NORTH CAROLINA
Case Study Transitional Care Program Table of Contents
TABLE OF CONTENTS
2 Executive Summary 3 Glossary of Acronyms 5 Introduction 6 Methods 7 Data Management 8 North Carolina Background 10 The Problem—Transitional Care 12 The Problem—Improving Care Coordination and Identifying At-Risk Patients 14 Policy Development and Implementation 23 Outcomes 28 Sustainability and Transferability 29 Lessons Learned 33 Conclusion 34 References 41 Appendices 41 Appendix 1: de Beaumont Medicaid-Public Health Expert Group Members 43 Appendix 2: Interview Instrument 46 Appendix 3: Interview Data Collection Tool 49 Appendix 4: Document Review Data Collection Tool 51 Timeline
1 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Executive Summary
EXECUTIVE SUMMARY
For the better part of the last decade, North Carolina has been at the cutting edge of managing the costs and quality of healthcare and related services for its most vulnerable populations. Central to this suite of offerings has been Community Care of North Carolina (CCNC), a statewide, physician-led, public-private partnership that links Medicaid recipients to primary care patient-centered medical homes. Specifically, this case study examines how Medicaid, public health, and CCNC worked together to improve transitional care for at-risk patients in North Carolina. Based upon a foundation of electronic data collection, analysis, and communication, this transitional care program enjoyed growth and stability as a result of its demonstrated positive impact upon key components of the Institute for Health Improvement’s Triple Aim—improving the health of the population, enhancing the quality of care and patient experience, and reducing per capita healthcare costs.
The North Carolina Division of Medical Assistance (Medicaid) and the Office of Rural Health have been CCNC’s essential partners since its early beginning as the Wilson County Health Plan. With the expansion of the program in the early 2000s, the North Carolina Division of Public Health (DPH) has also been engaged in each implementation stage. In particular, DPH played a key role in the development of the statewide surveillance system, which was critical as it allowed CCNC to know whether an individual was in the hospital for their transitional care program in real-time. As such, key components for the program’s success include leadership alignment at the very top offices of state government; strong, long-standing working relationships between agencies, notably between public health and Medicaid personnel at the state and local levels; recognition of how essential reliable technology is to the identification of at-risk patients and communication between providers; and mission-driven individuals.
Although North Carolina experienced a seemingly lucky combination of technology and resources to make this program work, other states or regions may be able to adopt pieces of the complex program, since so much of the implementation components are open source or available in published articles. Positive outcomes for this challenging target population involve leveraging medical, technological, and public health resources. Stakeholders need a combination of political will, collaboration, and skill in alignment for a program like this to succeed.
In late 2015, North Carolina’s General Assembly passed House Bill 312, which was signed into law by Gov. Pat McCrory. This law is likely to change the landscape of care delivery in North Carolina including potential changes that may impact CCNC.
2 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Glossary of Acronyms
GLOSSARY OF ACRONYMS
ACO Accountable Care Organizations ACA Affordable Care Act ABD Aged, Blind, and Disabled ADT Admission, Discharge, or Transfer ASTHO The Association for State and Territorial Health Officials CMIS Case Management Information System CDC Centers for Disease Control and Prevention CMS Centers for Medicare and Medicaid Services CHIP Children’s Health Insurance Program CRGs Clinical Risk Groups CCNC Community Care of North Carolina DEEDS Data Elements for Emergency Department Systems DHHS North Carolina Department of Health and Human Services DMA North Carolina Division of Medical Assistance DPH North Carolina Division of Public Health EHR Electronic Health Record ED Emergency Department FMAP Federal Medical Assistance Percentage HIE Health Information Exchange HIT Health Information Technology HITECH Health Information Technology for Economic and Clinical Health Act NC DETECT North Carolina Disease Event Tracking and Epidemiologic Collection Tool NCEDD North Carolina Emergency Department Database NCFAHP North Carolina Foundation for Advanced Health Programs, Inc. NCHA North Carolina Hospital Association NCHESS North Carolina Hospital Emergency Surveillance System ORH North Carolina Office of Rural Health PMPM Per Member Per Month PCCM Primary Care Case Management
3 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Glossary of Acronyms
PCMH Patient-Centered Medical Home PCP Primary Care Provider ROI Return on Investment SPA State Plan Amendment UNC University of North Carolina
4 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Introduction
INTRODUCTION
Project Overview With support from the de Beaumont Foundation, ASTHO has created a series of six case studies designed to describe successful collaborations between state public health departments and Medicaid agencies in which a state implemented an innovative policy change. For the purpose of this series, success is defined as demonstration of—or evident promise of—improvements in population health, cost savings to Medicaid, or both.
ASTHO and the de Beaumont Foundation convened a diverse expert group in May 2014 and provided essential guidance in choosing the programs featured in the series of case studies. This case study describes the innovations undertaken in North Carolina to improve care coordination for individuals transitioning from inpatient care.
The de Beaumont Foundation The de Beaumont Foundation believes that a strong public health system is essential. The foundation works to transform the practice of public health through strategic and engaged grant-making. Programs funded by the foundation build the capacity and stature of the public health workforce, improve public health infrastructure, and advance the distribution and relevancy of information and data in the field. Please visit www.debeaumont.org for more information.
ASTHO ASTHO is a 501(c)(3) nonprofit membership association serving the chiefs of state and territorial health agencies and the more than 100,000 public health staff that work in those agencies. Its mission, from which its organizational strategy flows, is to transform public health within states and territories to help members dramatically improve health and wellness. ASTHO tracks, evaluates, and advises members on the impact and formation of policy—public or private—pertaining to health that may affect state or territorial health agencies’ administration and provides guidance and technical assistance to its members on improving the nation’s health. ASTHO supports its members on a wide range of topics based on their needs, including, but not limited to, ASTHO’s leadership role in promoting health equity, integrating public health and clinical medicine, responding to emergencies, and bringing voluntary national accreditation to fruition through the Public Health Accreditation Board. Please visit www.astho.org for more information.
5 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Methods
METHODS
Interviews The project team, consisting of Lisa Dulsky Watkins, Brian Costello, and Megan Miller, interviewed 11 individuals involved in the development and implementation of North Carolina’s data-driven transitional care coordination program:
One Medicaid senior official.
One leader in public health at the North Carolina Department of Health and Human Services (DHHS).
Five statewide officials at Community Care of North Carolina (CCNC).
Three regional CCNC directors.
An officer at a CCNC-partnering information exchange.
A project team member, Lisa Dulsky Watkins, led forty-five minute to one-hour phone interviews using identical questions from a standardized interview tool. Two additional team members served as note-takers, listening to and documenting each conversation. The interviews were recorded and, if necessary, transcribed for clarification. Data gathered from each interview was recorded into a data collection tool for analysis.
Document Review With assistance from the interviewees and through independent research, the team collected government resources, news articles, and educational material on the case study topic. Project team members selected the most relevant documents for further review. All documents are listed in the references.
6 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Data Management
DATA MANAGEMENT
Data Synthesis The project team developed three tools to facilitate data collection for the case studies: (1) the interview instrument, (2) the interview data collection tool, and (3) the document review data collection tool. These items are located in the appendices.
The interview instrument (see Appendix 2) included a structured set of questions designed to address the domains of interest suggested by the expert group (see Appendix 1), and focused on three primary domains: the interviewee’s interaction with the policy change, the processes by which the policy change was implemented, and the impact of the policy change. Following each interview, the two note-takers entered their notes into the interview data collection tool (see Appendix 3), which designated where content from the interview fit best into the various coding categories. Next, the two note-takers collaborated to create a consensus document for each interview. To do this, they compared summary documents and reached agreement regarding any discrepancies in their accounts of the content of the interview and categorization of the content. The primary interviewer then reviewed the consensus document. The team created a similar tool to gather information from documents reviewed for each case study (see Appendix 4). The document was double-coded by two researchers and reviewed by a third, primary researcher.
