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CC4C Orientation Module One April 2012

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CC4C Orientation

Module One

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Goals of Module One

Identify all agencies involved in the CC4C Partnership

Present a brief description of each partner

Introduce an overview of CC4C services

Share resources for CC4C Care Managers

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Care Coordination for Children (CC4C)

Brings together:

State Partners: DMA, DPH, & CCNC Central Office

Local Partners: LHDs & CCNC networks

CC4C & CCNC care managers

to 1) improve quality of care for children & families, 2) increase efficiency through collaboration, and 3)decrease cost. 4

Community Care of North Carolina

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Community Care of North Carolina

Statewide Program for Managing Carolina Access Recipients

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North Carolina Medicaid

1.5 Million Medicaid Recipients

1,233,000 enrolled in

a CCNC Medical Home

1542 Practices

4500+ Providers


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CCNC Origins Medical Home Capacity & Accountability

Started with 9 pilot networksSingle-disease initiatives

1998 asthma (data-driven, evidence-based guidelines, population-management approach, rapid cycle QI)

Other initiatives followed (DM, HF, etc.)

Achieved cost-savings & improved quality of care9 pilot networks grew to 14 Sustained Networks in 100 counties

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Local Community Care Networks

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Community Care Networks

Non-profit, Physician-led, Locally owned and operated organizationsReceive a designated amount of $$$ per Medicaid recipient enrolled in a CCNC practice in their Network per month from the Medicaid (Division of Medical Assistance/DMA)Funds the Primary Care Management modelPartner with other safety net providers Use existing resources to build better local systems of carelocal flexibility to create local solutions to local issuesHave Medical Management Committee oversight & Board of DirectorsParticipating Practices receive an enhanced pm/pm incentive to function as a medical home and participate in CCNC Initiatives (disease management and quality improvement)

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CCNC Networks

LegendAccessCare Network Sites Community Care Plan of Eastern CarolinaAccessCare Network Counties Community Health PartnersCommunity Care of Western North Carolina Northern Piedmont Community CareCommunity Care of the Lower Cape Fear Northwest Community CareCarolina Collaborative Community Care Partnership for Health ManagementCommunity Care of Wake and Johnston Counties Community Care of the Sandhills Community Care Partners of Greater Mecklenburg Community Care of Southern PiedmontCarolina Community Health Partnership

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CCNC Network TEAMS

>1500 Medical Homes/4500 Providers14 Network Directors30 Local Medical Directors>500 Local care managers (Embedded = 118 practices 48 hospitals)14 Local Psychiatrists>20 Local Clinical Pharmacists14 Local Palliative Care Champions14 Local Quality Improvement TeamsPartner w/local hospitals, health dept., other community agenciesCENTRAL SUPPORT:Team of clinical, quality, and data experts; Call CenterInformatics Center providing Quality & Care Management data to networks, practices, hospitals, other partners 12

FOCUS of CCNC

improved quality, utilization and cost

effectiveness of chronic illness care


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Managing Clinical Care(Spreading Best Practice)

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Chronic Care ModelOver time, visits/interactions (planned and acute) will

meet patient needs and assure the delivery of proven clinical and behavioral elements of care.

INFORMED PREPAREDACTIVATED PROACTIVEPATIENT TEAM

IMPROVED OUTCOMES http://www.improvingchroniccare.org

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CCNC Network Teams Support the Medical Home

Improved Care

Process Improvement

Evidence-Based Guidelines

Provider Engagement

Improved Utilization

Outcome Improvement

Education, Referrals, Follow-Up

Patient Engagement

Local Network Team

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Main Program ActivitiesManagement of Priority Populations

*TREO Priority Population List (PPL)*Patients in the Hospital/Transitional Care*Real-Time Referrals*Other Data Reports

Chronic Disease Management of Key Conditions (e.g. Asthma, Diabetes, Heart Failure, Hypertension, Ischemic Vascular Disease, Mental Health Conditions)

Medial Home Quality Improvement ActivitiesEmergency Department UtilizationIntegration of Physical and Mental HealthChronic Pain InitiativePrevention InitiativesPharmacy InitiativesPalliative CareInformatics Center/Pharmacy Home/Provider Portal/CMIS

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A few of the challenges…

The General Assembly charged DHHS (and CCNC) to save $90 million in FY2012 (July 2011 thru June 2012).

