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“The Project Described is supported by Funding Opportunity Number CMS 1C1-12-0001 from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation”. Northland . Care coordination for seniors.
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“The Project Described is supported by Funding Opportunity Number CMS 1C1-12-0001 from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation” Northland Care coordination for seniors “Contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.”
What is Northland? • What do we do • Services • Programs
Northland Services • Account Management • Anesthesia Equipment • Benchmarking Services • BioMed Equipment Services • Capital Equipment Maintenance • Capital Equipment Acquisition Services • Collections • Community Reporting • Care Coordination • Grants Management • Grant Writing Services • Infectious Waste Disposal • Information Technology • Leadership Training • Medical Records Review • Mobile Imaging • Natural Gas Purchasing • PACE • Sterilizer Maintenances • Sterilizer Installation • Supply Management Services • Telemedicine
Northland PACE • Began work with PACE in 2004 • Attend Rural PACE meeting • One of 14 sites to receive a CMS Core Grant.
An expansion of an idea • ALTC Concept • Modify PACE • Innovation Funding • Gave it a shot
Idea overview Basic principles
Conceptual design • Bounced idea off members • Modified concepts • Developed funding proposal • Developed a PACE-like Model
The aim • To use the PACE model of care as a means of maintaining and improving the health of the frail elderly for less cost to the healthcare system over time.
Goals/Drivers • Goal 1: Create a Rural Community Partnership to increase the access of healthcare services to the rural elderly. LOWER COSTS • Care management will increase the utilization of cost-effective services. • Coordinate services for the elderly at the right place and the right time. • Reduce ER visits, better coordination of prescriptions and medicines, reduction of medication errors, etc. • Use prevention to reduce readmissions to long term care and acute care.
Goals/Drivers • Goal 2: Introduce a variation of the PACE Model in the rural areas that will increase the services available and expand options of care to maintain health and independence in a safe environment. BETTER HEALTHCARE • Lighter model will include limited coordinated care assessments and planning. • Limited integrated disciplinary team will create a plan of care and recommend improvements to the participant’s primary provider. • CCCs will assist with the coordination of care for the participant.
Goals/Drivers • Goal 3: Improve and/or maintain the health of participants in six rural communities by increasing collaboration or providers and using better information along with defined processes that are a part of the PACE Model. BETTER HEALTH • Develop of core interdisciplinary teams • Recruitment and education of that local team along with community healthcare providers • Implementation of care assessments • Track services and interventions in order to measure the effectiveness of the coordination efforts.
Specifics • Community Care Coordinator in each community • Telemedicine available • Enrollment goal • 845 end of three years • Community Care Coordinators • Clinical personnel • Complete intake/admission assessments • Develop Care Plan with Interdisciplinary Team • Reassessment every six months • Communication with Care Participant as needed • Communication with Primary Care Provider
Budget • Three year cooperative agreement – total $2.7 million • Interdisciplinary Team Member fees • Care Coordination Service fees • Personnel and Travel • Supplies • Marketing items
Progress • Community Care Coordinators hired and trained • Networking in communities • Home Health Agencies • Physicians • Senior Centers • Parish Nurse Programs • Public Health • Volunteer programs • PACE • Revised and improving metrics • Enrolling Care Participants • Program “kicked off” January 31, 2013
Policies & Procedures • Marketing Workflow • Eligibility requirements • Enrollment Workflow • Contact request form • Enrollment Agreement form • Release of Information • Participant Intake form • Memorandum of Understanding • Referral follow up letters • Assessment Workflow • Care Plan Workflow • IDT Workflow • Reporting Workflow
Benefits to Northland • Provides Flexibility to Learn Care Coordination • Provides Expanded Program of Services • Provides a Marketing Tool with PACE
Challenges • Bureacratic partners (not unlike PACE challenge) • Need to demonstrate savings • Enrolling as fast as we need to • Hiring adequate staff as enrollment increases • Finding the right staff • Consistency and flexibility
Replication • Impossible (just kidding) • This is not really a new concept • Challenge to fund the services • Believe that this services has value • Intend to market as a service to insurance companies and possibly CMS and the State
Sustainability • Lost Leader Service for PACE Marketing • Package Services to Work with Insurance Companies and work with Integrated Delivery Networks to reduce costs • Develop a Slate of Services and Gear up to Charge (billing???)
