www.hcgc.org

May 2016

Medical Neighborhood Referral Infrastructure Project

In-Person Work Session

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Today’s Agenda

• Welcome and Introductions

• Aligning Shared Referral Infrastructure

• Small Group Work Session

Align Shared Infrastructure

Organizations Exchanging Referrals• Alliance Healthcare Partners

• Central Ohio Area Agency on Aging

• Central Ohio Diabetes Association

• Central Ohio Primary Care

• Charitable Pharmacy of Central Ohio

• Clintonville-BeechwoldCommunity Resource Center

• Equitas Health (formerly ARC Ohio)

• Helping Hands Health and Wellness Center

• LifeCare Alliance

• Lower Lights Christian Health Center

• Metropolitan Family Care

• Mount Carmel Health Partners

• Physicians CareConnection

• PrimaryOne Health

• Ripple Life Care Planning

• Southeast, Inc.

• Syntero

• The Breathing Association

• YMCA of Central Ohio

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Align Shared Infrastructure

Organizations Committed to Participate

• Caliber Patient Care

• Franklin County Office on Aging

• Health & Wellness Pharmacy

• Kroger Pharmacy

• Mount Carmel Medical Group

• National Church Residences

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Medical Neighborhood

Purpose: Advancing accountable care coordination across clinical and social service organizations

• Relationships: Strengthening the relationships between clinical and social service organizations

• Reduce Variation: Adopt and spread results-based practices

• Align Shared Infrastructure: Link/make sense of shared infrastructure being utilized in the region

Healthcare Provider

CliniSyncReferral Tool

Social Service

Healthcare Provider

Mid-Ohio Foodbank

Social Service

PantryTrak

Local Food PantryLocal Food

Pantry

Local Food Pantry

Local Food Pantry

*Data bridge in development

• Creates buffer between CliniSyncand non-covered entities

• May be able to replicate approach with other care coordination efforts

Align Shared Infrastructure

Franklin County Pathways

Community HUBAligning accountable care coordination

Learning Session – May 20, 2016

8

Session Objectives

Learning Session Objectives

WHYWhy do we need a Pathways Community HUB

in central Ohio?

WHAT What future value can it add?

HOWHow does a Pathways Community HUB

operate?

Why do we need a Pathways Community

HUB in central Ohio?

9

People in need face

complex and

interconnected

issues, often

requiring them to

seek help from

multiple sources

Health and social

service providers

recognize clients’

multiple needs and

often coordinate

referrals, but varying

approaches and

limited resources

affect results

Funders/payers

question whether

their dollars are

achieving the results

they seek or if

they’re paying for

something that

could have been

prevented

Our community

continues to have 1

in 5 people living

poverty, and 1 in 3

struggling to meet

basic needs

10

Why do we need a Pathways Community

HUB in central Ohio?

What future value can this model add?

11

FIND PROVIDE MEASURE

What future value can this model add?

12

FROM THIS

….

…TO THIS

How does a Pathways Community HUB

operate?

13

HUB

• Administrative and information

technology infrastructure that

provides tools, standards, and

resources to operate model

• Provide data processing,

reporting, invoicing, and

collection tools

• Provide or arrange training for

community care coordinators

in Pathways Method and use

of Hub data system

• Support and assist care

coordination agencies in

quality improvement and

quality assurance activities

• Maintain all client data in

compliance with applicable

requirements of HIPAA,

HITECH, and other

regulations

Care Coordination Agencies (CCAs)

• Establish contract and

business associate agreement

with HUB

• Provide care coordination

services to clients using

community care coordinators

trained and supervised in

Pathways Method

• Perform mutually agreed upon

supervision, quality

improvement, and quality

assurance activities

• Ensure sufficient education

and training to community

care coordinators on HUB’s

data system, Pathways

Method, and community

resources

Funders/Payers

• Public-private entities

establish contracts/

agreements with HUB to

support delivery of care

coordination services to

specific populations using

accountable payment

arrangements

• Contract terms structured

based on payments to care

coordination agencies for

qualifying activities and

outcomes

• Payments will directly support

care coordination activities

and be reinvested in support

of HUB operations

Using Data

to Improve

Results and

Reduce

Duplication

17

What are your questions?

18

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Small Group Work Session #1

Question 1: What lessons have you learned from implementing/using the shared referral infrastructure?

Question 2:What best practices has your organization identified that have made the shared referral infrastructure more effective?

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Small Group Work Session #2

What activities could HCGC, CliniSync and project partners do to improve the referral network?