PREGNANT CLIENT Pathways Community HUB Model Click to
PREGNANT CLIENT Pathways Community HUB Model Click to edit Master text styles • Second level • Third level • Fourth level • Fifth level 1
Community HUB Care coordination agencies Client Community Care Coordinator Regional organization and tracking of care coordination 2
Definition of Care Coordination “Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care. " AHRQ Care Coordination Measures Atlas Update, June 2014
Direct Services = Intervention Care Coordination = clinic based Community Care Coordination = home based Community Care Coordination – care coordination provided in the community; confirms connection to health and social services. A Community Care Coordinator: • • Finds and engages at-risk individuals Completes comprehensive risk assessments Confirms connection to care Tracks and measures results 4
Care Coordination “While all experts with whom we spoke agreed that better communication with community organizations and social services is critical, especially for Patient Centered Medical Homes (PCMHs) that focus on treating low-income patients or frail elders, many describe the connections with the broader community as the most challenging for the medical neighborhood at large. . connections between primary care and community services. . . simply are absent or highly fragmented and disorganized. ” AHRQ #11 -0064: White Paper on Coordinating Care in the Medical Neighborhood
Why do we need Community Care Coordination? • More than ½ of patients can’t state their diagnosis when leaving the hospital. • More than ⅓ of patients can’t explain their medications. • Less than ½ of patients saw a primary care physician within 2 weeks of leaving the hospital. • 1 in 5 patients has an adverse event transitioning from hospital to home. 2 out of 3 events are related to prescriptions!
Key Points in Building a HUB • The HUB must be a neutral entity in the community and cannot employ its own care coordinators. • There is only one Pathways Community HUB in a community or region. • The HUB must be an independent legal entity or an affiliated component of a legal entity. • The HUB must be based in the community or region it serves. • There must be a Community Advisory Board made up of members reflecting the community or region the HUB serves. 8
AHRQ Pathways Community HUB Manual 9
Who conducts National Certification?
Collaborating Partners Georgia Health Policy Center (GHPC) Community Health Access Project (CHAP) The Rockville Institute (RI) Communities Joined in Action (CJA)
Benefits of Pathways Community HUB Certification Project A framework for standardizing how community care coordination services are organized, delivered, measured, and financed Tools, metrics, and mechanisms developed that can be used to monitor, assess, and evaluate various aspects of community care coordination services Demonstration of your HUB’s accomplishments
TIERED CERTIFICATION DESIGNATIONS The Pathways Community HUB Certification Designations Three designations are available for Community HUB certification: § Provisional Certification Designation is granted when a HUB demonstrates compliance with less than 80% of the standards; and meets all of the prerequisites. § Level I Certification Designation is granted when a HUB demonstrates compliance with 80% or more of the certification requirements. § Level II Certification Designation is granted when a HUB demonstrates 100% compliance with the certification requirements. 14
HUB Certification Life Cycle Initial Certification Desk Review Recertification INITIAL CERTIFICATI ON DESK AUDIT REVIEW RECERTIFICAT ION • Initial Certification- requires the HUB ‘s completion of all of the action steps that are delineated in the certification process. The initial certification status remains in effect for two years, barring any indications requiring revocation of certification status. • Desk Audit Review-HUB maintenance of certification status requires submission of an application for a Desk Audit Review at the end of the two-year period. At this stage in the certification process, a site visit is not required. However, a HUB must participate in a comprehensive review of current documentation to ensure continued compliance with the standards. • Recertification –HUBs are able to maintain certification status by submitting an application for re-certification at the end of the fourth year of certification. This process requires the HUB to complete the same action steps as required during the initial application, including participation in a formal site visit. 15
Key Steps in the Certification Process (5) RECOMMENDATION TO EVALUATION REVIEW PANEL (4) FEEDBACK AND HUB IMPROVEMENT ACTION PLAN (3) COMPLIANCE REVIEW AND ASSESSMENT HUB ion at c i f i t Cer (2) CONSULTATION & TECHNICAL ASSISTANCE (6) DETERMINATION OF CERTIFICATION STATUS AND DESIGNATION (1) APPLICATION
THE CERTIFICATION PROCESS 1) Application § HUB contacts the Pathways Community HUB Certification Program at the Rockville Institute to request application or downloads application from the certification website
2) Consultation & Technical Assistance § A certification staff member consults with the HUB Director and determines if Technical Assistance (TA) is needed § Staff members sends the certification packet electronically to the HUB or HUB staff accesses the materials online from the certification program website. § HUB submits completed application § A certification staff member performs an initial assessment of the HUB’s eligibility for certification and assigns the HUB to a certification assessor— contingent upon the HUB’s eligibility to move forward. § If the HUB is not ready to advance to the next steps, the certification staff member refers the HUB Director to the Pathways Community HUB Institute for individualized TA services.
