RCCO and the Medical Home Concept Molly Markert, Colorado
Access RCCO Region 3 Contract Manager Devra Fregin, Director of
Practice Management Kids First Health Care
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Alphabet Soup Welcome to the Accountable Care Collaborative
(ACC) The Accountable Care Collaborative (ACC) is a new Medicaid
program to improve clients' health and reduce costs. Medicaid
clients in the ACC will receive the regular Medicaid benefit
package, and will also belong to a "Regional Care Collaborative
Organization" (RCCO). Medicaid clients will also choose a Primary
Care Medical Provider (PCMP). What is a Regional Care Collaborative
Organization (RCCO)? The RCCO connects Medicaid clients to Medicaid
providers and also helps Medicaid clients find community resources
and social services in their area. The RCCO helps providers to
communicate with Medicaid clients and with each other, so Medicaid
clients receive coordinated care. A RCCO will also help Medicaid
clients get the right care when they are returning home from the
hospital or a nursing facility, by providing the support needed for
a quick recovery. A RCCO helps with other care transitions too,
like moving from childrens health services to adult health
services, or moving from a hospital to nursing care.
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What is a Primary Care Medical Provider (PCMP)? A primary care
medical provider (PCMP) is a Medicaid client's main health care
provider. A PCMP is a Medicaid client's medical home, where he/she
will get most of their health care. When a Medicaid client needs
specialist care, the PCMP will help him/her find the right
specialist. All clients enrolled in the ACC have a PCMP. What are
the Goals of the RCCO Program? By assisting Medicaid clients in
getting connected to a PCMP as their Medical Home and by ensuring
the medical, specialty, mental health care and other related
services are well coordinated, clients experience in the health
care system will improve. Clients will be the primary drivers of
their healthcare decisions, but will have the support and
assistance they need to achieve their personal healthcare goals. In
addition, by having a primary source of medical care that attends
to both sick care and wellness and prevention activities, the
overall health of Medicaid clients will improve. Finally, when
clients are more satisfied and empowered in their healthcare
decisions and overall health improves, the total cost of care is
reduced.
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Program Measures Emergency Room Visits: Medical care in an
emergency room is costly, disruptive, and not always necessary By
helping Medicaid clients understand what alternatives they have for
using the emergency room for non- emergent conditions, unnecessary
use of emergency rooms will be reduced. Inpatient Readmissions
Within 30 Days: Inpatient care is necessary for many healthcare
conditions and circumstances, and as such is an essential component
of the healthcare continuum. However, rapid readmission to
inpatient care can often be avoided if Medicaid clients get the
assistance they need to ensure timely post-discharge after care
with their PCMP, understand their discharge instructions and
medications, and have adequate supports to make a successful and
sustained transition out of the hospital. High Cost Imaging: This
refers to costly diagnostic procedures such as MRIs and CT scans.
While these are valuable, necessary tools, they are often
unnecessarily repeated when multiple providers are involved in a
clients care. By ensuring better communication and coordination of
care between providers, some of these duplicative services can be
eliminated. Well Child visits added this year as a measure specific
to pediatric and family practices
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RCCO Regions
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Benefits of being a PCMP in the RCCO Network $3.00 PMPM FFS
Reimbursement Incentive payment Shared Savings Data Analytics and
Reporting Capabilities Care Coordination and Medical Management
Practice Supports Technical Supports
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Responsibilities of being a PCMP in the RCCO Network Adopt the
tenets of being a medical home Especially access criteria similar
to all Medicaid Promote quality health care Coordinate care with
specialists and referrals Promotes partnership with patient and
provider Integrated with other needs Decide care planning together
Consistent care geared to your past experiences Provide sick and
well care
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Its about Transformation! Using data and analytics is new,
scary, unique and extremely productive Attention to cost drivers
and incentives for improved care does influence results Knowledge
leads to empowerment for all Collaborating across the region is new
concept Best practices are shared as they emerge Clinical
Transformation happens together
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Kids First Health Care Care Coordination: The Clinic
Perspective
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Background on Kids First Health Care Private, non-profit
organization 2 Community Pediatric Clinics and 4 School-Based
Health Centers in Adams County Our clinics are staffed with 1-2
CPNPs and 1-2 MAs Pediatrician serves as our Medical Director
