Care Coordination Forum November 7th, 2017 Record of Learning
Over 200 Care Coordination Forum participants joined HCGC and the Care Coordination Learning Group for a collaborative conversation on improving care coordination efforts in our region. Participants were welcomed by HCGC President & CEO, Carrie Baker, and then heard an overview of the evolution of the Care Coordination Forum from HCGC’s Michelle Missler. The slides for this introduction can be found here. Opening Work Session Following the welcome and introduction participants worked through the following questions at their tables:
Consider our community in 5 years: What does care coordination look like in an ideal world? Coordination • Identified QB • Patients receive right care, affordable • Information is accessible to all partners • Patients receive right care, affordable • Collaboration between healthcare, behavioral health, social services • Access to transportation • Common assessment for patients, stop duplication of capturing patient information • Coordinated Post-Acute Care • Collaboration between primary care and aging services and supports • Each partner would have one point of contact • Seamless care transitions – for all populations • Less fragmentation between primary care and specialists • More coordination to address social needs • No silos Prevention • Health focused, not sick focused care Engagement • Engaged and educated patients who are involved in their healthcare Diversity/Inclusion • Improved cultural competency • Increased health literacy • Multi-generational approach to healthcare Maximizing Scope • CHW follows a person through the continuum of care • Individuals working to top of license Technology • One stop shop – Data base/registry • CliniSync as a tool – technology – one record • App for health records • Medical record – sharing information across different providers serving clients Integration
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Integrated, seamless Opioid Epidemic is resolved Pharmacy incorporation Robust teams working together
What would the impact be if we didn’t start/have this conversation? • • • • • • • •
Increased cost/wasted resources Fragmented care Duplication or inappropriate use Status quo Poor patient engagement Poor population health Increased frustration Lack of prevention
What are one or two priorities that our region could focus on following this Forum to move us toward the ideal future? • • • • •
Increased training and education Increase technology for referral/shared information Collaboration to improve social determinants, i.e. standardized screening tool Utilizing shared data to improve quality Integrating behavioral healthcare
Keynote Address A keynote address was provided by Vondie Woodbury, a nationally-renowned, senior-level strategic consultant with over 30 years of experience in community organizing, public policy and health improvement strategies. Woodbury provided an overview of the role of care coordination in the current healthcare landscape, helped participants understand the role of health system community benefit dollars in improving care coordination efforts, and acknowledged the imperativeness of a healthcare system that constantly works to address social determinants of health through collective impact. Ms. Woodbury’s slides can be found here. Morning Breakouts Following the Keynote participants had a choice to attend one of the following interactive morning breakout sessions. • • • •
Integration of Behavioral Health into Primary Care Practices – Linda Jakes, LISW-S, Associate Director, Concord Counseling Utilizing the HIE to Improve Care Coordination Outcomes – Dan Paoletti, CEO, The Ohio Health Information Partnership The Role of Data in Care Coordination and Quality Improvement - Mary Sheehan, MPH, Research Scientist, Battelle & Jeff Klingler, CEO, Central Ohio Hospital Council Care Coordination through Managed Care - Sara George, RN, BSN, MS, CCM, Health Services Manager, UnitedHealth Care Community Plan of Ohio
Lunch & Learn During the lunch break participants heard a presentation from Jeffrey Geppert and Nicole Brennan from Batelle discussing the role of quality measurement in quality improvement. Slides from the lunch and learn can be found here. Afternoon Breakouts There were a total of eight afternoon sessions that participants could choose from the following topics and speakers: •
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Social Determinants: Aligning to the SHIP with Community Health Workers – Erika Clark Jones, Executive Director, Celebrate One, DeLena Scales, Program Manager, Linden Neighborhood Intervention, St. Stephen’s House & Kiley Orchard, Connector Corps Manager, Celebrate One Utilizing Care Coordination to Address Medication Management – Stuart Beatty, Pharm.D., BCACP, CDE, FAPhA, Vice Chair for Clinical Affairs for The Ohio State University College of Pharmacy & Neeraj Tayal, MD, Director, Division of General Internal Medicine and Geriatrics, The Ohio State University Wexner Medical Center Addressing Health Literacy in Care Coordination – Emily Fisher, Program Manager, Access to Care, Columbus Public Health Care Transitions – Stephanie Lawrence, MD, The Ohio State University Wexner Medical Center Care Coordination Network’s Impact – Dave Ciccone, AVP, United Way of Central Ohio Reducing Hospital Readmissions via Care Coordination – Lt. J.D. Postage, EMT-P, EMSI, CHWC, Firefighter/Paramedic, Violet Township Fire Department Comprehensive Primary Care Plus’ Impact on Care Coordination – Caroline Carter, MS, LSW, BCC, CPC+ Practice Facilitator, Healthcare Collaborative of Greater Columbus Collaboratively Connecting Across Systems and Providers - Happy Together – Stephanie Vogt, RHIA, Lead Analyst, OhioHealth & Stacie Wolfe, RHIA, Systems Application Consultant, OhioHealth
Resource Fair Throughout the day, substantial networking opportunities were built into the agenda. During this time participants spent time networking with other Forum attendees as well as learning about organizations participating in the Resource Fair who are listed below: • • • • •
Center for Balanced Living Central Ohio Area Agency on Aging Charitable Pharmacy of Central Ohio Mental Health America of Franklin County Columbus Area Integrated Health
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National Church Residences OhioHealth Home Care OSUWMC - Rardin Family Practice
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Sunrise Senior Living Flying Horse Farms Physicians CareConnection
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Sanofi
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Comfort Keepers
Closing Work Session The Care Coordination Forum wrapped up with HCGC sharing the themes from the morning discussion. Participants were asked to reconsider the questions from the morning and narrow in on their top two priorities that they feel the region should focus in on first. Participants were encouraged to also identify action steps to begin to move this work forward. What are the top two priorities we should focus on and what are some immediate action steps that could be taken following this Forum to work towards these priorities? 1. Increase technology for referral/shared information - (Prioritized by 9 groups) Action Steps: • Make sure our technology is not duplicative • Universal Electronic Health Record • Sharing information about what can be shared between entities • Maximize what is allowable under HIPPA • HIE sounds good on paper but providers are struggling to use it and make it a meaningful tool 2. Collaboration to improve social determinants, i.e. standardized screening tool – (Prioritized by 6 groups) Action Steps: • Research existing screening tools • Need education and training on resources available to address social needs and gaps 3. Increased training and education - (Prioritized by 5 groups) Action Steps: • More Forums • Training of para-professionals 4. Utilizing shared data to improve quality –(Prioritized by 3 groups) Action Steps: • To reduce duplication, clarify roles 5. Integrating behavioral healthcare -(Prioritized by 2 groups) Action Steps: • Strengthening communication between medical and behavioral health partners Evaluation 93% of participants attending the Care Coordination Forum rated the event as having high or very high value. Participants identified the following themes as contributors to the events high value: • • • • • • •
Diversity and choice of breakouts Content of breakouts Keynote Presentation Organization of the day Opening small group conversation Venue Food at the Venue
A list of attendees for the event can be found here.