Care Coordination and Interoperable Health IT Systems Unit

Care Coordination and Interoperable Health IT Systems Unit 1: Overview of Care Coordination Lecture b – Care Coordination Models This material (Comp 22 Unit 1) was developed by The University of Texas Health Science Center at Houston, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90 WT 0006. This work is licensed under the Creative Commons Attribution-Non. Commercial-Share. Alike 4. 0 International License. To view a copy of this license, visit http: //creativecommons. org/licenses/by-nc-sa/4. 0/.

Overview of Care Coordination Lecture b – Learning Objectives • Objective 1: Define care coordination effectiveness (Lecture a) • Objective 2: Explain the purposes for care coordination (Lecture a) • Objective 3: Discuss various models of Care Coordination (Lecture b) • Objective 4: Compare coordination roles and responsibilities in the post-Affordable Care Act models of care across the care continuum (Lecture b) • Objective 5: Discuss Specialty care coordination (Lecture c) • Objective 6: Discuss Long term care/post-acute care (aka “The Last Mile”) (Lecture c) • Objective 7: Identify stakeholders in care coordination (Lecture c) 2

Models of Care Coordination • Patient-Centered Medical Home (PCMH) • Patient-Centered Medical Neighborhood • The Collaborative Care Model – Medicaid • Behavioral Health Home – Joint Commission • Care Transitions Program – Eric Coleman • Guided Care Johns Hopkins Program • Transitional Care Nursing Model: Naylor Advanced. Practice Nursing • Community-Based Care Transitions Program • The Integrating Care for Populations & Communities Aim (ICPCA) (previously The Care Transitions Theme) – Jane Brock • Primary Care Teamlet Model • Bridges to Health • Project RED; Re. Engineered Discharge – Boston Univ. • BOOST – Better Outcomes by Optimizing Safe Transitions – Society of Hospital Medicine • CMS Models: https: //innovation. cms. gov/initi atives/#views=models 3

Care Coordination • Partnerships between individual patients, their personal physicians, and the patient’s family • Facilitated by: – Registries – Information technology – Health information exchange • Provides care in a culturally and linguistically appropriate manner 4

PCMH Care Coordination Core Values • Multidisciplinary collaborative partnership relationships • Clinician-patient communication • Patient and family at the center of care • Fosters relationship with personal physician • Coordinating care for both wellness and illness 5

PCMH Care Coordination • Helps patients choose specialists • Share medical tests results to avoid retesting • Informs specialists of any necessary accommodations for the patient’s needs • Helps access other needed providers or health services 6

CMS Accountable Care Organizations (ACOs) • Voluntary organization of multiple health care providers • Focused on chronically ill – Provide right care at the right time – Avoid unnecessary duplication of services – Prevent medical errors 7

Comprehensive Primary Care Plus • Advanced primary care medical home model – Access and Continuity, – Care Management, – Comprehensiveness and Coordination, – Patient and Caregiver Engagement, and – Planned Care and Population Health 8

Care Transitions Model of Care Coordination • Developed by Eric Coleman • Addresses the problems of patients who are discharged from hospital to home • Advanced practice nurses: – Are trained as coaches – Assists patients and their families in self-care skills 9

Johns Hopkins Guided Care Model • Led by registered nurse – Assessment – Care Planning • Team provides care for chronically ill patients – Coordinated – Patient-centered – Cost-effective 10

Transitional Care Advanced – Practice Nursing Model • Developed by Mary Naylor • Advanced-practice nursing visits in hospital, home, and by telephone • Developed for older adults hospitalized for chronic health conditions 11

Community – Based Care Transitions Program • Promotes seamless transitions from acute hospital care to home • Centers for Medicare and Medicaid Services (CMS)-supported Care Transitions Quality Improvement Organization Support Center (QIOSC) • Health care coordination strategies, coalition charters, data analytic tools, and information on mapping and network analysis 12

Bridges to Health Model • Developing programs for segments of the population that meet patients’ needs for coordinated, integrated care delivery programs • Services that meet the needs of each of the populations outlined in the model • Improve the quality and efficiency of care coordination 13

Health Information Repository • Securely holds and shares whole-person health information • Necessary for – Care delivery measurement – Establishing target health goals through shared decision-making 14

Referrals are Coordinated, Tracked, and Monitored • Population health and chronic disease management systems: – Stratification – High acuity care needs • Systems evidence-based guidelines outline appropriate care 15

Care Coordination Information Systems • Track test results • Share information with patients • Ensure that patients receive appropriate follow-up care • Help in understanding results and treatment recommendations • Ensure smooth transitions from one care setting to another 16

Care Coordination Information Systems (cont’d – 2) • Help prevent errors • Help patients with: – Health insurance eligibility – Costs – Coverage and appeals – Refer patients to sources that can be of assistance. • Identify and address barriers due to individual’s social determinants of health 17

Unit 1: Overview of Care Coordination Summary – Lecture b – Care Coordination Models • Care coordination requires collaboration and communication between the primary care physician team leader, care team, and the patient • There are various post-Affordable Care Act models of care coordination across the care continuum 18

Unit 1: Overview of Care Coordination References – Lecture b References Agency for Healthcare Research and Quality. (n. d. ). Patient Centered Medical Home Resource Center. Retrieved March 08, 2016, from https: //pcmh. ahrq. gov/ Centers for Medicare & Medicaid Services. (2016, March 16). Community-based Care Transitions Program Select link to open options for. Retrieved March 8, 2016, from https: //innovation. cms. gov/initiatives/CCTP/ Coleman, E. A. , MD, MPH. (n. d. ). The Care Transitions Program® - Transitional Care & Intervention. Retrieved March 08, 2016, from http: //caretransitions. org/ Johns Hopkins University. (2013). Guided Care: Comprehensive Primary Care for Complex Patients. Retrieved March 8, 2016, from http: //www. guidedcare. org/ University of Pennsylvania School of Nursing. (2014). Transitional Care Model. Retrieved March 8, 2016, from http: //transitionalcare. info/ 19

Unit 1: Overview of Care Coordination Lecture b – Care Coordination Models This material was developed by The University of Texas Health Science Center at Houston, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90 WT 0006. 20