November 2016 ACCLG Record of Learning

Accountable Care Coordination Learning Group Work Session November 2, 2016 Record of Learning Meeting Participants • Stephanie Baker, Clintonville-Beechwold Resource Cente • Heather Carroll, PrimaryOne Health • Nita Carter, UHCAN Ohio • Dave Ciccone, United Way of Central Ohio • Shawn Clark, Sunrise Senior Living • Takeysha Cheney, Molina Healthcare • Maurice Elder, LifeCare Alliance • Carmela Hartline, OhioHealth Physician Group • Amy Headings, Mid-Ohio Foodbank • Leigh Anne Heher, American Cancer Society

Coordinated By:

• Alyssa Nance, Lower Lights Christian Healthcare Center • Meghan O’Brian, Franklin County Public Health • Caroline Rankin, YMCA of Central Ohio • David Reierson, Care Coordination Network • Joey Schulte, HandsOn Central Ohio • Staci Swenson, PrimaryOne Health HCGC Participants • John Leite • Michelle Missler • Krista Stock

Welcome & Framing To view slides used during the session, please click here.

Work Session #1 Case Study - Explore opportunities and challenges in care coordination.

Group Discussion

What are the ways care coordinators would experience challenges in this case study example?

• Burnout of staff • Costs money to change processes. Need to standardize how coordination is done among all care • •

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coordinators in the organization

Depending on patient to share medical history information versus shared information from providers Each organization’s coordinator may have a different goal based on organization’s focus.

How do you prioritize multiple health issues?

If care coordination is not available it is difficult to follow up at home Lack of communication among providers

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Lack of information sharing/IT connection Lack of resources available Lack of support

Like how the visual shows issues growing. Would be nice to include the rising cost with each level.

Literacy-about her condition and how to take care of herself Need enhanced follow up with patient from care coordinator, possibly a community health worker No incentive to follow up with patient, inquire about support system No loop back to PCP No referrals for social supports Patient understanding the care coordination as the point of contact.

Patients also impacted by “benefit cliff” due to age, income, and other factors.

Patients need to be risk adjusted to balance workload for care coordinators Payment structure – is there enough money to support sufficient amount of care coordination and earlier in the process. It is expensive to implement standardized process and workflow The silo approach leads to redundancy and duplication

Training/orientation Who will take the lead

How does the current system contribute to these challenges?

• Accepting referral without any patient history or communication with the PCP • Case management vs. care coordination • Coordination of ER care is difficult • Higher intensive intervention • Increased advocacy for care coordination • Increased education needed • Information flow-PCP needs information after ER visit • Lack of care coordination staff in each setting • Lack of communication/follow-up • Lack of record sharing • Multiple providers/different systems/closed loop • Need for provider to increase patient caseload in order to earn more money (Volume vs. Value) • No incentive to bring in care coordination-system breakdown • No linkage to care coordinator • Redundant/fragmented care coordination Work Session #2 From your unique perspective what next steps are necessary?

Group Discussion If success was guaranteed what bold next steps would we take to continue to improve care coordination in our region?

• 3rd party care coordination connected to all systems like HUB • Attribution of financial resources to highest value services • Care coordination cannot be only provided by a medical professional, but a combo of social services and medical • Emphasize the importance of primary care provider-incentivize those pursuing medicine to work in general or family care • If fragmentation issues are addressed it could mean revenue being shifted away from an organization(s).

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Implementing technology that could connect patients to providers in real time.

Increase numbers of community health workers who can spend time with patients Measure the value of addressing health-related social needs to determine ROI of care coordination.

One care coordinator contact per patient across episodes who connects back to the PCP. Make this determination and move forward Payment for community health worker services Payment for coordination of care, based on quality of care Robust, open systems so care coordinators can exchange referrals and coordinate care Screening each person on what is needed to create a more comprehensive, individualized plan and distribute appropriate care coordination resources – not one size fits all Utilizing care coordinators that come from the populations they serve

• Closing Results of the value survey administered at the conclusion of the session are listed below.

Meeting Scheduled All sessions hosted at the Nationwide & Ohio Farm Bureau 4H Center from 8:30 – 10:00am 2017 Meeting Dates: February 1, May 3, August 2, November 1 http://www.hcgc.org/acclg/

Learning Session Value Survey Very High High Medium Low No

xxx(3) xxxxxxxx (8) xx (2)

What are the key reflections you are taking away from today’s session?

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Good conversations how to improve care coordination.

Good discussion. Good use of case study example.

Good discussion. It was nice to get back to basics.

Great conversation around care coordination! There are a lot of issues but solutions start with conversations and idea sharing.

How do we connect all EMR systems?

How do we measure qualitative and quantitative outcomes?

I enjoyed reviewing and dissecting the case study. It was valuable to know what different organizations involved in care coordination are doing and how they would handle a patient like “Mrs. G.” I felt today’s session was the most informative so far. I feel like we are moving forward to a better world.

Most helpful to hear what others are doing, the problems they are solving. Meeting others with similar values for patient care.

Nice conversation-need more networking by participants Social services connecting with medical services.

The case study was a good learning tool and very helpful in framing the discussion.

Today’s conversation was very productive. It would be helpful to hear how partners in our region are figuring out collaborative ways to overcome the challenges we discussed today.