Data Analysis The project team entered interview content and consensus data collection tool documents into NVivo 10 (QSR International, Cambridge, MA), a qualitative research software, assigning codes and reviewing the content from the interviews and documents. These codes facilitated organization and analysis for each case study in the series and the cross-case study analysis. The team used a multiple-case replication approach to examine major points of interaction between Medicaid and public health which resulted in (1) population health improvement or (2) Medicaid cost savings.1 Additionally, the team analyzed interview and document review data to examine points of convergence and divergence, with respect to the processes and drivers of several significant policy changes at the state and local levels.
7 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM North Carolina Background
NORTH CAROLINA BACKGROUND
Demographics According to the 2014 United States Census Bureau, North Carolina has a population of 9.9 million, and its residents are 64.4 percent non-Hispanic white, 22.0 percent black, 8.9 percent Hispanic, 2.6 percent Asian, and 1.6 percent Native American. North Carolina covers more than 48,000 square miles in the Southeast United States, and is more rural than average: 22.2 percent of the population lives in towns with 2,500–50,000 people.2 As of May 2015, 1.9 million residents (19.5 percent of the population) were enrolled in Medicaid or the Children’s Health Insurance Program (CHIP). To date, North Carolina has not expanded Medicaid eligibility as allowed by the Affordable Care Act (ACA).3
Administrative Infrastructure DHHS manages the state’s health and social service programs. It is divided into 30 divisions and offices, including the Division of Medical Assistance (DMA), which manages Medicaid, the Division of Public Health (DPH), and the Office of Rural Health (ORH).4,5 DPH collaborates with federal agencies and organizations, local health departments, community health centers, hospitals, practitioners, and community agencies and organizations to promote and maintain the health of its residents.6 ORH aims to improve the quality and cost-effectiveness of healthcare and access to health services in rural communities by recruiting healthcare professionals and establishing related services.7 ORH, DMA, DPH, and other state agencies work together to develop and support community-based approaches that target underserved populations.
Community Care of North Carolina: Overview CCNC is a statewide, physician-led, public-private partnership that links Medicaid recipients to primary care patient-centered medical homes (PCMHs) to improve the quality of healthcare services and contain healthcare costs for North Carolina’s most vulnerable patient populations.8,9,10 As of August 2015, the CCNC network included 90 percent of North Carolina’s primary care practices (1,820 practices) and served 1.4 million Medicaid beneficiaries statewide.11 CCNC is composed of 14 regional networks that collaborate with local primary care practices, public health departments, hospitals, pharmacies, and social service agencies. Although they share many similarities, regional CCNC models vary in population density and other demographic factors.12
8 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM North Carolina Background
History of Community Care of North Carolina ORH and DMA have been essential CCNC partners since its inception more than 30 years ago. ORH was responsible for program operations, technical assistance, and data collection, analysis, and reporting during CCNC’s early development. DMA provided financing and has proposed and supported policy and regulations for CCNC’s development and continuing operation. With grant funding from the Kate B. Reynolds Health Care Trust, from 1983 to 1985 DMA and ORH partnered with the North Carolina Foundation for Advanced Health Programs (NCFAHP) to develop the first iteration of CCNC, the Wilson County Health Plan. This plan aimed to reduce emergency department (ED) visits for county Medicaid recipients by improving access to primary care and coordinating with social services.13
The Wilson County Health Plan successfully reduced healthcare spending. From 1989 to 1991, NCFAHP and its partners built on this success under an expanded model called Carolina ACCESS. This program grew throughout the 1990s, and by 1997 was in place in 99 out of the 100 North Carolina counties. To support this expansion, DMA and ORH obtained a 1915(b) federal waiver for primary care case management (PCCM) operations, which provided sustainable funding through a $3 per member per month (PMPM) payment.14,15
In the late 1990s, federal proposals shifted more financial responsibility for Medicaid to states. DHHS Secretary David Bruton responded by providing financial and fiscal support for networks like Carolina ACCESS, including for case management and clinical support. He also emphasized the importance of population health management and the role of data in making healthcare decisions.16
In the early 2000s the state experienced an economic downturn, and new DHHS Secretary Carmen Hooker Odom faced pressure to decrease Medicaid spending.17 The secretary and her team reviewed the efforts of Carolina ACCESS and found the results they sought—cost savings and quality improvement. Secretary Hooker Odom decided to expand this early successful effort through the Medicaid cost and quality program, renamed CCNC.18
Over the next decade, CCNC grew to include 14 community networks that served all of North Carolina’s counties through its PCCM program. In the 2000s, CCNC expanded its services beyond its traditional target population of children and women of childbearing age to include aged, blind, and disabled (ABD) individuals and dually eligible beneficiaries (individuals who qualify for both Medicare and Medicaid). They collaborated with private payers and providers to develop and implement best practice medical quality standards for five health conditions, developed a chronic care model, and developed a transitional care model targeting complex patients. CCNC has yielded considerable cost savings for North Carolina: an analysis from Treo Solutions found that from 2007 to 2009, CCNC saved North Carolina nearly $1.5 billion.19
9 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM The Problem - Transitional Care
THE PROBLEM - TRANSITIONAL CARE
Fragmented, complicated, and decentralized healthcare contributes to poor patient outcomes and increased costs. This is common after discharge from inpatient hospitalization, and is especially likely for complex patients with multiple chronic conditions.20 Thirty-day hospital readmission rates for Medicaid beneficiaries range from 13 percent for beneficiaries with one chronic condition to 36 percent for those with 10 or more chronic conditions.21 Hospital readmission rates are one of the Medicaid Adult Core Set performance measures, and are used as a quality measure for accountable care organizations (ACOs) in the Medicare Shared Savings Program.22
Coordinating a patient’s care in the transition period following a hospital or facility discharge is one mechanism for decreasing hospital readmission rates, lowering costs, and improving healthcare quality. Care transitions can include recurrent shifts between a hospital, a skilled nursing facility, and the patient’s home.23 Without proper care coordination during a transition period, patients are left to navigate and get access to services in the complex healthcare system on their own. Research indicates that inadequate care coordination increased U.S. healthcare costs by $25-$45 billion in 2011 alone.24
Multiple well-researched models address the issue of inadequate transitional care, which informed the transitions of care work in North Carolina. In the Coleman Care Transitions Intervention, a coach (a nurse or social worker) meets the patient in the hospital and maintains contact through home visits and phone calls over the following four weeks. Coaches target four key areas: follow-up care, medication self-management, patient recognition and response to “red flags” that might indicate a worsening condition, and the creation of a patient-centered health record that guides the patient through the complex care process.25,26 The Transitional Care Model targets older adults with recent hospitalizations, multiple chronic conditions, and poor self-rated care management. Through home visits and regular phone calls, which continue on average for two months, advanced practice nurses work with patients and their caregivers to guide better management and care coordination.27
The ACA promotes improved care transitions through multiple mechanisms. The law authorizes payments directly to PCMHs for medical home services, including transitional care services. Hospitals receive increased Medicare payments for achieving performance targets for quality measures that promote care transitions. The Centers for Medicare and Medicaid Services (CMS) is also reducing payments to hospitals with readmission rates exceeding targets for specific conditions, including heart failure, acute myocardial infarction, and pneumonia. ACO shared-savings models include financial incentives for a central ACO entity and its partnering (often private) providers that are tied to improved care coordination and transitions.28
10 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM The Problem - Transitional Care
The Role of Data in Care Transitions Primary care providers frequently lack access to adequate and timely information about their patients’ hospitalizations and the subsequent need for follow-up. This communication breakdown can occur between hospitals, primary care providers, specialists, and social service providers.29 Health information exchanges (HIEs) and other data and information sharing mechanisms can improve transitional care efforts. Providers can use healthcare data to monitor and analyze utilization patterns and trends.30 The analysis can identify the appropriate patients to target for care transition services, and data monitoring can tell providers which patients need these services.