As of 8/11, enrolled ABD population ~ 205,400 (total ABDs >361,000; NC Medicaid population ~1.48 MM; those enrolled in Carolina Access II & III > 1,082,000).

With health reform, the NC Medicaid rolls may grow by more than 500,000 new recipients by 2014.

Total ABD population represents less than 25% of NC’s Medicaid population, but consumes more than 70% of Medicaid dollars.0% of Medicaid dollars.

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Primary Goals of Community Care

Improve the care of Medicaid population while controlling costsA “medical home” for patients, emphasizing primary careCommunity networks capable of managing recipient careLocal systems that improve management of chronic illness in both rural and urban settings


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CCNCNationally Recognized Impact

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www.communitycarenc.org/

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Division of Public Health

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Definition of Public Health:Public health consists of the activities that

society undertakes to assure the conditions inwhich people can be healthy, includingorganized efforts to prevent, identify andcounter threats to the health of the public.

Mission of NC Public Health:To promote and contribute to this highest level of health possible for the people of NC.

From Introduction to Public Healthhttp://www.sph.unc.edu/nciph/introduction_to_public_health_in_nc_6386_7857.html

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Ten Great Public Health Achievements in the United States, 1900‐1999

1. Vaccination 2. Motor‐vehicle safety 3. Safer workplaces 4. Control of infectious diseases 5. Decline in deaths from coronary heart disease and

stroke 6. Safer and healthier foods 7. Healthier mothers and babies8. Family planning 9. Fluoridation of drinking water 10. Recognition of tobacco use as a health hazard


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Title V of the Social Security Act

Is a block grant program

Is administered by the Maternal and Child Health Bureau (MCHB) within the US Dept of Health & Human Services

Combines Federal, State, and local funds to provide comprehensive services to low income women and children with limited access to health care services

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Title V of the Social Security Act

Medicaid, the Children’s Health Insurance Program (CHIP or NC Health Choice) and Title V serve many low‐income women and children, including children with special health care needs.

Medicaid and CHIP provide free or low cost health insurance to eligible participants.

Title V provides Federal block grant funds to States, where they support comprehensive services to women and children with limited access to health care services. The Title V Agency in NC is the Women's and Children's Health Section within NC Division of Public Health

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Title V MCH Programs1. Assure access to quality care, especially for those with low‐

incomes or limited availability of care;

2. Reduce infant mortality;

3. Provide and ensure access to comprehensive prenatal and postnatal care to women (especially low‐income and at risk pregnant women);

4. Increase the number of children receiving health assessmentsand follow‐up diagnostic and treatment services;

5. Provide and ensure access to preventive and child care services as well as rehabilitative services for certain children;

6. Implement family‐centered, community‐based, systems of coordinated care for children with special healthcare needs; and

7. Provide toll‐free hotlines and assistance in applying for services to pregnant women with infants and children who are eligible for Title XIX (Medicaid). 28

History of DPH Care/Case Management for Children ages 0‐5 years

Began the High Priority Infant Tracking program in 1978

Expanded and name changed to Child Service Coordination Program (CSCP) in 1989

Initially viewed CSCP as a care coordination service

With HIPAA code conversion in 2002, CSCP became a targeted case management service

CSCP services ceased on February 28, 2011

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Example of National Public Health Initiativeshttp://medicalhomeinfo.org/

29 30http://www.ncpublichealthquality.org/ctr/

Example of NC Public Health Initiatives


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31From Introduction to Public Healthhttp://www.sph.unc.edu/nciph/introduction_to_public_health_in_nc_6386_7857.html 323232

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http://publichealth.nc.gov/

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Additional PH Resources

This is Public Health campaign by Association of Schools of Public Health

View This is Public Health Video at: www.thisispublichealth.org/video_highres.html

Learn more about This is Public HealthCampaign at: www.thisispublichealth.org/

Introduction to Public Health – a free online, one hour course at: http://www.sph.unc.edu/nciph/introduction_to_public_health_in_nc_6386_7857.html

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Local Health Departments

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As of 1949, each NC county had established a local health department (LHD)

Today, all 100 counties are served by an individual LHD, except for the following multi‐county health departments:

Albemarle District (Bertie‐Camden‐Chowan‐Currituck‐Gates‐Pasquotank‐Perquimans)

Appalachian District (Alleghany‐Ashe‐Watauga)

Granville‐Vance District

Martin‐Tyrrell‐Washington District

Rutherford‐Polk‐McDowell District

Toe River (Avery‐Mitchell‐Yancey) District

•Each LHD is governed by a local Board of Health


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37http://www.ncalhd.org/county.htm 38http://www.ancbh.org/

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Care Coordination for Children

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Beginning March 1, 2011

Local Health Departments began providing Care Coordination for Children (CC4C) services in partnership with local CCNC networks.

