Care Navigation Council Nenick Vu Cindy Hochart RN, MBA, PMP Care - - PowerPoint PPT Presentation

Care Navigation Council

Nenick Vu

Care Navigation Council Director Capitol Health Network

Cindy Hochart RN, MBA, PMP

Clinical Advisor to Care Navigation Sutherland Health Care Solutions

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Sacramento’s Healthcare Needs

• Large influx of newly insured Medi-Cal population
• Medi-Cal Managed Health Care System
• Four health plans - possibly more to come
• Four hospital systems
• Three IPAs
• Seven FQHCs
• Second most diverse city in America, next to Oakland
• High ER utilization for primary care: Over 50% at Dignity, 15% at Sutter,

25% at UC Davis

• High rates of no-shows to primary and specialty care appointments

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The Healthcare Policy Landscape

Federal Policies

• Affordable Care Act
• Guarantees Medi-Cal to all low income, legally present residents
• Mandates electronic medical records
• Incentivizes patient centered health homes
• Moves payment systems toward pay for performance measures
• Includes Community Health Worker language in the ACA

State Policies

• Movement of Medi-Cal to managed care
• 1115 Waiver - California has applied for federal Medicaid funding to

finance Community Health Workers and Peer Support Specialists

• CA adopts ACA Section 2703 Health Homes for complex care patients

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What does all that mean?

State and federal policies are beginning to incentivize expanding healthcare delivery systems to develop a community health workforce that is integrated with local clinical healthcare delivery systems. Sacramento can take advantage of this opportunity to support its diverse, underserved Medi-Cal community to properly access and utilize healthcare services, in order to improve their health outcomes, resulting in savings to health systems. Sacramento can grow its care coordination capacity and sophistication resulting in readiness for Health Homes and new revenue to the providers (90% match for state expenditures) with aim to reduce delivery system costs.

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The Triple Aim

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The Care Navigation Model

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The Care Navigation Council

First Phase Goals:

• 1. Bring together all healthcare stakeholders in the Sacramento region to discuss

health care prevention, access, utilization, and management issues, with an emphasis on the functions and roles of community health workers, care coordinators, and navigators in bridging gaps and eliminating barriers within the clinical healthcare delivery system

• 2. Develop standard language and definitions of roles of community healthcare

workers, care coordinators, and navigators

• 3. Create training and certification programs to support the development of community

health workers, care coordinators, and navigators

• 4. Support the development of pilot projects that integrate community based services

to clinical services to ensure that patients properly utilize and access care Second Phase: Advocacy to state policy makers, partnerships with healthcare stakeholders, as well as many other possibilities.

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Examples of Issues to Address

• Newly enrolled Medi-Cal beneficiaries who are not utilizing any services
• Engaging demographics that are at risk for certain health conditions and

not utilizing preventative services

• Pre-Diabetics, Diabetics, Hypertensive, Hep B, Cancer, SIDS
• Discharged outpatients who have difficulty finding timely primary care
• High no show rates to specialty care services
• Excessive ER utilization
• Poor health condition management including prescription adherence
• Linguistic issues and barriers
• Lack of culturally competent services

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Meeting the Triple Aim

To meet the Triple Aim, we’ve been able to identify how to improve care for individuals, but we also need to be able to improve the health for whole populations. In order to do so, we need data driven strategies to find patients with similar needs, coordinate across organizations, and deliver services to improve population level health outcomes.

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Planning for the Future

• The industry is moving to holding practices accountable for
• utcomes of assigned populations
• Care Navigation and Care Coordination are pivotal to

Successful Population Health Management

• Health Plans and Practices are going to need these services

to be effective in managing risk of high needs populations

• The focus on reimbursement for these services is on the

provider

• Health Homes (2703) adds reimbursement for care

coordination of high risk patients in MediCal

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Where We Are and Where We Need to Be

Where we are

• Many organizations
• No common definitions of

Community Health Workers

• Overlapping scope
• No common accountability for

service levels

• No common metrics for efficiency or

quality

• No systematic collaboration
• Health Plans and practices build

their own services resulting in system redundancy and higher cost

Where we Need to Be

• Common understanding of definitions
• Clear delineation of scope
• Training/certification available
• Metrics for service levels, efficiency and
• utcomes by service type
• Self governing collaboration
• It becomes easier for Health Plans and

providers to contract work out than to hire FTEs internally

• Define an effective model for the Country
• Improve economic viability of Care

coordination entities

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Needs for Effective Care Navigation and Coordination

• Common understanding of terms and scope
• Metrics for effective service delivery
• Clear delineation of scope, processes and outcome

expectations

• Resources for training
• Understanding of available community resources to address

Social Determinants of health

• Community based record of care coordination that:
• provides for a virtual care team
• Notifies care team of patient events
• Shares common understanding of goals w/ team

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Need for a Technology Platform

• Patient centered portal for care coordination including community

health workers - rather than one portal for each payer/ IPA/etc.

• Accessible by any community based member of a care team with

appropriate PHI security

• Simple/easy to use
• Non-duplicative of EMR/EHR
• Timely notifications for patient events (admits/ER)
• Shared information on open gaps in care
• Secure communication between providers who are not aligned in a

single organization

• Clear delineation of care coordination roles

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Building an IT Solution

• Supports all Payers, IPAs and Providers
• Developing feeds from HIE - seeking hospital support for improved transitions
• f care after hospital discharges and ER events
• Pilot location live in July with first FQHC and first Payer
• Potential for single community based solution for care coordination
• Contains workflows that are easy to use in a busy clinical practice - presents a

task list rather than having to search for a patient

• Role based security protects PHI
• Care Navigation/Care Coordination resources in community can use it as part
• f a designated patient care team at no cost
• Available to hospital systems and payers
• Configurable for goals of sponsor org. - extending closure of gaps into the

physician office practice and community care team

• This positions Sacramento for implementation of 2703 health homes since a

community based record of care coordination accessible by the whole care team is essential

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Contact Information

Nenick Vu nenickvu@gmail.com 916-897-7078 cell/text Cindy Hochart cindy.hochart@sutherlandglobal.com 816-588-9735 cell/text

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