In 2009, enactment of the Health Information Technology for Economic and Clinical Health Act (HITECH) made available significant investments in health information technology (HIT).31 The federal government had invested $26 billion in HIT as of August 2014, and $24.4 billion came in the form of incentive payments to hospitals and providers who have achieved meaningful use electronic health records (EHRs).32 Meaningful use incentives initially target process-driven HIT requirements for EHRs, such as medication and allergy lists. Later phases have incentives linked to improving health outcomes.33 The Office of the National Coordinator for Health Information Technology has also provided more than $547 million to promote the exchange of health information within a state and between states.34
Nationally, EHR adoption has increased significantly since 2009. As of late 2013, 48 percent of physicians and 59 percent of hospitals had EHRs, and HIE use had increased by 51 percent as of 2014.35
11 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM The Problem - Improving Care Coordination and Identifying At-Risk Patients
THE PROBLEM - IMPROVING CARE COORDINATION AND IDENTIFYING AT-RISK PATIENTS
There was consensus among the interviewees that the driving motivations behind this effort came from the combination of poor communication leading to fragmented care, with resulting high costs and less than hoped for quality. A CCNC regional quality improvement expert said “[It was] very evident that there was fragmented care driving utilization and that impacts quality …and of course, that was driving up costs.”36 Interviewees reported that North Carolina had high levels of inappropriate ED use and preventable hospital readmissions, and poor health outcomes, which were most marked in the ABD population that had recently become CCNC’s responsibility to manage.37,38,39,40,41 A CCNC board member said “When we brought in this very high-cost, high-risk, sick population, the problem that we were trying to solve was: how do you manage costs? How do you manage ED admissions, preventable readmissions, and ED utilization for this high cost population?”42
Without timely access to accurate information, this is a difficult task. One barrier to care coordination and care transitions is information exchange. A CCNC quality improvement expert remarked “[It] shocked me when the practices sat down and said, ‘I do not know who I should contact to get a discharge summary.’”43 An informatics and HIE expert said “The problem …is that primary care, acute care, specialty care, and behavioral care have a hard time communicating. When we need information and three to six months later at the next visit, hopefully we have the data.”44
Prior to the mid-2000s, CCNC provided PCCM services primarily to women and children.45 In 2005, the assistant secretary of DHHS and North Carolina’s Medicaid director addressed the expanding Medicaid budget by focusing efforts on the most costly and vulnerable category of patients—the ABD population. Although this group represents only 30 percent of the Medicaid population, it accounts for 70 to 80 percent of Medicaid expenditures.46
In late 2005, the North Carolina General Assembly directed DHHS to expand its scope of CCNC’s care management model. Instead of the previous focus on families and women of child-bearing age, all recipients of Medicaid and dually eligible individuals with chronic conditions and long-term care needs were to be included.47
12 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM The Problem - Improving Care Coordination and Identifying At-Risk Patients
In the same year, funding of six million dollars from the state budget, to begin in February 2007, was dedicated to chronic care pilot programs.48,49 Nine of the 14 CCNC networks opted to take part in these pilots.50 Planning began in the spring of 2006 to identify program components essential to implementation.51 CCNC adapted successful components of the pilots to develop a CCNC-wide chronic care model, which built upon its medical home model and community ties with hospitals, healthcare providers, and social service providers to reorganize and increase the delivery of care by improving efficiencies and reducing variations.52
A subset of the ABD and dually eligible population with the highest utilization became eligible for services for comprehensive care management which included the transitional care program, the focus of this case study.53 Care management oversight is the responsibility of the primary care manager (a registered nurse, certified case manager, or someone with a bachelor’s or master’s degree in social work). The interdisciplinary team may also include pharmacists, pharmacy assistants, nutritionists, experts in behavioral health, palliative care experts, and care management assistants. The staffing model is designed to enable an efficient workflow andallow professionals to work at the top of their license.54 Following a one year pilot period, the CCNC transitional care program was launched statewide in 2008.55 By 2011, there were 91 full-time care managers in 118 primary care practices and another 50 full-time care managers in 48 hospitals.56 The program has grown to serve 2,600 Medicaid recipients per month.57
13 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Policy Development and Implementation
POLICY DEVELOPMENT AND IMPLEMENTATION
According to a CCNC official, its transitional care program is an adaptation of both the Coleman and Naylor models. It was designed “to improve coordination, the quality, and the cost of care for high-risk populations and this brought us to having transitional care as key component of the activities.”58 Although the program varies in each of the 14 regions as a function of local demographics, infrastructure, and available services, there are four consistent components:
1. Face-to-Face Patient Encounters CCNC care managers are embedded in hospitals in each of the CCNC regions and interact frequently with hospital physicians, pharmacists, nurses, and discharge coordinators. Care managers meet with patients and their families at the bedside prior to discharge to ensure understanding of and adherence to the discharge plan. The care managers then engage with clients through home visits, meeting in the community, or accompanying clients to appointments with their primary care providers (PCPs).59 The home visits contribute to the depth of the relationship forged between the care manager and the patient and also improve medication reconciliation.60
2. Appropriate Follow-Up and Patient Education CCNC care managers facilitate timely follow-up with each patient’s PCMH, ensuring that his or her PCP has accurate information regarding the hospitalization, the patient’s involvement with other providers and services, and relevant psycho-social issues that can impact a patient’s health. The timing of this follow-up visit may vary based on patient complexity but is within three days of discharge for individuals determined to be at a high-risk for hospital readmission or other poor outcome.61 The care manager coaches the patient to maximize the benefit of this appointment by helping the patient prepare a list of questions and making sure that he or she has an accurate medication list and personal health record.
Patient education and self-management are core to transitional care. Care managers work with patients and their family members to identify signs, symptoms, or circumstances that might indicate a complication or an exacerbation.62 Care managers teach patients and their families how to get access to the healthcare system before another problem develops. Care managers also provide patients with self-management notebooks to educate them on how to best manage their health to prevent exacerbations and complications. Patients use these notebooks as health records in which they track their symptomology and the self-management tools they employ. The notebooks also enhance communication with providers, as patients are instructed to bring them to all appointments.63
14 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Policy Development and Implementation
3. Medication Management Realizing that standard medication reconciliation would not always be effective for the high-risk patients targeted in CCNC’s transitional care program, in 2009 CCNC implemented Med Rec Plus, a comprehensive program involving pharmacists, nurses, social workers, and care managers.64 Through this program, the care manager interviews the patient about his or her medication history and use, ideally during the admission.65 The pharmacist then compares the patient’s discharge medication list with the patient’s fill history from the pharmacy. After discharge, the care manager meets with the patient at home, observes medication use, and educates the patient as needed.66 This process empowers the patient by helping him or her develop medication self-management skills.67
CCNC found that only one-third of medication problems or discrepancies—drug interactions, dosing errors, or duplications—are found through the standard medication reconciliation process. The remaining two-thirds stem from patient management errors or lack of coordinated efforts between healthcare providers. Med Rec Plus identifies and addresses these coordination issues. The program also identifies barriers to medication self-management, such as lack of knowledge or non-adherence, and personnel work with the patient to develop plans of action to overcome these barriers.68
4. Data-Driven Care From the inception of the transitional care program, CCNC used its network of information-sharing relationships with area providers and hospitals to target high-risk patients.69 (Please see the next section for more information.)