The name of the CC4C service provided by LHDs is population Care Management.

The LHD staff providing CC4C services are referred to as CC4C Care Managers.

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CC4C Target PopulationChildren from birth to 5 years of age (both Medicaid & non‐Medicaid) who are:

Children with Special Health Care Needs

NICU Babies

In Foster Care & Not Linked to a Medical Home

Exposed to Toxic Stress in Early Childhood

Children Flagged on a Priority Population List Based on Above‐Expected Potentially Preventable Hospital Costs

Other children identified through claims data reports that could benefit from follow‐up and/or transitional care services 42

CC4C Responsibilities CC4C CMs are responsible for all the children 0‐5 in their county who are in the CC4C Target Population. In order to meet this responsibility, CC4C CMs will:

• level the service based on the family’s needs (e.g. heavy, medium, light)

• determine the length of time that services are provided depending on family’s need and evidence that progress is being made


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CC4C Medical Home ResponsibilitiesCC4C CMs are required to work with the Medical Homes (MH) by:

Linking or embedding CC4C CMs with MH practices

Communicating and collaborating with MH for children in CC4C Target Population in order to best meet child/family needs

Note: Recruitment of CC4C MH is not a program focus, as most MHs serving children 0‐5 years were already enrolled as CCNC providers. However, assuring that children we serve are linked to Medical Homes is a priority.

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Performance MetricsCC4C Contract Metrics [Reported to DMA]

PM #1:

Increase in NICU graduates who have their first PCP visit

within one month of discharge.

PM #2:

Reduce the rate of hospital admissions for children birth to <5.

PM #3:

Decrease the rate of readmissions for children birth to <5.

PM #4:

Reduce the rate of ED visits for children birth to <5. 46

Performance MetricsCC4C Contract Metrics [Continued]

PM #5:

Increase percent of comprehensive assessments completed for CC4C patients identified as having a priority (heavy/medium case status).

PM #6:

Increase the Life Skills Progression (LSP) Assessments for the targeted population of children ages birth to five (Toxic Stress) receiving care coordination through CC4C on entry into the system, every six (6) months thereafter and/or upon closing.

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CC4C Program Measures

Increase the # (and rate) of infants < 1 year of age referred to Early Intervention (EI) Program.

Increase the percent of children with special health care needs enrolled in a medical home.

Increase the percent of children in foster care who are enrolled in a medical home.

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MEASURES

Success = Meeting Performance Metrics and Program Measures

Meeting Measures depends on:

1. # of children touched

2. Actions taken when touching

CCNC has long history of meeting measures that demonstrate ↑ quality & ↓cost.


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CC4C Funding

To assist in meeting the responsibilities of the CC4C Target Population, the LHDs:

receive a Per Member Per Month (PMPM) allocation to serve Medicaid clients; amount of PMPM is based on the number of Medicaid children 0‐5 years in each county.

have the opportunity to draw down CC4C Agreement Addenda funding to serve non‐Medicaidchildren; level of funding is consistent with past CSCP AA funding.

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Cheryl LoweCC4C Program ManagerDivision of Public Health

WCH Section / C & Y BranchWork Cell: 336‐813‐[email protected]

CC4C Program Development

Carolyn SextonCC4C Project ManagerCCNC Central OfficeOffice: 919‐745‐2428

[email protected]

CC4C WorkgroupDPH, DMA, CCNC’s Central Office, Physician Community, Local CCNC Networks, Local HDs & the DPH C&Y Family

Council.

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Pulling it all together 52

Exhibit A: LHD responsibilities in providing CC4C services (page 11)

Exhibit B: CC4C Performance Measures (page 15)

Exhibit C: Payment (page 16)

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A critical component to the success of the CC4C Program is establishing a close relationship between the local CCNC & the LHD

To achieve a fully integrated and collaborative system of care, decisions about how to manage the targeted populations must be decided at the community level ‐ building on the strengths and resources that each partner offers.

