PREGNANT
CLIENT
Pathways
Community
HUB Model
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Community
HUB
Care
coordination
agencies
Client
Community Care
Coordinator
Regional organization
and tracking of care
coordination
2
Definition of Care Coordination
“Care coordination is the deliberate organization of
patient care activities between two or more
participants (including the patient) involved in a
patient's care to facilitate the appropriate delivery of
health care services. Organizing care involves the
marshalling of personnel and other resources needed
to carry out all required patient care activities and is
often managed by the exchange of information among
participants responsible for different aspects of care."
AHRQ Care Coordination Measures Atlas Update, June 2014
Direct
Services =
Intervention
Care
Coordination =
clinic based
Community
Care
Coordination =
home based
Community Care Coordination – care coordination
provided in the community; confirms connection
to health and social services.
A Community Care Coordinator:
•
•
•
•
Finds and engages at-risk individuals
Completes comprehensive risk assessments
Confirms connection to care
Tracks and measures results
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Care Coordination
“While all experts with whom we spoke agreed that better
communication with community organizations and social services is
critical, especially for Patient Centered Medical Homes (PCMHs)
that focus on treating low-income patients or frail elders, many
describe the connections with the broader community as the
most challenging for the medical neighborhood at large.
. . . connections between primary care and community
services . . . simply are absent or highly fragmented and
disorganized.”
AHRQ #11-0064: White Paper on Coordinating Care in the
Medical Neighborhood
Why do we need Community Care
Coordination?
• More than ½ of patients can’t state their diagnosis
when leaving the hospital.
• More than ⅓ of patients can’t explain their
medications.
• Less than ½ of patients saw a primary care
physician within 2 weeks of leaving the hospital.
• 1 in 5 patients has an adverse event transitioning
from hospital to home. 2 out of 3 events are
related to prescriptions!
Key Points in Building a HUB
• The HUB must be a neutral entity in the community and
cannot employ its own care coordinators.
• There is only one Pathways Community HUB in a
community or region.
• The HUB must be an independent legal entity or an affiliated
component of a legal entity.
• The HUB must be based in the community or region it
serves.
• There must be a Community Advisory Board made up of
members reflecting the community or region the HUB
serves.
8
AHRQ
Pathways
Community
HUB Manual
9
Who conducts National
Certification?
Collaborating Partners
Georgia Health Policy Center (GHPC)
Community Health Access Project (CHAP)
The Rockville Institute (RI)
Communities Joined in Action (CJA)
Benefits of Pathways Community HUB
Certification Project
A framework for standardizing how community care
coordination services are organized, delivered,
measured, and financed
Tools, metrics, and mechanisms developed that can be
used to monitor, assess, and evaluate various aspects
of community care coordination services
Demonstration of your HUB’s accomplishments
TIERED CERTIFICATION DESIGNATIONS
The Pathways Community HUB Certification Designations
Three designations are available for Community HUB certification:
 Provisional Certification Designation is granted when a HUB
demonstrates compliance with less than 80% of the standards; and
meets all of the prerequisites.
 Level I Certification Designation is granted when a HUB demonstrates
compliance with 80% or more of the certification requirements.
 Level II Certification Designation is granted when a HUB demonstrates
100% compliance with the certification requirements.
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HUB Certification Life Cycle
Initial Certification Desk Review  Recertification
INITIAL
CERTIFICATION
DESK AUDIT
REVIEW
RECERTIFICATION
• Initial Certification- requires the HUB ‘s completion of all of the action
steps that are delineated in the certification process. The initial
certification status remains in effect for two years, barring any
indications requiring revocation of certification status.
• Desk Audit Review-HUB maintenance of certification status requires
submission of an application for a Desk Audit Review at the end of the
two-year period. At this stage in the certification process, a site visit is
not required. However, a HUB must participate in a comprehensive
review of current documentation to ensure continued compliance with
the standards.
• Recertification –HUBs are able to maintain certification status by
submitting an application for re-certification at the end of the fourth year
of certification. This process requires the HUB to complete the same
action steps as required during the initial application, including
participation in a formal site visit.
