centralized tools for PCA QI support
• Participation in public health programs and research
• Data sharing with public health
• Insider conversations about funding

What else have we done on top

• f using Azara?
• Central data network
• New data sources
• Complete scores
• Social analysis
• Medicaid attribution reports
• Research databases
• Analysis as a service
• Care management tool
• Community partner integration with Data Vaults
• Patient overlap reports

Performance Reportin ing for Valu lue Based Paym yments

Depression Screening

Co Comple lete Sc Score Example le

Co Colo lorado Co Communit ity Ca Care Management

So Soph phisticated Aut Automation in n Co Community Car Care Ma Management

Try ry Me! e!

▪ Data Monitoring and Automation ▪ Patient Summary ▪ Care Plans ▪ Tasking/Alerting ▪ Care Team Communication ▪ Gap Opportunities ▪ Assessments ▪ Productivity Tracking and Reporting ▪ Community Data Sharing

Data Vaults Data Collection and Data Sharing

 Identify what data each

• rganization needs to

share

 Legal agreements  Clinical  Claims  HIE  Social  Environmental  Any other relevant data

Patient Overlap

Data Analytics

2020 Plan - Improvements

UNDERSTANDING THE SHARED POPULATION MATERNAL AND CHILD WELLNESS MEDICAID AND MEDICARE SHARED SAVINGS

What success looks like to us

• 1. Development of a learning system that demonstrates that

community organizations can come together to improve

• utcomes in public health priorities and payer priorities
• 2. The system creates an opportunity to strengthen the financial

position of each participating organization

CCMCN Community Integration Overview

Individual organizations with highly effective systems

Connect

Organizations to operate together toward common goals

Strengthen

Public health impact, efficiency and return on investment (ROI)

Measure

Together we can make a greater impact in outcomes and cost

Demonstrate

• 1. Define the

Community

• 2. Establish

Governance

• 3. Set the

Goals

• 4. Create

Strategies to address goals

• 5. Integrate

Enterprise Tools

• 6. Data

Collection

• 7. Establish

Baselines

• 8. Analysis
• 9. Connect

Care Teams

• 10. Share

Data

• 11. Incentive

Model

• 12. Measure

Impact

• 13. Distribute

Success Stories

• 14. Sustain

The Anatomy of Community Coordination

Connecting Community Care Teams

Understand which patients the

• rganizations have in

common Who is on the patient’s care team from each

• rganization

What are the care teams discussing with each patient What information can be shared between care teams

Impact Studies

• The Performance

Analyze

• Describe the Successes

Stories

• Actuarial Analysis of ROI

Calculate

Empowering Colorado Health Centers in 2020

Community Facilitation on Improvements Community Data Management Creating Awareness Community Care Plan Development Establishing Care Teams Tasking and Incentives Impact and ROI

Ja Jason Greer

Chief Executive Officer Jaso Jason@ccmcn.com (303 (303) 601 601 - 2266 2266 www.ccmcn.com 121 1212 Sou South Br Broa

• adway

Den Denver, , CO 8021 80210