CCSP CCSPathw thways ys HUB HUB CHW CHW Leading the Way in - - PowerPoint PPT Presentation

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CHW CHW

HUB HUB Leading the Way in Delivering Better Community Health

CCSP CCSPathw thways ys

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Reducing Risk f ducing Risk for Communities r Communities

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CCSP CCSPathw thways ys

Pathways

– Evidence‐based model for risk reduction integrated with community‐ based care coordination.

Pathways HUB

– Community‐based, neutral entity that convenes and facilitates community care coordination.

Pathways HUB Connect and Mobile

– Tools to enable care coordination, connectivity and reporting.

Professional Development

– Activation of care coordinators and HUB staff.

Pathways RiskQ

– Evaluates population risks. Actionable results for care teams.

Certified Pathways HUBs

– Optimization, Comparability, Best Practices, Quality Assurance

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CHW CHW

Leading the Way in Delivering Better Community Heath

Care Coordination Systems

Certified Pathways HUB Pathways RiskQ Pathways HUB Connect & Pathways Community CHW & Pathways Training Pathways

CCS pr CCS provides the P ides the Path athways ys Community HUB Community HUB solution - solution - includin ncluding the necessar the necessary com y comprehensiv rehensive e ser services and syst ices and systems - ems - that can lead hat can lead to HUB cer HUB certification. ification. – Pathways – Training – Pathways mobile and HIPAA software – Integrated patient portal – Customizable systems – HUB operations advisory – Risk Scoring and stratification

Dramatic Pathways Results

6.1

13.0 2 4 6 8 10 12 14 16 18 % of Low Birth Weight Births

Pathways Intervention

Achieved through focus

• n social risk

factors and

• rganized care

coordination in Pathways Community HUB

Control Group

Maternal and Child Health Journal

Maternal and Child Health Journal ISSN 1092-7875 Matern Child Health J DOI 10.1007/s10995-014-1554-4

Leading the Way in Delivering Better Community Heath

13.4 13.2 9.5 9.5 2 4 6 8 10 12 14 16 Ohio 2013 Lucas County 2013 Pathways 2013 Pathways 2014

Lucas County African American Low Birth Weight Rates

79% 74% 80%

10 20 30 40 50 60 70 80

2012 2013 2014

Percentage of NW Ohio Pathways Clients Attending Post-Partum Appointment 2012-2014

In 2013, 63% of women on Medicaid attended post-partum appointment within 90 days

Medicaid Costs: PER MEMBER PER MONTH

B4-B1: 6 month periods before the beginning of MPBH (Jan 2011 – Dec 2012) T1-T3: 6 month periods since MPBH services began (Jan 2013 – June 2014) : indicates cohort enrollment into MPBH

$0 $0 $400 $400 $800 $800 $1,200 $1,200 $1,600 $1,600 B4 B4 B3 B3 B2 B2 B1 B1 T1 T1 T2 T2 T3 T3 Cohort 1 Cohort 2 Ref: Super- utilizers Ref: Multiple chronic disease

Distinctions between Pathways & HUB

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Pat Pathways

 Care coor Care coordination f dination facilitation t cilitation tool

• ol

 Pa Patient-cent t-centered ered  Identify patient risks Identify patient risks  Social and traditional health Social and traditional health issues issues identified identified  Actionable & tionable & accountable accountable  Measured outcomes Measured outcomes  Trained & q ained & quality assurance t ality assurance to achie achieve results e results  Pa Payments f yments for measured Pathw r measured Pathway y

• utcom
• utcomes

Community HUB Community HUB

 Tr Tracks P Pathways ( (outcomes) acr across agencies ss agencies  Eliminat Eliminate duplication e duplication  Streamline ref Streamline referrals rrals  Pr Provide infrastructure f ide infrastructure for r community community-base based care d care coor coordination dination  In Involv lve braided funding – e braided funding – Pathw thways can be pur ys can be purchase hased b d by different f erent funder ers  In Invoicing syst icing system em

HUB

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HHS Housing AAA Medicare/ Medicaid Managed Care State Agencies County Departments Private Health Plans Foundations Clinics FQHCs Hospitals Physicians

One Care Coordinator for the Entire Family

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CCSP CCSPathw thways Syst ys System em

Care Coordination Systems (CCS) system and security highlights:

Virtual Private Cloud-based  US based-solely.  SOC1 and SOC2 environment.  NIST cybersecurity standards.  Encrypted - volumes (at rest) and in-transit.  Redundant encrypted backups geographically. Security compliance  Third party independent annual audit  Report available as requested

