From the Front Lines: Lessons on Care Coordination

CHI, to learn how care coordination occurs on the front lines of the Colorado Medicaid Accountable Care Collaborative (ACC), conducted more than  20 key informant interviews with health care providers, care coordinators and Regional Care Collaborative Organization (RCCO) executives. The findings were presented at CHI’s second Safety Net Advisory Committee (SNAC) Lab on June 28. CHI documented three ways care coordination is being implemented:

• Assembling multidisciplinary care coordination teams.

Care coordinators often come from diverse disciplines, including medicine, social work, behavioral and public health. The breadth of experience on a care coordination team may help patients who have complex medical as well as social supports needs. Care coordinators may talk to patients via telephone, meet them at their medical home or even visit them at their residence. The trust they build with patients is crucial to promoting better health outcomes.

• Practicing targeted scheduling.

Care coordinators, including social and behavioral health workers, may have regular office hours at a medical home. This allows a patient to be scheduled for an appointment when both their medical and social supports needs can be addressed. For example, a diabetic patient needing housing assistance may be scheduled for her check-up at her medical home when a social worker is available. Targeted scheduling improves efficiency by treating disparate health factors in one place during the same appointment.

• Combining data resources.

The ACC is data driven. RCCOs use data provided by the Statewide Data and Analytics Contractor (SDAC) to learn a patient’s history, categorize patients into risk tiers and respond to patient behaviors. However, the data, which originates from Medicaid claims, is not available in real time.  If a patient visited the emergency department yesterday, care coordinators may not learn of the incident for months. But many RCCOs and PCMPs are building relationships and combining data resources to fill the data gap. By establishing trust and data sharing agreements with other providers, hospitals, mental health clinics and other facilities, care coordinators have an enhanced ability to know where their patients are presenting and more effectively intervene.

The ACC completed its pilot year last month and entered a new phase in July to enhance the incentives for RCCOs and PCMPs to achieve metric goals, such as decreasing emergency department use, hospital readmissions and high cost imaging. During the pilot year, the Department of Health Care Policy and Financing provided RCCOs and PCMPs with per member, per month (PMPM) payments to finance care coordination and medical home services. Beginning this month, one dollar from the PMPM payments will be withheld to create a bonus pool that rewards RCCOs and PCMPs that meet metric goals.

CHI will analyze how this payment structure affects Colorado’s on-the-ground care coordination efforts.

More information about the 2012-13 SNAC Lab series, including the proceedings from the first SNAC Lab, is available here.