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

1. Community Care Coordination Scorecard—Raising 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*? *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 • 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

3. What is the Work of RUAH? • Client Advocacy and System Navigationvia Health Access Workers • Pharmacy Assistance – access to low or no cost drugs connecting through Medication Access Coordinators (MAC’s) • 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-admissionsfor 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-Off’s” • 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… -Learned about Pathways; -Began building a Community HUB -Invited to be part of the Innovations Exchange: AHRQ Community Care Coordination Learning Network Joined the CCCLN: -Hub Manual Development -Outcome Measure Scorecard Project

8. Program & Community Benefits • Best Practices are shared • There’s 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 • There’s a reason most communities don’t 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 • We’ll be able to tell you next year!