Together we will also need to determine how we can build strong,stable relationships and communications between CCNC Care Managers, CC4C Care Managers and the Medical Homes they serve.

Together we will monitor progress and discuss strategies for achieving the outcome measures of the CC4C Program (many of which are objectives that we share).

Care Coordination for Children (CC4C)

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CC4C Resources


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Possible Responsibilities of Network Lead CC4C Contact

1. Responsible for CC4C and other network duties

2. Facilitates regular meetings of local CC4C staff

3. Provides CMIS support

4. Monitors CMIS activities

5. Knowledgeable of Medical Homes in each county

6. Works with local Medical Homes to ensure close working relationship with CC4C CMs

7. Discusses local network case load & face‐to‐face expectations

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Possible Responsibilities of DPH Regional Child Health Nurse Consultants (CHNCs)

1. Provides technical assistance to a region of LHDs for CH Programs, including CC4C

2. Monitors the number of cases and staffing

3. If a need is identified, works with the agency using QI tools todevelop a step‐by‐step plan to address the need, including timelines.

4. Provides support to regional meetings for CC4C staff and network staff (role varies from network to network).

5. Support CC4C CM orientation and training needs.

6. Provide training and support to local health department staff on using the Quality Improvement Model.

5858Department of Health and Human Services • Division of Public Health • Women’s and Children’s Health Section • Children & Youth Branch

Child Health & CC4C Nurse ConsultantsRegional consultants are initial contact for CC4C & Child Health programs

Buncombe

Anson

Ashe

Beaufort

Bertie

Bladen

Brunswick

Burke

Caldwell

Carteret

Caswell

CatawbaChatham

CherokeeClay

Columbus

Dare

Davie

Duplin

ForsythFranklin

Gaston

Gates

Graham

Greene

Guilford

Halifax

Harnett

Hertford

Hoke

Hyde

Iredell

Jackson

Johnston

Jones

Lee

Lenoir

McDowell

Macon

MadisonMartin

Moore

Nash

NewHanover

Northampton

Onslow

Orange

Pamlico

Pender

Person

Pitt

Polk

Randolph

Robeson

Rockingham

Rowan

Rutherford

Sampson

Scotland

Stanly

StokesSurry

Swain

Transylvania

Tyrrell

Union

Wake

Warren

Washington

Watauga

Wayne

Wilkes

Wilson

Yadkin

Yancey

Chowan

PasquotankPerquimans

CamdenCurrituck

MontgomeryHenderson

GranvilleVance

Durham

Mecklenburg

Lincoln Cabarrus

Richmond Cumberland

Alexander

Craven

Haywood

Alleghany

Mitchell Avery

Cleveland

Alamance

DavidsonEdgecombe

REGION 2

Melody McCune [email protected]: 336-940-2358Fax: 336-940-2349Cell: 704-662-2108

REGION 5

Lynette Robinson [email protected]: 252-223-2016Fax: 252-223-2029Cell: 252-514-5905

REGION 4

Stephanie [email protected]: 919-266-9524Fax: 919-266-9527Cell: 252-571-2387

Greene

BEST PRACTICENURSE CONSULTANT

Jackie [email protected]: 252-678-3247

1A

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STATE CHILD HEALTH NURSE CONSULTANT

Jean [email protected]: 919-707-5644Cell: 919-609-2904Fax: 919-870-4880

Effective February 1, 2012

Bertie

STATE CHILD CARE CONSULTANT

Debra [email protected]: 919-707-5646Fax: 919-870-4880

Davie

REGION 1A

Linda Harrison [email protected]: 828-369-6940Fax: 828-369-8231Cell: 828-342-4265

CHILD CARE FOR CHILDREN(CC4C) PROGRAM MANAGER

Cheryl [email protected]: 336-813-2068

REGION 3

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REGION 1B

Robin [email protected]: 828-697-4615Fax: 828-697-4616Cell: 919-624-6652

1B

REGION 6

Angel [email protected]:Fax: Cell: 919-218-6522

Map available at:http://ncdhhs.gov/dph/wch/doc/aboutus/maps/CHNC-MAP-020112.pdf

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CC4C Webinar for Supervisors & Care Managers

1st Thursday of every month

2:00 p.m.

Via the internet

Announcement sent via the CC4C Email List

Handouts posted on the CC4C Training Web Page at http://childrenyouth.cc4c.sgizmo.com/s3/

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Strong Partnership = Success

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