15 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Policy Development and Implementation
POLICY DEVELOPMENT - INFORMATICS
In 1999, the University of North Carolina’s (UNC) Department of Emergency Medicine, funded by the CDC, developed the North Carolina Emergency Department Database (NCEDD) as a three-year proof of concept to address the need for secure and timely electronic collection of ED data.70 The data collected was standardized using the CDC’s Data Elements for Emergency Department Systems (DEEDS), developed in 1997.71,72 In 2002, following the 9/11 events, DPH expanded funding for NCEDD to address the need for early event detection.73 In 2004, the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) was created to serve as an early disease detection and surveillance system.74,75
One interviewee involved in this process recalled that during the development of the surveillance system, DPH faced resistance from the North Carolina Hospital Association (NCHA) which viewed its data feeds as proprietary. Negotiations between DPH and NCHA eventually led to the passage of a law in 2005 that mandated that all EDs in North Carolina submit select data elements to the North Carolina Hospital Emergency Surveillance System (NCHESS).76,77 NCHESS data was then incorporated into NC DETECT to investigate public health threats, including bioterrorism or infectious disease outbreaks.78 By 2008, NC DETECT was collecting data from all North Carolina hospitals and had population-wide data. DPH and UNC used this data for surveillance, and hospitals used it for quality improvement.79
CCNC staff realized that its standard quarterly claims data reports were not timely enough to monitor when high-risk patients were hospitalized, compromising the likelihood of care managers’ interventions during what a Medicaid official termed “actionable moments.”80 NC DETECT provided a mechanism to get real-time data feeds and improve patient care and care coordination. A CCNC official reported “I was aware of that system, so I started wondering if we could leverage that for patient care and care coordination.”81 Although the initial intention of the mandate supporting NC DETECT was to monitor for public health threats, an interviewee close to the process explained that the mandate was stated broadly enough to allow for use of the data, as long as it was a public health benefit.82 After determining that it was legal to use the data, CCNC engaged in a process with DPH and NCHA to access the data and to address privacy concerns through compliance with the Health Insurance Portability and Accountability Act.83,84
By September 2010, CCNC had access to admission, discharge, or transfer (ADT) data from 28 hospitals.85 Eventually, all hospitals using the system maintained by NCHA submitted the data. However, not all of the hospitals used NCHA’s system, so CCNC has engaged in a separate process with some hospitals for access to their data feeds. A Medicaid official reported that currently “for 80 percent of the hospitalizations in the state, we get the data transfers several times a day, so there is no lag. That is a huge piece of it.”86 The real-time hospital data feeds are essential to the operation and success of CCNC’s transitional care program. A CCNC official claimed “None of this would even be possible without the ability for us to know in real-time when someone is in the hospital.”87
16 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Policy Development and Implementation
Medicaid Claims Data Historically, the principal source of health data for CCNC’s enrolled Medicaid beneficiaries has been claims data. Since it was possible to do so, DMA has allowed CCNC analysts access to the claims dataset, and the analysts provided reports to the regional CCNC network.88 In 2001, CCNC developed a Case Management Information System (CMIS).89 Initially a Microsoft Access database that allowed care managers to make administrative and therapeutic notes, CMIS has evolved into a web-based portal that incorporates claims data to populate the record with information about beneficiaries’ hospital, ED, and pharmacy claims.90 As the population that CCNC served expanded to include the ABD population, it made coordination between the claims database and CMIS difficult. In addition, there was growing recognition that providers and care managers needed access to better and more useful data to serve that complex population. In response, CCNC officials convened an advisory panel of clinicians, technical experts, and care managers to collaboratively identify and address CCNC’s health information needs.91
Through these discussions, several problems with the claims dataset emerged:
There was a lag time between when a service was utilized and when the claim was processed, and an additional delay between when the regional networks’ care managers and providers could get access to that data.
Claims data depended upon coding that is used for billing purposes, which does not always best reflect a patient’s health record. For example, claims data might indicate that a certain laboratory test was performed, but it does not show the result of the test.
For the dually eligible population, some services—such as certain hospitalizations, laboratory services, and pharmacy services—were billed to Medicare and were therefore not in the Medicaid claims database.92
In addition, the advisory panel discussed the utility of additional datasets, the need to automate what was then a manual process of creating reports, and the expansion of the CMIS system to additional health and service providers, notably PCPs.93
17 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Policy Development and Implementation
POLICY IMPLEMENTATION - INFORMATICS
CCNC Informatics Center CCNC’s health information advisory panel’s thoughts and ideas served as the objectives for CCNC’s Informatics Center, which began in May 2009. The Informatics Center is an electronic HIE infrastructure that is maintained through a joint effort of DHHS, ORH, and CMS. The Informatics Center aggregates information from multiple datasets, including Medicaid claims data, real-time ADT feeds, pharmacy claims data, Medicare claims and pharmacy data specifically for the dually eligible population, EHRs from PCPs, laboratory results, and DHHS data, including information from the birth certificate data and immunization records.94,95
CCNC continues to successfully incorporate clinical data from many sites into the Informatics Center’s HIE, and this is already in place for EHRs from 35 hospitals and 300 practices, covering about 1 million lives. (The EHR clinical data is more robust, with rich clinical information, than the data feeds received from NC DETECT). Using a CMS Center for Innovation grant, CCNC added tools to its HIE to capture pharmacy information and reconcile medications. Pharmacists now have access to the informatics platform, like PCPs, which is an important step in improving coordination. As a CCNC official explains, a “typical patient will see a primary care provider three times per year, but will see the pharmacist 35 times if they have multiple conditions.”96
The Informatics Center maintains multiple applications, including CMIS, a shared medication management platform called PHARMACeHOME, a provider portal, and population health management tools. CMIS and the provider portal provide “transition priority” alerts to care managers and PCPs to alert them when a priority patient is admitted to the hospital.97 These applications are used by CCNC and its partners to risk-stratify patients, facilitate and coordinate care and pharmacy management, enhance communication of health information across care networks, and monitor the quality of care delivered.
Identifying Priority Patients At the beginning of the transitional care program, CCNC staff determined priority enrollees for care management services, including transitional care, by mining claims data to determine the patients at highest-risk for readmission and complications following a hospitalization. Participating practices would then receive lists of patients generated from the claims data and use that list as a basis for selecting patients to target with the intervention. Regions also relied on hospital-embedded CCNC care managers, who had access to hospital medical records and/or a faxed census of Medicaid admissions to the regional network.98 This approach to identifying the best patients for the transitional care program was time-consuming and inefficient. Advances in and use of HIEs have streamlined the process in recent years.
18 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Policy Development and Implementation
Transitional Care Priority DHHS’ collaboration with NCHA to enable and encourage hospitals to exchange ADT feeds for Medicaid patients with the CCNC Informatics Center enabled changes to CMIS and other Informatics Center applications that could alert personnel of a patient’s hospital admission. The ADT feeds are used to provide real-time notification about a hospital admission to providers and care managers for patients flagged as “transitional care priority.” Providers are informed through the Informatics Center’s electronic reporting mechanisms.99,100 An evaluation expert explained that “The prioritization algorithm sits in our Informatics Center report, and lives in the Care Management Information System. [Care managers] see these [Transitional Care] priority flags, and when they see if someone with this flag is in the hospital, then they know they need to go after this person.”101
Clinical Risk Groups CCNC’s process for classifying a patient’s status as a “transitional care priority” has evolved. The first step in appropriate patient identification involved using TM3M Clinical Risk Groups (CRGs), which classify people based on utilization history from claims, and includes inpatient, outpatient, physician, and pharmacy data. Within each CRG, certain patients have more “potentially preventable” readmissions or ED visits relative to other patients within their CRG (in those with a similar disease burden). These patients become the targets for more intensive care management, including the transitional care program.102
Of note, patients with higher disease burden were also more likely to have readmissions and future admissions that could be averted through transitional care.103 A CCNC official explained “When we provided transitional care efforts to patients who had none or only one chronic condition, we had to apply the intervention to 133 people to prevent one readmission, as compared to when [the intervention was] applied to individuals with two or more chronic diseases, we had to apply the intervention to six people to prevent one readmission. It enabled us to take the information and apply to analytics and reporting.”104
The Impactability Score The next step in the evolution of targeting priority patients was to determine the amount of benefit a patient was predicted to receive from an intervention, coined “the impactability score.” CCNC assigns each patient an impactability score between 0 and 1,000 that reflects its best estimate of the savings likely to be achieved from delivering transitional care to that patient. This savings estimate is based on results from several rigorous, controlled evaluations and builds on the knowledge described above about the types of patients that benefit most from transitional care.
