Community Care of North Carolina: HLC Wellness Frontier Award Winner - - PowerPoint PPT Presentation

Community Care of North Carolina:

HLC Wellness Frontier Award Winner 2013 HLC Wellness Frontier Award Winner 2013

Combatting Obesity Through Community Networks Tom Wroth, MD, MPH

National Model for What Works National Model for What Works

• Community-based, physician-led
• Health informatics target at-risk

beneficiaries and high impact care medical homes coordinate care across health systems

• Managed through 14 local, non-

profit networks ~1 800 practices beneficiaries and high-impact care settings

• Use of data to drive performance

and standardization across profit networks, ~1,800 practices & 6,000+ providers

• Population Health Approach:

Case management and medical networks

• Medicaid savings achieved in

partnership with doctors, hospitals Case management and medical home capacity building

• Goal: Ensure patients receive
• ptimal care, avoid

and other providers

• Able to demonstrate improved

quality and health outcomes and t t i t l b d unnecessary utilization and reduce costs cost containment = value based model

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CCNC Regional Networks

CCNC Medical Home

Population t mgmt: Stratify population, choose targets Data to inform g P i C decisions & focus efforts Primary Care Foundation Multi-disciplinary team: RX, Behavioral, Care Manager

CCNC Practice Network: 90% of Primary Care Providers in NC

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Large Health System Owned Practices Other Hospital Owned Practices

CCNC HEDIS Performance Compared to Medicaid Managed Compared to Medicaid Managed Care Benchmarks

>10,000 more North Carolinians with good diabetes control

CCNC National HEDIS Mean for Medicaid Managed Care

>11,000 more North Carolinians with

Higher is better!

Ca o a s t good blood pressure control

Peer-reviewed research

Cuts Program Costs

• Significant savings for 169,667 non-elderly,

Cuts Program Costs

disabled Medicaid recipients

• $184 million savings

$ g in about 5 years

• Higher per-person

g p p savings for patients with multiple chronic conditions.

Medicaid Population Obesity and Diabetes by County: A1C 9 d BMI 30 A1C >9 and BMI >30

CCNC Population M t A h Management Approach

Practices/Communities People

• Identify practices and

communities with high prevalence of p

• Use data to identify

individuals who are ‘impactable’ high prevalence of

• besity
• Coach practices on

impactable

• Develop care plan and

set patient centered incorporating evidence based care into their workflow goals

• Refer patients with
• besity to
• Measure results and

provide feedback

• besity to
• Dietician on care

management team

• Community resource or

health coach

Improving Quality: Identifying Practices with Opportunities to Improve Improve

Claims-derived measures; annual chart reviews chart reviews

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• Engage practice in

g g p evidence based approach

• Use of motivational

interviewing techniques techniques

• ‘Workflow Friendly’

CCNC Pediatric Quality C ll b ti (26 P ti ) Collaborative (26 Practices)

Lessons Learned from N h C li North Carolina

• It takes a village

It takes a village

• Patient engagement is the new

bl kb t d blockbuster drug

• Cross silo work is essential
• You get what you pay for

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