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Key Steps in the Certification Process
(5)
RECOMMENDATION TO
EVALUATION REVIEW
PANEL
(4)
FEEDBACK AND
HUB IMPROVEMENT
ACTION PLAN
(6)
DETERMINATION OF
CERTIFICATION
STATUS AND
DESIGNATION
(1)
APPLICATION
(3)
COMPLIANCE REVIEW
AND ASSESSMENT
(2)
CONSULTATION &
TECHNICAL ASSISTANCE
THE CERTIFICATION PROCESS
1) Application
 HUB contacts the Pathways Community HUB
Certification Program at the Rockville Institute to
request application or downloads application
from the certification website
2) Consultation & Technical Assistance
 A certification staff member consults with the HUB
Director and determines if Technical Assistance (TA)
is needed
 Staff members sends the certification packet
electronically to the HUB or HUB staff accesses the
materials online from the certification program
website.
 HUB submits completed application
 A certification staff member performs an initial
assessment of the HUB’s eligibility for certification
and assigns the HUB to a certification assessor—
contingent upon the HUB’s eligibility to move
forward.
 If the HUB is not ready to advance to the next steps,
the certification staff member refers the HUB
Director to the Pathways Community HUB Institute
for individualized TA services.
3) Compliance Review and Assessment
 For those HUBs that are determined ready to
move forward with certification……
 The assessor contacts the HUB Director to
acquaint him/her with the certification
process and to respond to questions
 Assessor reviews the HUB Work Sheet and
provides a detailed description of the type
of documentation that is required to
complete the review process.
 The process for completing the HUB
Worksheet is similar to a self-study
questionnaire that many
accreditation/certification bodies require.
It provides the HUB with an opportunity to
assess their operations and the adequacy
of their documentation.
3) Compliance Review and Assessment
(continued)
 Once the HUB staff completes and submits the
HUB Worksheet along with other relevant
documentation to the certification assessor, a
site visit is scheduled.
 Planning for the site visit is an interactive
engagement process during which a discussion
of the agenda for the site visit occurs.
 Typically, the site visit agenda includes an
opportunity for the certification assessor to
meet with the HUB Director, staff, and
stakeholders.
 The agenda also allocates time for the assessor
to review required documentation and to visit
one or more CCAs.
4) Feedback and HUB Improvement Action Plan
 The certification process fosters a continuous
learning organization, so there will always be
opportunities for improvements.
 A HUB Improvement Action Plan is created for
all HUBs that pursue certification (not limited
just to deficiencies, but provides an opportunity
to identify areas that the HUBs could enhance.)
 The Assessor communicates with the HUB
Director and reaches agreement about the
areas in need of improvement and a timeframe
for resolving needed improvements.
 An agreement is then signed and an iterative
process is used to update the plan.
5) Recommendation to Evaluation Review Panel
(ERP)
 On the basis of the review/assessment process
and the status of the HUB Improvement Action
Plan, the Assessor recommends whether the
HUB is eligible for further review and
consideration by the ERP or whether further TA
is needed to improve HUB compliance with the
prerequisites and standards.
Who ensures that the HUB
model is effective?
STANDARD #4 -- The HUB engages and is
advised by a Community Advisory Board.
To ensure the HUB understands and meets the needs of those
who are at risk, the HUB leverages existing community
resources and seeks to add value to the community. Local
leaders, therefore, need to be meaningfully engaged and
empowered to guide and advise the strategies of the HUB.
What tested Pathways
currently exist?
20 Core Pathways – National Certification
•
•
•
•
•
•
•
•
Adult Education
Employment
Health Insurance
Housing
Medical Home
Medical Referral
Medication Assessment
Medication
Management
• Smoking Cessation
• Social Service Referral
• Behavioral Referral
• Developmental
Screening
• Developmental Referral
• Education
• Family Planning
• Immunization
Screening
• Immunization Referral
• Lead Screening
• Pregnancy
• Postpartum
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Example – United Healthcare 2015 contract
Normal
Risk
RVU
High
Risk
RVU
Modifier
Completed one time at Member enrollment
G9001
7
G9003
9
A1
Completed at each face-to-face encounter with
Member
G9005
2
G9010
4
A1
G9002
4
G9009
5
AB
G9002
1
G9009
1
AE
LARC (long-acting, reversible) or permanent
method
All other family planning methods
G9002
5
G9009
6
G1
G9002
4
G9009
5
G2
Residing in affordable & suitable housing for 2
months.
Confirmation of kept appointment with medical
home.