Most programs use risk scores to drive their transitional care priorities, and they can be very useful. However, they may point workers toward patients with high likelihoods of going to the hospital, but for whom transitional care may have limited benefit. The impactability concept takes risk scores to the next level. A CCNC official explained that they “created the ‘impactable patient’ concept….There are some patients [whose circumstances make it] hard to control costs or quality, and for whom the intervention we offer will not make much of a difference. Our focus is on patients for whom we will make a difference.”105
19 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Policy Development and Implementation
POLICY IMPLEMENTATION - TRANSITIONAL CARE
Stakeholder Engagement: the Power of Interdisciplinary Collaboration CCNC and its transitional care program are supported by efforts at the state level (from DPH, DHHS, including DMA, and NCHA), as well as local level public health personnel, hospitals, community providers, and social service agencies. A CCNC clinical administrator explained that “to be a CCNC network…the main requirement was that you need safety net providers as stakeholders. You’ve got to have hospitals, health providers, your primary care providers, [social service providers], [federally qualified health centers], and health departments. …All of those safety net providers need to be at the table and agree and understand what their role is going to be to manage the Medicaid population.”106 Another CCNC leader stated “There is an ongoing HIT cost issue, especially for rural and safety net providers. They can access the informatics platform for free, but other HIT tools ([electronic medical records], even internet access) are on them.”107
Communication Developing the transitional care program initially involved much face-to-face communication, which the CCNC team led over several years during the statewide expansion. This occurred through individual conversations and meetings, board meetings, workgroups, and steering committees. As CCNC formed the transitional care program, its personnel set out to give presentations in the field to primary care practices, hospitals, and other entities to share information, gather feedback, and garner support for its program.108
During regional implementation, CCNC convened community groups of hospital and ED personnel, PCPs, home health and skilled nursing facility staff, and hospice providers to work together on transitional care. After the model was up and running, a similar panel convened to discuss the program’s successes, obstacles, and how to improve it.109 This intentional feedback loop created a program that aligned with the needs and capacity of the local systems. There have been several publications about CCNC’s transitional care program in peer-reviewed journals (see Outcomes section). The credibility that CCNC gained from these publications provided CCNC with another mechanism to communicate the program’s effectiveness.110
As the model evolved and technology improved, all 14 regional networks that involved personnel added statewide virtual meetings and webinars to discuss the program. The regional networks’ medical directors and the clinical directors continue to meet in person monthly or quarterly, depending on the region.111
20 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Policy Development and Implementation
Community Organizations and Primary Care Practices A physician leader at CCNC said “One of the beauties of our program is our connection with our community providers, with different segments of the healthcare system, and the trust and collaboration on the ground… One piece is the recognition that we needed staff embedded in hospitals and primary care provider offices.”112 The official said that these local level partnerships are critical to the success of CCNC programs: “That is a big ‘take-home.’ State level policy without the local level buy-in will never work… and local level efforts will never work without state level ability to give the vehicle for change.”113 A different CCNC official echoed this sentiment, and said “Even though we are talking about a statewide program …it is much more on the ground and in the weeds. The CCNC coordinators know the primary care providers, the discharge nurse, and the hospitalists. It’s human beings that are at a local level. It is really helpful when they know each other and have a trusting relationship. The success of our model is that it actually gets executed in local relationships.”114
The primary care practices and social service agencies involved in CCNC’s transitional care program are critical to its success. Local CCNC personnel meet in person with the practices to explain the transitional care program and also maintain email communication, reminding them of CCNC’s “involvement with their patients and the purpose…. We [are] engaged with social service organizations, particularly in rural settings that involve interactions to make sure that the patient has transportation services, pharmacy services …the whole gambit of whatever it took. Our staff at times has to be imaginative and look for resources that are not always straightforward to access.”115
PCPs in CCNC’s program have access to informatics portals that inform them of a patient’s priority status and potential need for more intensive care management intervention, and they and their staff work directly with care managers to help coordinate care for patients enrolled in the transitional care program. Care managers also coordinate and communicate with community social service organizations as necessary. Although it is effective, this communication process is dependent upon a reliable internet connection, a challenge in rural areas, and the cumbersome process of logging in and out of the separate electronic information systems.116,117,118
Medicaid DHHS and its Medicaid division (DMA) were integral to the development of CCNC. A CCNC official explained that “[…] We’re really a brainchild of [Medicaid] from the beginning. [Medicaid] wanted something out of state government to build community networks and infrastructure.”119 In addition, Medicaid provides financial and technical support, specifically for targeted programmatic development and evaluation. The same official added “90 percent of funds come through a contract with North Carolina Medicaid, so we work very closely with them.”120 Through mid-2015, DMA has continued to support the funding for CCNC. CCNC receives PMPM funding from Medicaid, including the higher costs associated with managing the ABD population. DMA has also helped CCNC obtain programmatic evaluation data and was “very collaborative on determining evaluation metrics.”121
21 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Policy Development and Implementation
Public Health CCNC’s charter explicitly calls for collaboration with public health, and CCNC has implemented this at both the state and local levels. State statute compels each county in North Carolina to have a county board of health and health department, as well as regional health departments. Some of these local health departments directly provide primary care. Local public health officials sit on the board of many of the 14 regional CCNC networks, and senior state public health officials report that DPH and CCNC continue to collaborate and share information to best manage the health of the state’s population.122,123
Patients CCNC involves patients in its ongoing programmatic development and evaluation and “relies on the patient perspective to inform [its] model.”124 As recipients of care, patients provide feedback about their perceptions of the practice through surveys to their care managers and other CCNC personnel. However, CCNC did not involve patients or patient representatives explicitly when developing the transitional care program. A nurse who has worked with and for CCNC in a variety of roles explained: “We do not have patients or patient representatives on our team. However, we rely on the patient perspective to inform our model. We have patient-based surveys about the practice—perception, knowledge of practice—we incorporated their feedback, but we did not have a patient on the team.”125
Funding CCNC receives PMPM funding from Medicaid that was initially allowed by a 1915(b) waiver and later through a state plan amendment (SPA).126 The PMPM is higher for the ABD population than for the rest of the Medicaid population: $5.00 PMPM to the practice and $5.00 PMPM to CCNC for ABD enrollees, and $2.50 PMPM to the practice and $3.00 PMPM to the CCNC network for all other Medicaid enrollees.127 More recently, in May 2012, CMS approved an ACA Section 2703 Health Homes SPA that provides a 90 percent enhanced federal medical assistance percentage (FMAP) for two years for specific health home services provided to qualified enrollees (those with two chronic conditions, or those at-risk for developing another).128 This allowed CCNC to expand its Section 2703 Health Homes program to additional provider practices, an enhanced resource for Medicaid beneficiaries.129
22 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Outcomes
OUTCOMES
CCNC’s informatics platform has provided the essential data to complete multiple evaluations of the transitional care program. CCNC completed some evaluations in partnership with UNC. CCNC measures enrollment, costs, ED visits, hospital admissions and readmissions, including potentially preventable admissions, the time from discharge to home visit occurrence, and the time from discharge to a patient’s follow-up with his or her PCP.130,131,132,133 CCNC’s budget funds the majority of its evaluations, and the North Carolina Healthcare Quality Alliance provides additional funding.134 CCNC’s evaluations found cost savings and improvement in utilization and quality measures. These findings have been published in peer-reviewed publications, several of which are summarized on the next page.
