Community Care Coordination Scorecard

1
Community Care Coordination ScorecardRaising
the Bar for Measuring Improvements in Access to
Care Across Communities
Building and supporting community capacity
Measuring the Success and Barriers to Medical
Home Placement for Our Most Vulnerable Community
Members

• Sherry E. Gray, Director
• Rural and Urban Access to Health-St. Vincent
  Health

AHRQ 2010 Annual ConferenceMonday, September 27,
2010
2
WHO is RUAH?
10 Health Access Workers (HAW) in 8
communities Hospital associates community
focused 7 Medication Access Coordinators
(MAC) Hospital and Community Agency
Associates System Administrative Support
Health Access Manager Operations Facilitator
Language Access Staff System Director

• What does it mean?
• The word ruah, in yiddish means Breath of
  Life. The Goal?
• to breathe new life into a health care system
  that serves our most vulnerable community members

3
What is the Work of RUAH?

• Client Advocacy and System Navigation via Health
  Access Workers
• Pharmacy Assistance access to low or no cost
  drugs connecting through Medication Access
  Coordinators (MACs)
• Creation of Medical Homes for the underserved
• Access to Specialty Care for the underserved
• Program enrollment (financial resource review and
  application
• assistance public AND private)
• Reduction of inappropriate Emergency Room
  utilization
• Reduction of hospital re-admissions for chronic
  diseases
• Assistance with supportive social services (wrap
  around)
• Outcome Based Measurement
• Pathway Model
• Community Care Coordination Hub
• Language Access Medical interpretation and
  translation of vital documents
• System Change

4
Why?

• To provide increase access for
  uninsured/underinsured community members
• Right Care
• Right Time
• Right Place
• Right Provider
• Right Payer

5
So That

• Un/underinsured community members can receive
  care sooner vs. later
• Consistent and familiar care is provided along
  with follow up follow through treatment is
  across time and not episodic
• Resources are used as effectively as possible,
  including
• Human
• Providers, Practitioners, Care Coordinators,
  Administrative support, etc.
• Financial
• Reimbursement, Funding, Cost-Avoidance,
  Write-Offs
• Technological
• Connecting Information in a timely, meaningful
  way
• Support (wrap-a-round) Services
• Connecting medical treatment, public health
  practices, psychosocial principles
• Vital connections are made
• Integrate and coordinate care not duplicate and
  replicate care
• Best Practice Learning's are shared and
  solutions are not re-created

6
How RUAH got HERE

• Realization increased access, services
  provided, and reimbursement was intuitively a
  good thing, but proved NOTHING!

• Resolved to find out if a positive difference
  was made in the lives of those we are seeking to
  serve. If so, how could that be demonstrated and
  or verified? If not, what needed to change?

• Researched Best Practice models in OUTCOME
• MEASUREMENT, specific to community care
• coordination.

7
One thing leads to another
8
Program Community Benefits

• Best Practices are shared
• Theres no charge for advice/consultation
• Moves individual, community programs out of an
  isolated vacuum
• Increases credibility
• Creates momentum
• Improves chances of sustainability
• Demonstrates that in the healthcare delivery
  system change can and does happen

9
Challenges

• Balance between differences similarities for
  each community involved
• How to design a structure that also respects the
  inherent need for flexibility?
• How to explain, define, communicate the
  structure?
• Outcome Measurement
• Agreed upon
• Definitions?
• Operations/Practices?
• Parameters?
• Reporting Structure?

10
Lessons Learned

• Theres a reason most communities dont gravitate
  to this work
• The work has to be communicated in different ways
  for different audiences and stakeholders
• Integration and coordination of care goes against
  the grain of how the health system has evolved

11
Medical Home Assessing the Effectiveness of
Access Initiatives

• Scorecard group formed through the Community Care
  Coordination Learning Network
• Initiatives/measures developed
• RUAH data submission initiated Spring, 2010
• Developed the Required Data Points for the
  Medical Home Scorecard Measure, for all
  participants

12
Required Data Points for the Medical Home
Scorecard Measure

• Clients demographic data during 1 month time
  frame
• Insurance Status
• Source of Ongoing primary care
• Was a referral started to achieve an ongoing
  source of primary care?
• Barriers to completing that referral
• Date the connection to ongoing primary care was
  made
• Supportive (wrap around) social service
  referrals
• Barriers
• Date connection was made to resolve identified
  social service need

13
Where RUAH is at in the Process

• Able to submit most of the required data
• Beginning stages of implementing Pathways
• RUAH Eight different communities
• Piloting Pathways in one site currently sole
  data reporting community
• Challenge reporting outcomes for ongoing source
  of primary care and social service referrals
• Participation in the Scorecard Measure process is
  accelerating the goal of appointment verification
  and follow-up coordination and verification.
• Adopting the Pathways model Report on outcomes
  vs. counting referrals/activities
• Adds accountability, credibility and rationale
  for system change and sustainability

14
So What Gains Have been Made?

• Five Pathways have been developed for the
  Anderson Site
• Medical Home
• CCCLN Scorecard Measure Project Also
• Pregnancy Care
• Childhood Immunizations
• Government Funded Program Enrollment
• Government Funded Program Re-Enrollment

15
Now What?

• Agreements for HUB being signed
• Common ROI developed for HUB members
• Common Care Coordination check in line
  developed to start a Pathway
• Process being implemented for monthly Pathway
  process checks and outcome measurement
• Well be able to tell you next year!