3) Compliance Review and Assessment § For those HUBs that are determined ready to move forward with certification…… § The assessor contacts the HUB Director to acquaint him/her with the certification process and to respond to questions § Assessor reviews the HUB Work Sheet and provides a detailed description of the type of documentation that is required to complete the review process. § The process for completing the HUB Worksheet is similar to a self-study questionnaire that many accreditation/certification bodies require. It provides the HUB with an opportunity to assess their operations and the adequacy of their documentation.
3) Compliance Review and Assessment (continued) § Once the HUB staff completes and submits the HUB Worksheet along with other relevant documentation to the certification assessor, a site visit is scheduled. § Planning for the site visit is an interactive engagement process during which a discussion of the agenda for the site visit occurs. § Typically, the site visit agenda includes an opportunity for the certification assessor to meet with the HUB Director, staff, and stakeholders. § The agenda also allocates time for the assessor to review required documentation and to visit one or more CCAs.
Action Plan § The certification process fosters a continuous learning organization, so there will always be opportunities for improvements. § A HUB Improvement Action Plan is created for all HUBs that pursue certification (not limited just to deficiencies, but provides an opportunity to identify areas that the HUBs could enhance. ) § The Assessor communicates with the HUB Director and reaches agreement about the areas in need of improvement and a timeframe for resolving needed improvements. § An agreement is then signed an iterative process is used to update the plan.
5) Recommendation to Evaluation Review Panel (ERP) § On the basis of the review/assessment process and the status of the HUB Improvement Action Plan, the Assessor recommends whether the HUB is eligible for further review and consideration by the ERP or whether further TA is needed to improve HUB compliance with the prerequisites and standards.
Who ensures that the HUB model is effective?
STANDARD #4 -- The HUB engages and is advised by a Community Advisory Board. To ensure the HUB understands and meets the needs of those who are at risk, the HUB leverages existing community resources and seeks to add value to the community. Local leaders, therefore, need to be meaningfully engaged and empowered to guide and advise the strategies of the HUB.
What tested Pathways currently exist?
20 Core Pathways – National Certification • • • Adult Education Employment Health Insurance Housing Medical Home Medical Referral Medication Assessment Medication Management Smoking Cessation Social Service Referral • Behavioral Referral • Developmental Screening • Developmental Referral • Education • Family Planning • Immunization Screening • Immunization Referral • Lead Screening • Pregnancy • Postpartum 26
Example – United Healthcare 2015 contract Normal Risk RVU High Risk RVU Modifier Completed one time at Member enrollment G 9001 7 G 9003 9 A 1 Completed at each face-to-face encounter with Member G 9005 2 G 9010 4 A 1 G 9002 4 G 9009 5 AB G 9002 1 G 9009 1 AE LARC (long-acting, reversible) or permanent method All other family planning methods G 9002 5 G 9009 6 G 1 G 9002 4 G 9009 5 G 2 Residing in affordable & suitable housing for 2 months. Confirmation of kept appointment with medical home. G 9002 9 G 9009 10 AI G 9002 5 G 9009 6 AM Checklists Initial Adult Checklist Pathways Behavior Kept three scheduled behavioral al Health appointments Educational module delivered. Family Planning Housing Medical Home health
Transportation
What about adding new Pathways? The Pathways Community HUB Institute (PCHI) would take any applications for new Pathways: • HUB Certification requires that you have all 20 Pathways in place before requesting a new Pathway. • Pathways can be “bundled” to reach larger outcomes. • New Pathways that are developed would need to be applied across full HUB network.
