Key Recommendations: Care Management in • Increased process standardization, including Vermont: increased use of common care management tools Gaps and Duplication • Creation of an organizational mechanism to coordinate the “family of care coordinators” Prepared for the Vermont Care Models & • Increased development and use of IT resources to Care Management Work coordinate care management activities Group • Increased use of a shared data set to coordinate By: care and measure effectiveness Bailit Health Purchasing, • Increased opportunities for care managers to build LLC their skills through initiatives of share best practices and learn new skills September 14, 2015
Complex Care Program can Aid in Achieving Quadruple Aim & APM Goals • Better Health for Patients • Improved access to primary care (and other needed services) • Reduced prevalence and morbidity of chronic disease • Reduce deaths due to suicide and drug overdose • Better Patient Satisfaction • Improved understanding and coordination of services and supports • Better Cost Control • Savings to reinvest in population health programs • Better Workforce Satisfaction • Retain employees; recruit new employees • Improve joy in work onecarevt.org 2
Population Health Approach: A plan for every person ➢ 44% of the population ➢ 40% of the population ➢ Focus: Maintain health through preventive care and ➢ Focus: Optimize health and self-management of community-based wellness activities chronic disease ➢ Key Activities: ➢ Key Activities: Category 1 plus • Preventive care (e.g. wellness exams, immunizations, • outreach for annual Comprehensive Health health screenings) Assessment (i.e. physical, mental, social needs) • Wellness campaigns (e.g. health education • Disease & self-management support* (i.e. and resources, wellness classes, parenting Category 1: Category 2: education, referrals, reminders) education) • Pregnancy education Healthy/Well Early Onset/ • RiseVT (includes Stable Chronic unpredictable Illness unavoidable events) L OW RISK M ED RISK V ERY HIGH RISK H IGH RISK ➢ 6% of the population ➢ 10% of the population Category 4: Category 3: ➢ Focus: Address complex medical & social Complex/High Full Onset Chronic ➢ Focus: Active skill-building for chronic challenges by clarifying goals of care, Cost Illness & Rising condition management; address co- developing action plans, & prioritizing tasks Acute Risk occurring social needs Catastrophic ➢ Key Activities: Category 3 plus ➢ Key Activities: Category 2 plus • Designate lead care coordinator (licensed)* • Outreach & engagement in care coordination • Outreach & engagement in care coordination (at Create & maintain shared care plan* least monthly)* • Coordinate among care team members* • Coordinate among care team members* • Emphasize safe & timely transitions of care • Assess palliative & hospice care needs* • Facilitate regular care conferences * * Activities coordinated via Care Navigator software platform onecarevt.org 3
Central Components of the Care Coordination Model 1 Person-centered Shared Care Plan Vision 3 2 To provide high-quality, person- centered, community-based care Multi- Risk coordination services in an integrated disciplinary Care Stratification delivery system to achieve optimal Teams health outcomes 4 5 Inclusive Tools & Training Payment Model 4 onecarevt.org
Agency of Human Services Economic Services In-Patient Criminal Justice Medical Specialists Programs Community Health Team Long-Term Support Emergency Departments Services Nurses, Social Workers, Counselors, Health Coaches, Dieticians, Community Health Workers Mental Health Agencies Housing Providers & Independent PCMH Providers Alcohol &Substance Home Health Abuse Programs Whole population, all payer supported Disease Schools Management Area Agencies on Aging Family Services Programs Legal Aid 8/8/2019 5
Agency of Human Services ST. JOHNSBURY Patients/Clients In Common 8/8/2019 6
Agency of Human Services ST. JOHNSBURY Medical Services Full Network Services, Schools Mental Health, Substance Abuse, Child & Family Services, Schools Elder Care Services 8/8/2019 7
Agency of Human Services Child & Family Services BENNINGTON Full Network Elder Care Services 8/8/2019 8
Looking to 2020 and Beyond… initial ideas • Mature & Expand Adoption of the Care Model Evolve OneCare’s Complex Care Payment Model (capacity building → paying for value) • Explore expansion to additional payers and increase # Vermonters under an aligned care model (scale) • Tests: home health longitudinal care project, Chronic Kidney Disease care coordination intervention, etc … • Advance the approach to population segmentation for the pediatric population • • Ensure Sustainability of Community-based Model by Demonstrating: Positive outcomes for patients • Financial Return On Investment (ROI) • • Explore Community Health Workers and other approaches to extended care teams • Continue to evolve IT resources to support effective coordination of care and reduce administrative burdens E.g. Care Navigator, Patient Ping, technology-enabled devices, telemedicine • • Coordinate data sharing across AHS and ACO (e.g. integrate social determinant of health data) OneCareVT.org 9
Looking to 2020 and Beyond… What ideas do you have? OneCareVT.org 10
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