Care Coordination Network Aligning performance for results-based health and social services November 7, 2017
BIRTH OUTCOMES
Columbus Public Health; Office of Epidemiology, Population Health Division, 2017
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POVERTY
Kirwan Institute for the Study of Race and Ethnicity; 2017
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DRIVERS OF POOR HEALTH AND SOCIAL CONDITION Effect – • Poor birth outcomes • Financial instability • Lack of school readiness Cause – • Social environment • Neighborhood • Culture • Social support network • Employment • Race/ethnicity • Education
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PROGRAM RICH AND SYSTEM POOR?
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WHAT’S OUR RESPONSE? Care Coordination Network (CCN) Service: • aligns accountable payments • through a network of high-quality community-based care coordination agencies • to ensure at-risk populations are connected with the supportive services needed to improve their health and social condition.
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WHY • Catalyze more efficient and effective care coordination • Embrace results-based interventions to connect atrisk people with services they need • Align care coordination with payment innovation – rewarding value, not volume • Stabilize at-risk people and improve their likelihood of success
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HOW
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FOCUSED ON RISK REDUCTION Patients/clients affected by multiple risk factors: • Developmental delays • Social/emotional concerns • Unemployment/underemployment • Housing instability • Chronic disease • Food insecurity • Lack of healthcare access • Lack of social support • Involvement with justice system
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CCN MILESTONES
2014 - Listening tour to learn and adapt Pathways model for central Ohio
2015 - Public private advisory council convened to design and launch Pathways HUB - Pathways HUB pilot with Columbus Kids - United Way secures initial funding from OCMH
2016 - Pathways HUB launched - Initial 3 CCAs contracted - Healthier Buckeye grant awarded - Care coordination services to >900 clients
2017 - CCA network expanded to 10 - Achieved national certification - Finalizing contracts with Medicaid MCOs - Collaborative referral partnerships with Mt. Carmel, FC Public Health, CSCC - Care coordination services to > 2,800 clients
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CCN CLIENT ENROLLMENT Care Coordination Network Client Enrollment 2015 - 2017 1986
2000
1838
1800 1600 1400 1200
996
1000 800 600
450
400 200 0
227 37
171 82
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2015 Initial Adult Checklist
2016 Initial Pediatric Checklist
2017 Initial Pregnancy Checklist 11
CCN BIRTH OUTCOMES % of Births Delivered Full Term & Normal Birth Weight 100%
100%
100%
93%
90%
76%
75%
80% 70%
83%
82% 73%
67%
60% 50% 40% 30% 20% 10% 0%
1st FT/NW
2nd FT/NW 2015
2016
3rd FT/NW 2017
Pregnant clients served through OCMH Pathways HUB project; n = 154 12
CCN PARTNER DIALOGUE Panelists •
Jackie Calderone – Director TRANSIT ARTS; Central Community House
•
Matt Kosanovich – AVP, Community Impact; United Way of Central Ohio
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Mary Mutegi – Program Coordinator; Physicians CareConnection
•
Debra Thomas – Clinical Manager, Delegation Oversight; CareSource
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SMALL GROUP DISCUSSION • What are opportunities to make collaborative referral arrangements beneficial for CCN and partners? • What are opportunities to maximize community partnerships that effectively leverage a model like CCN?
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