G9002
9
G9009
10
AI
G9002
5
G9009
6
AM
Checklists
Initial
Adult
Checklist
Adult
Checklist
Pathways
Behavior Kept three scheduled behavioral
al Health appointments
Education Educational module delivered.
Family
Planning
Family
Planning
Housing
Medical
Home
health
Transportation
What about adding new Pathways?
The Pathways Community HUB Institute (PCHI) would take any
applications for new Pathways:
• HUB Certification requires that you have all 20 Pathways in
place before requesting a new Pathway.
• Pathways can be “bundled” to reach larger outcomes.
• New Pathways that are developed would need to be applied
across full HUB network.
For children ages 20 and under
1. Childhood immunization status
Immunization Screening and Referral Pathways
2. Well-child visits in the 3rd, 4th, 5th and 6th years of life
Medical Referral Pathways
3. Medication management for people with asthma
Medication Assessment and Medication Management Pathways
EPSDT “Bundles”
EPSDT
0 – 6 months
7 – 12 months
13 – 18 months
19 – 24 months
25 – 36 months
4 years
5 years
6 years
CODE
G9011
RVU
4
Mod.
10
G9011
4
11
G9011
4
12
G9011
4
13
G9011
4
14
1 Medical Referral (well child), 2 Education, optional – 1 G9011
Immunization Screening
1 Medical Referral (well child), 2 Education, optional – 1 G9011
Immunization Screening
1 Medical Referral (well child), 2 Education, optional – 1 G9011
Immunization Screening (Immunization Referral if
needed)
4
15
4
16
4
17
1 Medical Home, 4 Medical Referrals (well child), 3
Immunization Screenings, 1 Developmental Screening,
2 Education
2 Medical Referrals (well child), 1 Immunization
Screening, 1 Developmental Screening, 1 Lead, 2
Education
1 Medical Referral (well child), 1 Immunization
Screening, 1 Developmental Screening, 2 Education
1 Medical Referral (well child), 1 Developmental
Screening, 1 Lead, 2 Education
2 Medical Referrals (well child), 2 Education
For Adults age 21 and up:
1.
2.
3.
4.
Controlling high blood pressure
Comprehensive Diabetes Care (HbA1c) poor control
Comprehensive Diabetes Care: blood pressure control
Antidepressant medication management: effective acute
phase treatment, and effective continuation treatment
Example of a “bundle” (UHC contract – 2015)
Hospital Readmission
Basic
G9011 52
RVU = 7
Intensive
G9011 53
RVU = 10
1 Medical Home and/or Medical Referral (primary care), 1
Medication Assessment, 1 Social Service Referral, 2
Education, 1 Tool (PAM, PHQ9, etc.), no readmissions
from date of hospital discharge for 30 days
Basic Hospital Readmission Bundle plus 1 Medical Referral
(specialty care), 1 Medication Management, 2 Social
Service Referral, 2 Education, any 2 of the following: Adult
Education, Behavioral Health, Employment, Housing,
Smoking Cessation, no readmissions from date of hospital
discharge for 30 days
Diabetes “Bundle”
Diabetes
CODE RVU
1 Medical Home and/or Medical Referral G9011
(primary care), 1 Medical Referral
(specialty care), 1 Medication Assessment,
1 Social Service Referral, 3 Education –
Diabetes specific modules, HgbA1c
reduced by 1 point
Intensive Basic Diabetes Bundle plus 1 Medication G9011
Management, 2 Social Service Referral, 2
Education, any 2 of the following: Adult
Education, Behavioral Health,
Employment, Housing, Smoking Cessation,
HgbA1c reduced by 1 point
Basic
Mod.
7
54
10
55
The Health Home Program was created by Affordable Care
Act (ACA) section 2703. It allows states to provide Health
Home services and care coordination to high cost high risk
Medicaid and Medicare/Medicaid (duals) eligible clients. Its
purpose is to reduce duplication of services and provide
smoother transition and more personalized care to help
reduce the progression of chronic disease, reduce
inappropriate emergency department utilization and
preventable hospital readmissions, and improve health and
self-management of conditions.
Health Homes – January 2016 preliminary findings
• 10,632 individuals by the end of
6th quarter (over 7 million by
July 1, 2015; 6.6% increase
since 2010
• 6% savings
• Positive impact in PMPM Medicare
spending
• Health Homes in 37 Counties