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QCCP Care Coordination Training. DAY 1. Trainers & CAI. Welcome. Housekeeping. Activity: Introductions. Agenda: Day 1. Welcome, Housekeeping, & Introductions Health Home Model What is Coordinated Care? Understanding the Clients We Serve Social Determinants of Health Health Literacy
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Trainers & CAI Welcome
Agenda: Day 1 • Welcome, Housekeeping, & Introductions • Health Home Model • What is Coordinated Care? • Understanding the Clients We Serve • Social Determinants of Health • Health Literacy • Roles and Responsibilities of Care Coordination • Care Coordination: Tasks and Competencies • The Importance of Care Coordination • Pros & Cons
Training Objectives • Describe the design and importance of the Health Home model, the concept of social determinants of health and the care coordinator’s role within the healthcare system • Utilize effective communication skills when engaging clients
Training Objectives • Identify the stages of change and apply OARS skills as a way of supporting the process of behavior change • Demonstrate ability to organize and record client information in a clear, concise and objective way. • Describe effective crisis management and practice stress management, self-care and boundary setting
Group Norms • Respect/Risk • Openness/Ouch • Participation/Pass • Education/Energy • Sensitivity/Safety
Video: Eye To Eye: Dr. Harold Freeman (6:14) Video found here
Overview & Importance Health home Model
Health Home: History & Goals • Patient Protection and Affordable Care Act (ACA) of 2010 (P.L. 111-148) Section 2703 • Goal to ultimately reduce costs and improve health for the highest needs/highest users of services among Medicaid beneficiaries
Chronic Care & ER • Chronic diseases are a major contributor to health care costs • Poorly managed chronic conditions may become acute conditions • Financial Cost
Health Home: Organization • Organizations are designated as Health Homes by DOH • Adult and Children’s Health Homes are separate • Health Homes make referrals to Care Management Agencies & build provider networks • Service Providers must have agreements with HH to refer
What is a Health Home? • What a Health Home isn’t… • A physical place • A medical home • What a Health Home is… • Care Coordination service delivery model • Coordinated medical & behavioral health care
What Is The Health Home Supposed To Do? • Assure access • Improve health outcomes • Reduce preventable hospitalizations and emergency room visits • Promote use of health information technology • Avoid the use of unnecessary care • Prevent adverse health outcomes
Ultimately, Health Home is designed to reduce costs and improve health for the highest needs/highest users of services among Medicaid beneficiaries
Who Is Eligible For Health Home Services? Individuals who: • Have Medicaid AND • Have either two chronic conditions OR a single qualifying condition AND • i.e. HIV/AIDS or Serious Mental Illness/Emotional Disturbance • Meet Appropriateness Criteria
“Chronic Condition” According to the Affordable Care Act, “eligible individuals with a “chronic condition” includes: • A serious mental health condition • A substance use disorder • Asthma, diabetes, heart disease, HIV/AIDS • Obesity as defined by a Body Mass Index (BMI) over 25
Appropriateness Criteria • Individuals meeting the Health Home eligibility criteria must be appropriate for Health Home care management • Assessing whether an individual is appropriate for Health Home services includes determining potential risk and current experience
Appropriateness Criteria • Probable Risk for Adverse events • e.g., death, disability, inpatient or nursing home admission, mandated preventive services, or out of home placement • Inadequate social/family/housing support, or serious disruptions in family relationships • Inadequate connectivity with health care system
Appropriateness Criteria • Does not adhere to treatments or has difficulty managing medications • Recently been released from incarceration, placement, detention, or psychiatric hospitalization • Deficits in activities of daily living, learning or cognition issues • Concurrently eligible/enrolled, along with either their child or caregiver, in a Health Home
What are they? Social Determinants of Health (sdoh)
Social Determinants of Health “The social determinants of health are the conditions in which people are born, grow up, live, work and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, social norms, social policies, and political systems.” --World Health Organization (WHO) .Social Determinants of Health are mostly responsible for “health inequities”
SDOH: Health Implications • Inadequate screening for diseases • Less preventive care • Delayed diagnoses • Late or inadequate treatment • Higher risk of death, illness & injury • Unhealthy behaviors
Health Literacy https://www.youtube.com/watch?v=7X4CoXIdlCA
What is Health Literacy? “Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”
What is Health Literacy? The degree to which an individual has the capacity to obtain, process, and understand basic health information and services needed to make appropriatehealth decisions
The National Survey Of Health Literacy found: Use a table to calculate an employee’s share of health insurance costs for a year Read a pamphlet and give 2 reasons for a screening test Read a prescription label and determine time to take meds Read instructions and identify what is permissible to drink before a medical test
The Big Disconnect Only 12% of Americans have a proficient level of health literacy, but our health care system generally caters to this 12%.
The Big Disconnect • Medication Instructions: “1 tablet, by mouth, twice a day, 10 days, for a total of 20.” • Insurance/Billing: “Your health plan doesn’t require that you pay a deductible, but your co-pay will be what is indicated for the office visit on your insurance card.”
The Big Disconnect • Immunization Recommendations: “While it isn’t clear whether people with HIV are susceptible to a more severe case of the flu than others, studies show that HIV-positive people tend to have higher rates of complications from influenza than others and more prolonged cases of flu and flu symptoms, so it is recommended that people living with HIV get a flu vaccine every year.” • Signage: “Ambulatory Care”
What is the Impact of limited health literacy? What is the Impact of Limited Health Literacy? People with low health literacy… People with low health literacy have more difficulty: • Navigating the healthcare system • Finding providers • Completing forms (registration, consent, billing) • Filling prescriptions • Sharing health information with providers • Enrolling in insurance
What is the Impact of limited health literacy? What is the Impact of Limited Health Literacy? People with low health literacy… People with low health literacy: • Use preventive services less • Use emergency rooms more • Have a higher incidence of chronic diseases • May have more difficulty with disease management • Have more difficulty taking medication properly • Increase health care costs $50 billion to $73 billion annually
Health Literacy RED FLAGS • Difficulty explaining symptoms • Use excuses to avoid reading (e.g. “I forgot my glasses.”) • Lots of papers folded up together-important, unimportant, and expired • Missed appointments • Difficulty explaining how to take medications • Take overly long or refuses to fill out forms.
Bring Up the Topic • “How far did you go in school?” • “A lot of people have trouble reading things they get from the doctor because of all the medical words. Is it hard for you to read the things you get here at the clinic?”