23 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Outcomes
Selected Published Studies
1. A study published in 2015 in Population Health Management was a retrospective analysis of North Carolina Medicaid claims from 2008 through 2012. The analysis was limited to CCNC members who met the criteria for multiple chronic or catastrophic conditions, as defined by 3MTM’s CRG methodology.135 The authors found that readmissions per 1,000 beneficiaries per year fell significantly during the study period, from 123.3 readmissions in 2008 to 110.7 readmissions in 2012 (Figure 1). The number of overall inpatient admissions per 1,000 beneficiaries decreased from 579.4 to 518.5 over that same time period. However, the readmission rate per discharge increased from 18.3 percent in 2008 to 18.7 percent in 2012. The authors attributed the discrepancy between a decline in readmissions per beneficiary and an increase in the readmission rate per discharge to an increase in hospitalized patients’ overall complexity during this time period. According to the authors, “If improvements in access to care, chronic disease management, and care coordination successfully decrease hospitalization rates among chronically ill beneficiaries over time, it is reasonable to expect that those individuals who do require hospitalization will have greater clinical complexity or more advanced illness.”136 Overall, according to a senior CCNC official, admissions and readmissions went down, and the study highlighted how to effectively measure readmissions.137
FIGURE 1: Thirty-day readmission rates per beneficiary over time for North Carolina Medicaid beneficiaries with multiple chronic conditions. (Not limited to beneficiaries in the transitional care program.)
130
120
110
100
2008 2009 2010 2011 2012 READMISSIONS PER 1,000 BENEFICIARIES YEAR
YEAR
Source: Dubard, C. et al. “Conflicting Readmission Rate Trends in a High-Risk Population: Implications for Performance Measurement.” Population Health Management. 2015. Available at http://www.ncbi.nlm.nih.gov/pubmed/25607449. Accessed 8-17-2015.
24 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Outcomes
2. A study published in Health Affairs in 2013 examined patients who were hospitalized in 2010 and 2011 and compared claims data from patients receiving transitional care following a hospital discharge to clinically similar patients not receiving transitional care. (The researchers categorized patients using 3MTM’s CRG methodology into risk strata.) Results showed that patients enrolled in the transitional care program were 20 percent less likely to have a readmission in the subsequent year compared to clinically similar patients not receiving transitional care (Figure 2). The researchers also found that patients in a higher CRG risk stratum were more likely to obtain benefit from the intervention than patients considered lower risk (Figure 3).138
The study found that it was easy to compare populations because not all eligible or appropriate patients were immediately enrolled in the transitional care program because of initial size limitations. CCNC researchers also found that complex patients experienced the greatest impact from the transitional care program: for every 1,000 complex chronic patients who received transitional care, the program prevented an estimated 174 admissions over the next year. This amounted to $1.2 million in savings per 1,000 complex chronic patients per year.139
CCNC has observed that protocols at its primary care practices change in response to transitional care program implementation. For example, participating practices make sure that front office staff members contact patients within one to three days of discharge to schedule a follow-up appointment, and clinical practices hold same day appointments open for that purpose. Some practices have also extended the length of the post- discharge visit. A quality improvement specialist said “Practices did change behavior and workflow, and developed communication linkages that they didn’t have before.”140
25 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Outcomes
FIGURE 2: Patients’ Readmissions Over Time By Risk Stratum, Transitional Care and Usual Care Groups.
PERCENT OF PATIENTS WITH:
READMISSIONS, 12 AVERTED NO READMISSION AFTER: NO SECOND NO THIRD MONTHS AFTER FIRST READMISSIONS PATIENTS READMISSION READMISSION DISCHARGE (PER 100 (USUAL CARE– TYPE OF CARE (n) 30 DAYS 90 DAYS 6 MONTHS 12 MONTHS AFTER 12 MONTHS AFTER 12 MONTHS DISCHARGES) TRANSITIONAL CARE)
RISK STRATUM 1 (LOWEST RISK)
USUAL 1,236 93 88 83 78 92 97 33 7 TRANSITIONAL 1,340 97 93 89 79**** 96** 99** 26 _*
RISK STRATUM 2
USUAL 1,313 90 82 76 66 87 96 52 9 TRANSITIONAL 1,600 95 87 82 71**** 90** 97 42 _*
RISK STRATUM 3
USUAL 1,213 89 80 72 61 84 92 63 9 TRANSITIONAL 1,709 93 85 77 67**** 87 93 54 _*
RISK STRATUM 4
USUAL 1,220 83 71 60 48 74 88 91 18 TRANSITIONAL 2,194 91 82 73 55**** 81**** 91**** 73 _*
RISK STRATUM 5
USUAL 627 79 68 58 44 71 87 98 15 TRANSITIONAL 1,581 91 79 67 51**** 76** 90**** 83 _*
RISK STRATUM 6
USUAL 670 70 54 38 30 55 65 150 19 TRANSITIONAL 1,351 83 66 53 39**** 60**** 71** 131 _*
RISK STRATUM 7
USUAL 1,035 75 56 38 25 47 69 159 32 TRANSITIONAL 1,966 84 69 54 37**** 61**** 76** 127 _*
RISK STRATUM 8 (HIGHEST RISK)
USUAL 585 61 41 23 12 32 55 201 26 TRANSITIONAL 1,735 77 57 39 20**** 43**** 61** 176 _*
Source: Jackson, C. et al. “Transitional Care Cut Hospital Readmissions for North Carolina Medicaid Patients with Complex Chronic Conditions.” Health Affairs. 2013. Vol. 32. No. 8. 26 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Available at http://content.healthaffairs.org/content/32/8/1407.full.html. Accessed 8-17-2015. Outcomes
FIGURE 3: Times Before First and Subsequent Readmission for Patients in Risk Stratum 7, Transitional Care and Usual Care Groups.
100
80 Transitional care—3rd readmission
Usual care—3rd readmission 60 Transitional care—2nd readmission
Usual care—2nd readmission 40 Transitional care—1st readmission
20 Usual care—1st readmission
0
PERCENT OF PATIENTS WITH NO READMISSION PERCENT OF PATIENTS 0 1 2 3 4 5 6 7 8 9 10 11 12
MONTHS SINCE INITIAL DISCHARGE
Source: Jackson, C. et al. “Transitional Care Cut Hospital Readmissions for North Carolina Medicaid Patients with Complex Chronic Conditions.” Health Affairs. 2013. Vol. 32. No. 8. Available athttp://content.healthaffairs.org/content/32/8/1407.full.html . Accessed 8-17-2015.
27 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Sustainability and Transferability
SUSTAINABILITY AND TRANSFERABILITY
Many of the interviewees for this case study felt that because CCNC’s transitional care program has demonstrated significant return on investment (ROI) for the state, it should be automatically seen as sustainable.141,142,143,144 As a CCNC official explained “The intervention that we do in care management… has a large ROI. Other interventions might bend curves on utilization trends or potentially reduce chronic disease burden, but these are softer returns. This intervention has a real monetary ROI that occurs within a short cycle, so we can really say that for every person receiving intervention, we save X amount. It is very sustainable from a policymaker’s point of view because of the ROI.”145
The current political environment has exposed the potential vulnerability of the Medicaid- public health collaboration in CCNC. An official acknowledged that “[CCNC’s transitional care program] is sustainable unless we undergo a huge transition to commercial managed care….We will be intact during the transition period, and it is very likely the state will continue to fund transitional care because of the ROI. There would be opportunities to plug in our transitional care model into those models.”146
Others expressed a similar sentiment. An interviewee said “It is frustrating because we can demonstrate improvement and their return on investment is demonstrable.”147 A CCNC official offered “I think guarded optimism is [the] best way to describe it. The system is going to change; our premise is that because of the relationships and networks we’ve already built, we’re in the best position to move with the system and have positive outcomes for North Carolina.”148 The official said that it is the role of DHHS and its Medicaid division to engage in a dialogue with the legislature, and that providers and provider associations discuss the value of CCNC with legislators from their home districts.149 Another CCNC official said “There are huge savings to delivering care to the right people at the right time.”150
A CCNC official said “We hope that our state, any state, understands the value and importance of this statewide, solid infrastructure around supporting complex, chronic care needs. These are folks who are not neatly contained within one healthcare system… Complex care management is strongest as a statewide infrastructure and shouldn’t be siphoned off.”151 Another CCNC leader stated that “even if [managed care organizations] were to adopt/contract for/rent portions of the CCNC informatics system, unless it is applied statewide, the savings generated for the state under the new hybrid system spelled in the reform plan may not come close to the savings currently generated by the existing CCNC system.”152
The transitional care model is not only potentially threatened by policies that do not support continued funding of its services, but by its dependence on informatics. One of the CCNC regional medical directors said that the Informatics Center requires continued funding and some in the legislature might believe that Medicaid funds should only be used for direct patient care.153 The medical director said “I can appreciate their concern to make sure that the funds spent by the state are actually spent on healthcare, but our perspective is that informatics is important in the process and that it pays dividends.”154 28 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Lessons Learned
LESSONS LEARNED
This case study is designed to describe successful collaborations between the North Carolina state public health department and Medicaid agency in which the state implemented an innovative policy change. While sustainability remains unsettled, important lessons can be learned. Table 1 below highlights the points of intersection that enabled the project to be successful.
