Community Care of North Carolina

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Community Care of North Carolina

• Child Health Accountable Care Collaborative
  (CHACC)

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Key Goals

• Improve access to, quality of, and coordination
  of care
• By doing so, decrease the cost of care.

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Community Care of NC

• Statewide primary care medical home care
  management system
• Rests on foundation of Carolina Access Medicaid
  in which Medicaid patients are linked to a
  primary care home
• Provides resources to improve access to, quality
  of and coordination of care across the different
  segments of the local health care system and
  decrease cost of care
• Private-public partnership (all savings stay in
  NC)
• Provides ready access to data
• Community based, locally driven, provider led

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Local Networks

• 14 local Networks across all 100 NC counties with
  more than 4500 Primary Care Physicians (1360
  medical homes)
• Over 1.4 million Medicaid enrollees, including
  dual Medicare/Medicaid and Health Choice
  enrollees

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Local Networks

• Are non-profit organizations
• Provide resources to primary care homes to better
  manage Medicaid population
• Join public and private sector primary care homes
  with other segments of the health care system
  (e.g. hospitals, health departments, mental
  health agencies, social services) to create local
  systems of care
• Utilize local multi-disciplinary RN and SW care
  managers, pharmacists, psychiatrists,
  obstetricians, medical directors
• Pilot potential solutions, share best practices
• Are capable of and accountable for managing
  recipient care

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Main Program Activities

• Chronic Disease Management Initiatives (e.g.
  Asthma, Diabetes)
• Chronic Care Initiative
• Hospital Transition Care
• Quality Improvement Initiatives
• Emergency Department Utilization
• Chronic Pain Initiative
• Integration of Physical and Mental Health
• Prevention Initiatives
• Pharmacy Initiatives
• Palliative Care
• Access to Primary Care
• Support of IT Initiatives
• High Risk Pregnancy Care Management

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Key program Asset- Access to dataInformatics
Center

• Medicaid claims data
• Utilization (ED, Hospitalizations)
• Providers (Primary Care, Mental Health,
  Specialists)
• Diagnoses
• Medications
• Labs
• Costs
• Individual and Population Level Care Alerts
• Reports on high-opportunity patients
• Quality Measurement and Feedback Review System

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Key program Asset- Access to dataReal Time Data

• Hospitalizations
• ED visits
• Provider Referrals

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Link to local health care system and community
resources
Multidisciplinary management support
QI Support
Primary Care Home
Patient
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Public Health
Hospital
Behavioral Health
Primary Care Home
Patient
Specialists
Community Resources
Social Services
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Child Health Accountable Care Collaborative
(CHACC)

• CMS Innovations Project
• Partnership of Community Care of North Carolina
  and Childrens Health Care Providers

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CHACC

• 3 year Cooperative Agreement from the CMS
  Innovations Center to Community Care of North
  Carolina--July 1, 2012- June 1, 2015
• Partnership of CCNC with Childrens Primary Care
  and Specialty Care Providers and the Academic
  Medical Centers and Childrens Tertiary Care
  Hospitals to improve the health of NC children
  who have complex and chronic illness

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Child Health Accountable Care Collaborative
(CHACC)

Partnership with North Carolinas Childrens
Healthcare Providers, North Carolinas Academic
Medical Centers and Tertiary Medical Centers
Community Care of North Carolina
CHACC Project Director Steve Wegner,
MD Medical Directors Elizabeth Tilson, MD (CCNC
Networks) David Tayloe, MD (Primary Care)
Alan Stiles, MD (Pediatric Subspecialists/Hospital
s) CHACC Integration Workgroup Program
Director Sherri Branski, RN, MSN, CCM Lynn
Guerrant, RN, MS
CCNC Networks/Primary Care Providers Medical
Home CCNC Network Care Managers
Pediatric Subspecialists/AMCs/Tertiary Childrens
Hospitals
CHACC Lead Care Managers, Care Managers, and
Patient Coordinators
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Program Goals

• Improve the health of NC children with complex
  chronic illnesses through improved value of care.
  
• Engage primary care providers and pediatric
  subspecialists across the state to share
  responsibility and accountability for pediatric
  primary, subspecialty, and hospital care.
• Jointly develop and utilize evidence based
  guidelines of care for pediatric chronic
  illnesses with pediatric subspecialists and
  primary care physicians and actively engage in
  co-management of these children.
• Provide active care management to children under
  the care of pediatric subspecialists through
  embedded care managers and patient coordinators
  at tertiary hospitals and provide a warm hand off
  to CCNC network care managers.

