About CCMCN BACKGROUND AREAS S OF FOCU CUS ▪ Colorado’s Health Center Controlled Network (HCCN) ▪ Data Management ▪ Composed of 20 Colorado Health Centers (BOD) ▪ Health Information Technology Non-Profit Performance Improvement ▪ ▪ ▪ Founded in 1994 Sister company of CCHN (Colorado’s Primary Care ▪ Association)
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 otect and and Empower FQHC’s and and the their Co Communit ity Partners wi with Infor ormatio 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 of 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
Co Comple lete Sc Score Example le Depression Screening
Co Colo lorado Co Communit ity Ca Care Management So Soph phisticated Aut Automation in n Co Community Car Care Ma Management ▪ Data Monitoring and Automation ▪ Patient Summary ▪ Care Plans ▪ Tasking/Alerting ▪ Care Team Communication ▪ Gap Opportunities ▪ Assessments ▪ Productivity Tracking and Reporting Try ry ▪ Community Data Sharing Me! e!
Data Vaults Data Collection and Data Sharing Identify what data each organization needs to share Legal agreements Clinical Claims HIE Social Environmental Any other relevant data
Patient Overlap
Data Analytics
2020 Plan - Improvements UNDERSTANDING THE MATERNAL AND CHILD MEDICAID AND MEDICARE SHARED POPULATION WELLNESS SHARED SAVINGS
What success looks like to us 1. Development of a learning system that demonstrates that community organizations can come together to improve outcomes in public health priorities and payer priorities 2. The system creates an opportunity to strengthen the financial position of each participating organization
Connect Individual organizations with highly effective systems Strengthen Organizations to operate together toward common goals CCMCN Community Integration Overview Measure Public health impact, efficiency and return on investment (ROI) Demonstrate Together we can make a greater impact in outcomes and cost
The Anatomy of Community Coordination 4. Create 2. Establish Strategies to 1. Define the Governance 5. Integrate 3. Set the address goals Community Enterprise Goals Tools 6. Data 10. Share 8. Analysis 7. Establish Collection 9. Connect Data Baselines Care Teams 12. Measure 13. Distribute 14. Sustain 11. Incentive Impact Success Model Stories
Connecting Community Care Teams Understand which Who is on the patients the patient’s care team organizations have in from each common organization What are the care What information can teams discussing with be shared between each patient care teams
Impact Studies Analyze • The Performance Stories • Describe the Successes Calculate • Actuarial Analysis of ROI
Community Facilitation on Improvements Community Data Management Empowering Creating Awareness Colorado Health Community Care Plan Development Centers in 2020 Establishing Care Teams Tasking and Incentives Impact and ROI
Ja Jason Greer www.ccmcn.com Chief Executive Officer 121 1212 Sou South Br Broa oadway Jaso Jason@ccmcn.com Den Denver, , CO 8021 80210 (303 (303) 601 601 - 2266 2266
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