TABLE 1: Points of Collaboration
Legislative Care Coordination Reporting and CCNC Informatics Advocacy and Outreach Evaluation
Division of Medical Assistance (DMA) X X X X X
Division of Public Health (DPH) X X X X X
Office of Rural Health (ORH) X X X X
University of North Carolina (UNC) X
Health Foundations X X X
Data Elements for Emergency Department X X X Systems (DEEDS)
29 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Lessons Learned
Informatics The state’s long-term infusion of resources into CCNC’s Informatics Center substantially contributed to the program’s success. This was accomplished through a combination of leveraging federal dollars, directing state funds through the Medicaid budget, and contributions from private foundations. Course corrections naturally occurred, highlighted below.
In the early years of CCNC’s transitional care program, before officials established automated techniques that created workflows for distributing data, CCNC relied on manually populated spreadsheets to manage large amounts of data that was very difficult to parse. An informatics expert explained that there “was no way to make sense of all that aggregate data.”155
Although CCNC has greatly improved its Informatics Center’s usability, clinical staff still find accessing the CCNC portal cumbersome. Users often still have to log-in to a separate CCNC portal with a different password than what they use with their own practice EHR. An interviewee stated “It would be better to have a single log-in,” one that would provide access to a patient’s full medical record.156 These barriers might seem subtle, but are very costly to remediate, and could hinder providers from maximally using the CCNC system.157
Reflecting on establishing data feeds for NC DETECT, a public health expert close to this process explained “We would have [liked to have] partnered with the hospital association sooner. I think that at first, the hospital association …[saw itself as] a business rival in trying to set up data feeds to hospital emergency departments within the state… We had to overcome this difficulty, so we provided them with funding from our grant.”158
30 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Lessons Learned
Policy and Program Development Cultivating working relationships was key to the success of CCNC’s transitional care program, from the state government cabinet level through regional community leadership to individual staff at local primary care practices and social service agencies. The complex planning needed to successfully run the program was an iterative process, refashioned along the way, but with a strong set of guiding principles embraced by participants. Several areas did stand out as opportunities for improvement. One interviewee said “The dedication to quality improvement and doing adoption of best practices at the local level cannot be underestimated as a reason for success in the development of the CCNC model. This may ultimately explain difficulty in adopting the CCNC model in other states” since other models may be introduced and adopted in a “top-down” approach.159
CCNC did not solicit patient engagement during the development of its care transition program. Describing this omission, an official with CCNC said “This is definitely a misstep, and a priority moving forward. I have spoken to other states with [patient] advisory panels. We have discussed how to better do the patient engagement piece.”160 One of CCNC’s networks in Charlotte does involve patients in programmatic decisionmaking processes, and has patients who serve on workgroups and on committees.161
CCNC’s statewide transitional care program has historically been limited to Medicaid and Health Choice recipients. A CCNC official expressed regret that the transitional care program was not accessible to the sizable uninsured population.162 Although some of the regional CCNC networks voluntarily use the care coordination information system for high-risk uninsured patients and others have used the system in local initiatives that include Medicare and commercially insured populations, the practice is not universal. The official postulated that there might be legal hurdles to making this practice standard across CCNC. In contrast, the same official noted that “Technically speaking, it is relatively easy. It would really help hospitals [and patients] if we did this.”163
Policy and Program Implementation The design and implementation of CCNC’s policies and programs vary, despite the clear direction from the top of the organization and infrastructure. This stems from local service providers and health departments’ varying capabilities, as well as differences between rural and urban areas. As a CCNC official explained, there is good reason that these regional programmatic differences exist: “We recognize that all healthcare is local. They best know their local community. [However,] trying to prove from a legislative standpoint and to [DHHS] that we have a consistent model across the state can be challenging sometimes. The way that it happens in a rural county, and the way that it happens in Charlotte… it’s going to be different… [We make] sure that the variability is locally driven, and it is a value to what they are going to accomplish locally, but it does not become a vulnerability to the consistency and the quality of a statewide program.”164 The current requirement for the National Committee for Quality Assurance certification for case management is one example of a program core component that is uniform statewide. Less formally, a clinical leader pointed out that “local variability could impact programs,
31 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Lessons Learned
but in the developmental stages of the CCNC model, local leaders recognized the importance of sharing innovations freely with other regions which lead to the adoption of those innovations across the state.”165
A board member pointed out the need for a broad care management approach that emerged when CCNC took on the ABD population.166 Prior to working with this patient population, CCNC’s care model was disease-focused, but the organization adopted a more holistic model to better respond to the multiple chronic conditions it frequently saw in the ABD population. The board member noted that treating the combined physical, behavioral, emotional, and social needs of these patients was initially difficult for some of CCNC’s implementing staff, who did not have significant experience in treating behavioral health conditions.167 In response, regional CCNC offices provided training for these staff.
One of the regional CCNC officials said “If I was able to turn the clock back, I would better explain to the practices [during] the initiation of [the transitional care program] and other projects, the dynamics involved and how practice staff would be involved with the project.”168 The official highlighted the importance of explaining to practice staff how to work with the target population.169
Transferability and Sustainability As far as transferability is concerned, there is understandable skepticism that the seemingly lucky alignment of technology and resources can be replicated in other states or regions. This does not prevent other states from adopting pieces of the complex CCNC program, as so much of the implementation components are available through published articles and as open source. The evidence base is strong for the underlying components of care management, specifically for transitions of care.
After the research for this study was completed, the North Carolina General Assembly passed House Bill 312, which was signed into law by Gov. Pat McCrory, enacting Medicaid privatization.170
32 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Conclusion
CONCLUSION
There is a growing body of evidence showing that states can reduce the human and financial costs of fractured health systems by improving coordination of communication, risk stratification, needs assessment, and person-oriented delivery of appropriate services. One vulnerable point for many patients, especially those with underlying complex medical conditions and socioeconomic challenges, is the transition from an inpatient hospital stay to a home or other outpatient setting. Positively impacting this population during care transitions involves leveraging medical, technological, and public health resources. There must be a combination of political will, collaboration, and skill in alignment for a program like CCNC’s transitional care program to succeed.
CCNC’s transitional care program is a clear example of long-standing successful collaboration between the private sector of service providers and the state’s public health and Medicaid agencies. The dedication of human, financial, and technological resources described in this case study factored into its demonstrated efficacy. While the impact of North Carolina’s recent law enacting Medicaid privatization is not fully known at this point in time, there are likely to be changes in care delivery in North Carolina impacting CCNC’s work.
33 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM References
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2 United States Census Bureau. “State and County Quick Facts: North Carolina.” Available at http://www.census.gov/quickfacts/ table/PST045215/37 Accessed 8-19-15.