(part-time) Certified Childrens Medical Home Participating in
Accountable Care Collaborative (ACC) since February 2011 Added
Clinic Manager to take on staff supervision and project management
(including the ACC) in August 2012
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Managing Our Participation in the ACC Attending monthly
Regional Care Collaborative Organization (RCCO) meetings at
Colorado Access Now Quarterly Many great resources and sharing of
best practices Getting to know Molly Markert and the expectations
of being in the RCCO Getting familiar with the SDAC Dashboard and
the patients assigned to us Clean up our patient list Originally
contained many adults Sent forms to the state to remove the adults
from our attribution Process for removing adults is currently being
revised Time spent varies In the beginning 6-8 hours per month in
meetings and reviewing data Now with Care Coordination/Delegation
responsibilities more time is needed, but it is spread out among
many staff members
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Getting Delegated to take on the Care Coordination of our
assigned patients Complete Pre-Delegation Audit Tool Review current
policies and procedures Revise/Create policies and procedures as
necessary Meet with representative from Colorado Access to review
Pre- delegation audit tool and our policies and procedures Colorado
Childrens Healthcare Access Program (CCHAP) was available to help
us with this process
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Pre-Delegation Audit Tool General Care Management Questions Do
you have a system to record care management notes, goals and
progress? (EMR) Do you have Care Management policies and
procedures? Regular communication Follow-up procedures Address
barriers to receiving care Cultural beliefs and values, and
language barriers Utilization of family or other support systems
Creation of Personal Health Record or patient web portal System to
stratify/tier levels of care management intervention
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Care Management Staff Training Questions Transitions of Care
Questions Quality Management/Quality Improvement Process Internal
and RCCO Communication Departmental Focus Areas Reducing
inappropriate ER use Preventing avoidable hospital re-admissions
Reducing duplicate, unnecessary, or inappropriate imaging
Increasing Well Child Checks
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Care Coordination Practices Review our monthly SDAC data
(Example) Stratify Patients (High Needs, Medium Needs, Low Needs)
High ER usage and high cost imaging services Complex Chronic and
Critical (ADHD, epilepsy, med changes) At Risk, Simple Chronic and
Stable (Asthma, Obesity, WCC) Track patients monthly on Excel
spreadsheet Update patient charts with comments, tasks, care plans,
etc. Complete Monthly Metrics Form for Colorado Access Attend
monthly meetings with other delegated practices Assign staff
members to manage the care for these patients (Providers, MAs,
Patient Navigators, etc.) Part time patient navigator (Obesity
grant from Kaiser) Full time SBHC patient navigator (CDPHE
Expansion Funding) Money from our RCCO and increased visits helps
sustain these positions
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SDAC Data
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Care Management Spreadsheet
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Monthly Metrics Assessment and Care Planning Process Number of
members with completed assessments Number of members targeted for
care coordination Number of members with at least one intervention
Population Stratification Process Number of RCCO members in each
tier (High, Med, Low) Transition of Care Process Number of
inpatient hospital discharges Number of known inpatient hospital
discharges that are eligible for transition of care Number of
members who participated in transition of care
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Plan for ER reduction Number of high ER utilizers identified
Description of interventions applied to high ER utilizers Community
Resource Referral Coordination Define your community resource
coordination process and the services/organizations with whom you
coordinate (food, shelter, education, social needs) Number of
members referred to community resources Integrated Care
Coordination (across medical neighborhood and RCCOs) Define
relationships you have in place to facilitate care coordination
process (Behavioral Health)
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Transformation Evaluate changes in data monthly (improvements,
set-backs) ER Visits Re-Admits High Cost Imaging WCCs Modify care
coordination and data management practices Merge data from previous
months to reduce duplication efforts Look into WCC coding practices
Engage staff in cycles of rapid improvement (PDSAs) Educate the
providers on who these patients are Come up with action plans
Spread Best Practices
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Monetary Benefit$ PMPM payments for all attributed patients $3
per month per patient Based on current attribution Incentive
payments for performance on Key Performance Indicators (KPIs)
Decrease in ER visits, Re-admits, and High Cost Imaging Increase in
WCCs Regional outcomes must be met in order to get $ Paid out
Quarterly Max payment $1 per member per month Delegated Care
Management $3.50 PMPM Varies by Region