For children ages 20 and under 1. Childhood immunization status Immunization Screening and Referral Pathways 2. Well-child visits in the 3 rd, 4 th, 5 th and 6 th years of life Medical Referral Pathways 3. Medication management for people with asthma Medication Assessment and Medication Management Pathways
EPSDT “Bundles” EPSDT 0 – 6 months 7 – 12 months 13 – 18 months 19 – 24 months 25 – 36 months 4 years 5 years 6 years CODE G 9011 RVU 4 Mod. 10 G 9011 4 11 G 9011 4 12 G 9011 4 13 G 9011 4 14 1 Medical Referral (well child), 2 Education, optional – 1 G 9011 Immunization Screening (Immunization Referral if needed) 4 15 4 16 4 17 1 Medical Home, 4 Medical Referrals (well child), 3 Immunization Screenings, 1 Developmental Screening, 2 Education 2 Medical Referrals (well child), 1 Immunization Screening, 1 Developmental Screening, 1 Lead, 2 Education 1 Medical Referral (well child), 1 Immunization Screening, 1 Developmental Screening, 2 Education 1 Medical Referral (well child), 1 Developmental Screening, 1 Lead, 2 Education 2 Medical Referrals (well child), 2 Education
For Adults age 21 and up: 1. 2. 3. 4. Controlling high blood pressure Comprehensive Diabetes Care (Hb. A 1 c) poor control Comprehensive Diabetes Care: blood pressure control Antidepressant medication management: effective acute phase treatment, and effective continuation treatment
Example of a “bundle” (UHC contract – 2015) Hospital Readmission Basic G 9011 52 RVU = 7 Intensive G 9011 53 RVU = 10 1 Medical Home and/or Medical Referral (primary care), 1 Medication Assessment, 1 Social Service Referral, 2 Education, 1 Tool (PAM, PHQ 9, etc. ), no readmissions from date of hospital discharge for 30 days Basic Hospital Readmission Bundle plus 1 Medical Referral (specialty care), 1 Medication Management, 2 Social Service Referral, 2 Education, any 2 of the following: Adult Education, Behavioral Health, Employment, Housing, Smoking Cessation, no readmissions from date of hospital discharge for 30 days
Diabetes “Bundle” Diabetes Basic CODE RVU 1 Medical Home and/or Medical Referral G 9011 (primary care), 1 Medical Referral (specialty care), 1 Medication Assessment, 1 Social Service Referral, 3 Education – Diabetes specific modules, Hgb. A 1 c reduced by 1 point Intensive Basic Diabetes Bundle plus 1 Medication G 9011 Management, 2 Social Service Referral, 2 Education, any 2 of the following: Adult Education, Behavioral Health, Employment, Housing, Smoking Cessation, Hgb. A 1 c reduced by 1 point Mod. 7 54 10 55
The Health Home Program was created by Affordable Care Act (ACA) section 2703. It allows states to provide Health Home services and care coordination to high cost high risk Medicaid and Medicare/Medicaid (duals) eligible clients. Its purpose is to reduce duplication of services and provide smoother transition and more personalized care to help reduce the progression of chronic disease, reduce inappropriate emergency department utilization and preventable hospital readmissions, and improve health and self-management of conditions.
Health Homes – January 2016 preliminary findings • 10, 632 individuals by the end of 6 th quarter (over 7 million by July 1, 2015; 6. 6% increase since 2010 • 6% savings • Positive impact in PMPM Medicare spending • Health Homes in 37 Counties
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