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CCSP CCSPathw thways T ys Technology chnology

– Systems

– Pathways HUB Connecttm – Pathways Mobiletm

– Services

– Pathways RiskQtm – Pathways Insighttm business intelligence – Pathways Communitytm HUB integrated education portal – EMR, HIE, 211 and other connectivity to systems/organizations – Invoicing for outcomes – Direct Messaging & Secure Fax / Care Team status updates – Licensed Screening Tools – PCMH TCM/CCM Tools and Reports (new) – Healthy Start Tools and Reports (new) – Health Homes (in discovery)

Pathw thways Mobile ys Mobile

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Real time Social Determinants

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Seeing Clearly Seeing Clearly

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Re Reporting

Reports:

• Operational
• Managerial
• Analytical
• Specialized / User customized

Maps:

• Maps through api
• Geo-coding of any Pathways or data attribute

Dashboards:

• Decision and analytical
• Tableau dashboards

Measure

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Step 3: T ep 3: Track and Measure Pr ack and Measure Progress with P

• gress with Pathw

athways ys

Exam Example T ple Tracking Filt acking Filters ers

• Pr

Program

• gram
• Pa

Patient

• Health

Healthcare Pr care Provide ider

• Comm

Community unity

• Re

Region

• HUB

HUB

• Ag

Agency

• Medical R

Medical Referrals rrals

• Social Ser

Social Service R ice Referrals rrals

Health Behavioral Health Social Patient Activation Family & Personal Health Management Financial

Pathw thways Risk s RiskQtm

tm

Pathw thways Risk s RiskQtm

tm Reduces Community Risk

duces Community Risk

Identify and prioritize highest at-risk. Converges real-time Social Determinants of Health information with clinical, financial and geographic information for risk stratification. Risk-adjusted caseloads and metrics for operating performance. Risk-adjusted performance payments for Pathways outcomes achieved. Risk RiskQ charting visually demonstrates risk reduction/levels over time. Risk RiskQ mapping provides geographic visuals of information and scoring.

Pathw athways ys Risk RiskQtm

Find and Treat the highest at-risk

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Pathw thways Risk s RiskQtm

tm

En Envir vironm nmen ental risk b risk by census census trac tract RiskQ status RiskQ status updat updated daily d daily

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Connectivity and Communication Connectivity and Communication

Care Team Dashboard Direct Messaging Virtual Private Network (VPN) Health Information Exchange API library

• Bi-directional
• Documented

Pathways HUB Community Agency Community Care Coordinator Patient Care Team Provider Clinic Hospital

Completing the Care Team Loop

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Connectivity Me Connectivity Methods thods

CCS shares information with others via –

 CSV files extracted from reports and transmitted to secure FTP locations  Direct messaging – CCS as its owns HISP (post office) transmits “single” client information to EMR systems, providers, pharmacies, and anyone with a valid HISP/Direct message account. CCS may create a Direct message account(s) as required for external organizations  Secure Fax – point to point encrypted fax of client documents  Application Program Interface (API) – library of 70+ APIs for connection to organizations and other systems,

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Connectivity Me Connectivity Methods thods

Care Coordination Systems (CCS) shares information with others via –

 Application Program Interface (API) – – For connectivity with systems and organizations – Library of proprietary 70+ fully documented APIs – APIs are customizable and support bi-directional transfer of information – Currently used to – Health Information Exchange (HIE) via VPN – 211 Referral system – Major national hospital system – Pathways Community – HUB integrated patient/client facing health decision portal – Communications with external vendors – Patient Activation Measure – ASQ Developmental Screening

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Standard Billing Codes

Normal Risk High Risk Modifier Checklists Initial Pregnancy Checklist Completed one time at Member enrollment, 1st trimester engagement G9001 G9003 R1 Completed one time at Member enrollment, 2nd trimester engagement G9001 G9003 R2 Completed one time at Member enrollment, 3rd trimester engagement G9001 G9003 R3 Pregnancy Checklist Completed at each face-to-face encounter with Member G9005 G9010 R Pathways Behavioral Health Kept three scheduled behavioral health appointments G9002 G9009 RB Education Educational module delivered. G9002 G9009 RE Family Planning LARC (long-acting, reversible) or permanent method G9002 G9009 G1 Family Planning All other family planning methods G9002 G9009 G2 Housing Residing in affordable & suitable housing for 2 months. G9002 G9009 RI

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PREGNANT CLIENT

Leading the Way in Delivering Better Community Health

708-906-3057 75 East Market Street Akron, Ohio 44308 Bob.Harnach@ccspathways.com Carecoordinationsystems.com

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