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CHACC

Children with complex, chronic Illnesses
Primary Care
Specialty Care
CCNC Networks--Medical Home/Primary Care Providers
Pediatric Subspecialists/AMCs/Tertiary Childrens
Hospitals
CHACC Care Manager
CCNC Care Managers
Co-management
Patient Coordinators
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Cost Savings Approaches

• Reduce hospitalizations through co-management and
  active monitoring of disease processes
• Improve primary and preventive care for children
  with chronic illnesses by providing this care in
  a medical home
• Reduce utilization of emergency services and
  pediatric subspecialists for acute common
  illnesses for these children
• Reduce duplication of laboratory and medical
  studies through streamlined communication between
  primary care providers and pediatric
  subspecialists
• Reduce pharmacy costs through formulary
  utilization and evidence based care

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Timeline

• Operations plan submitted to CMS, August 8, 2012
• Anticipate CMS approval by September 10, 2012
• Convene a CHACC Integration Workgroup August 2012
• Information sessions and discussion at the NC
  Pediatric Society Meeting September 2012
• Refine target population for intervention August
  to December, 2012
• Hiring and training of care managers and patient
  coordinators September 2012 to January 2013
• September 2012 to June 2013 Consensus Sessions of
  PCPs and Subspecialists

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The Role of the General Pediatrician

• David T. Tayloe, Jr., MD, FAAP

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Children and Youth with Special Health Care Needs
(CYSHCN)

• Registry of Patients
• Care Plans
• Subspecialist Care Coordination
• Primary Care Physician Care Coordination
• Community Partners
• Family Involvement

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Goldsboro Pediatrics

• 15 pediatricians, 7 nurse practitioners, a
  physician assistant, 2 behavioral health
  professionals, 1 lactation consultant
• 4 offices serving children in 7 counties
• Electronic Health Record System
• 2 Community Care of NC AccessCare staff
• Community Hospital with Level 2 Neonatal Unit

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Innovative Approaches

• Children and Youth with Special Health Care Needs
  in Wayne County
• Steering Committee of Family Members of CYSHCN
  and Community Partners
• Goldsboro Pediatrics electronic health record
  system (secure intranet)
• Registry and HIPAA-compliant /FERPA-compliant
  family consent procedures

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Wayne Pediatric CME Series

• Category I CME Sessions co-sponsored by the
  Office of CME at the Brody School of Medicine and
  Goldsboro Pediatrics
• Meets at 7 AM in the private dining area of the
  hospital cafeteria most every Tuesday morning
• Community Partners invited to attend sessions

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Wayne Initiative for School Health (WISH)

• Goldsboro Pediatrics is the medical home for the
  students enrolled in the six school-based health
  centers of WISH
• Nurse Practitioner and Physician Assistant, with
  the help of RNs, clerical staff, Registered
  Dietitians, behavioral health professionals
  provide comprehensive care for many at-risk
  middle/high school students in Wayne County

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Community Care of NC

• Care Coordinator and Patient Navigator are based
  in the main office of Goldsboro Pediatrics
• CCNC staff attend CME sessions of the Wayne
  Pediatric CME Series
• CCNC staff work closely with Community Partners

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4 of Children

• Need continuous care by pediatric subspecialists
• Should have care plans/passports developed by
  their subspecialist teams
• Need multiple services at the community level
• Need 24/7 access to a physician who has access to
  the medical records of the child

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Quality of Care for Children with Complex Medical
Conditions

• Guidelines and care plans/passports developed by
  subspecialists
• Electronic communication involving tertiary
  center specialists and community based
  generalists
• Regular visits with subspecialists and primary
  care physicians
• Family input/electronic communication with
  physicians
• Community partner collaboration coordinated by
  the community-based medical home

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Cost-effectiveness of Care for Children with
Complex Conditions

• 24/7 access to subspecialist and generalist
  physicians
• Avoid unnecessary expensive medications and
  therapies
• Avoid unnecessary hospital emergency department
  visits
• Avoid unnecessary hospital admissions

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Shortage of Pediatric Subspecialists

• Complex children need a lot of time from their
  pediatric subspecialists
• NC has shortages of most categories of pediatric
  subspecialists
• If these subspecialists are to maximize their
  time with complex children, general pediatricians
  must do their part to minimize unnecessary
  referrals to subspecialists

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David T. Tayloe, Jr., MD, FAAP

• Goldsboro Pediatrics
• 2706 Medical Office Place
• Goldsboro, NC 27534
• 919-734-4736
• fax [phone]
• dtayloe_at_aap.org

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The project described was supported by Funding
Opportunity Number CMS-1C1-12-0001 from Centers
for Medicare and Medicaid Services, Center for
Medicare and Medicaid Innovation. Its
contents are solely the responsibility of the
authors and do not necessarily represent the
official views of HHS or any of its agencies.