3 Medicaid. “North Carolina.” Available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/north-carolina. html. Accessed 8-13-2015.
4 North Carolina Department of Health and Human Services. “Overview.” Available at https://www.ncdhhs.gov/about/overview. Accessed 8-13-2015.
5 North Carolina Department of Health and Human Services. “About DMA.” Available at https://www2.ncdhhs.gov/dma/ whoweare.htm. Accessed 8-13-2015.
6 North Carolina Department of Health and Human Services. “Public Health.” Available at https://www.ncdhhs.gov/divisions/dph. Accessed 8-13-2015.
7 North Carolina Department of Health and Human Services. “Office of Rural Health.” Available athttps://www.ncdhhs.gov/ divisions/ORH. Accessed 8-13-2015
8 Community Care of North Carolina. “The Community Care Story.” Available at https://www.communitycarenc.org/about-us/. Accessed 8-13-2015.
9 Jackson CT, Trygstad TK, DeWalt DA, DuBard CA. “Transitional care cut hospital readmissions for North Carolina Medicaid patients with complex chronic conditions.” Health Affairs. 2013. 32(8): 1407-1415. Available athttp://content.healthaffairs.org/ content/32/8/1407.full.html. Accessed 8-17-2015.
10 Jackson C, Shahsahebi M, Wedlake T, Dubard CA. “Timelines of outpatient follow-up: An evidence-based approach for planning after hospital discharge.” Annals of Family Medicine. 2015. 13(2): 115-122. Available at http://www.annfammed.org/ content/13/2/115.full. Accessed 8-17-2015.
11 Community Care of North Carolina. “Physician Support for NC Medicaid Program Grows With Addition of 170 New Practices To Medical Home Program.” 2015. Available at https://www.communitycarenc.org/media/files/news-release-august-2015-ncccn- adds-170-practices.pdf. Accessed 8-17-2015.
12 Community Care of North Carolina. “The Community Care Story.” Available at https://www.communitycarenc.org/about-us/. Accessed 8-13-2015.
13 Community Care of North Carolina. “A History of CCNC.” Available at https://www.communitycarenc.org/about-us/history- ccnc-rev/. Accessed 8-17-2015.
14 Ibid.
15 Medicaid. “Managed Care in North Carolina.” Available at https://www.medicaid.gov/medicaid-chip-program-information/by- topics/delivery-systems/managed-care/downloads/north-carolina-mcp.pdf. Accessed 4-7-2016.
16 Community Care of North Carolina. “A History of CCNC.” Available at https://www.communitycarenc.org/about-us/history- ccnc-rev/. Accessed 8-17-2015.
17 Ibid.
18 Ibid.
19 Ibid.
34 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM References
20 Community Care of North Carolina. “CCNC Transitional Care Process.” 2012. Available at https://www.communitycarenc.org/ media/related-downloads/transitional-care-process-and-model.pdf. Accessed 8-17-2015.
21 Jackson CT, Trygstad TK, DeWalt DA, DuBard CA. “Transitional care cut hospital readmissions for North Carolina Medicaid patients with complex chronic conditions.” Health Affairs. 2013. 32(8): 1407-1415. Available athttp://content.healthaffairs.org/ content/32/8/1407.full.html. Accessed 8-17-2015.
22 Burton R. “Improving Care Transitions.” Health Affairs: Health Policy Briefs. September 13, 2012. Available athttp://www. healthaffairs.org/healthpolicybriefs/brief.php?brief_id=76. Accessed 8-18-2015.
23 Ibid.
24 Ibid.
25 Ibid.
26 California HealthCare Foundation. “Coleman Care Transitions Intervention.” 2009. Available at http://www.chcf.org/ projects/2009/coleman-care-transitions-intervention. Accessed 8-18-2015.
27 Transitional Care Model. “Essential Elements.” Available at http://www.transitionalcare.info/essential-elements. Accessed 8-18- 2015.
28 Burton R. “Improving Care Transitions.” Health Affairs: Health Policy Briefs. September 13, 2012. Available athttp://www. healthaffairs.org/healthpolicybriefs/brief.php?brief_id=76. Accessed 8-18-2015.
29 Ibid.
30 Marchibroada J. “Interoperability.” Health Affairs: Health Policy Briefs. August 11, 2014. Available athttp://www.healthaffairs. org/healthpolicybriefs/brief.php?brief_id=122&_cldee=anRob3JwZUBnd3UuZWR1&urlid. Accessed 8-18-2015.
31 Basch P, McClellan M, Botts C, et al. “High Value Health IT: Policy Reforms for Better Care and Lower Costs.” Health Policy Issue Brief. 2015. Available at http://www.brookings.edu/~/media/research/files/papers/2015/03/16-health-it-policy-brief/16-high- value-health-it-policy-reforms-mcclellan.pdf. Accessed 8-18-2015.
32 Ibid.
33 Ibid.
34 Ibid.
35 Ibid.
36 North Carolina Interviewee #3. Interview conducted by Lisa Dulsky Watkins, MD. July 17, 2015.
37 North Carolina Interviewee #1. Interview conducted by Lisa Dulsky Watkins, MD. July 2, 2015.
38 North Carolina Interviewee #2. Interview conducted by Lisa Dulsky Watkins, MD. July 6, 2015.
39 North Carolina Interviewee #3. Interview conducted by Lisa Dulsky Watkins, MD. July 17, 2015.
40 North Carolina Interviewee #9. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
41 North Carolina Interviewee #10. Interview conducted by Lisa Dulsky Watkins, MD. July 31, 2015.
42 North Carolina Interviewee #2. Interview conducted by Lisa Dulsky Watkins, MD. July 6, 2015.
43 North Carolina Interviewee #4. Interview conducted by Lisa Dulsky Watkins, MD. July 22, 2015.
35 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM References
44 North Carolina Interviewee #1. Interview conducted by Lisa Dulsky Watkins, MD. July 2, 2015.
45 Community Care of North Carolina. “A History of CCNC.” Available at https://www.communitycarenc.org/about-us/history- ccnc-rev/. Accessed 8-17-2015.
46 North Carolina Interviewee #7. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
47 Community Care of North Carolina. “Chronic Care Program Summary.” 2007. Available at https://www.communitycarenc.org/ media/related-downloads/chronic-care.pdf. Accessed 8-19-2015.
48 Community Care of North Carolina. “A History of CCNC.” Available at https://www.communitycarenc.org/about-us/history- ccnc-rev/. Accessed 8-17-2015.
49 Community Care of North Carolina. “Chronic Care Program Summary.” 2007. Available at https://www.communitycarenc.org/ media/related-downloads/chronic-care.pdf. Accessed 8-19-2015.
50 Ibid.
51 Ibid.
52 Ibid.
53 North Carolina Interviewee #6. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
54 Community Care of North Carolina. “NCCCN Clinical Program Analysis.” Available at https://www.communitycarenc.org/media/ files/ccnc-care-management-roi.pdf. Accessed 11-20-2015
55 Dubard CA, Cockerham J, Jackson C. “Collaborative accountability for care transitions: The Community Care of North Carolina Transitions Program.” North Carolina Medical Journal. 2012. 73(1): 34-40. Available at http://classic.ncmedicaljournal.com/wp- content/uploads/2012/01/73106-web.pdf. Accessed 8-17-2015.
56 Ibid.
57 Ibid.
58 North Carolina Interviewee #2. Interview conducted by Lisa Dulsky Watkins, MD. July 6, 2015.
59 Dubard CA, Cockerham J, Jackson C. “Collaborative accountability for care transitions: The Community Care of North Carolina Transitions Program.” North Carolina Medical Journal. 2012. 73(1): 34-40. Available at http://classic.ncmedicaljournal.com/wp- content/uploads/2012/01/73106-web.pdf. Accessed 8-17-2015.
60 North Carolina Interviewee #10. Interview conducted by Lisa Dulsky Watkins, MD. July 31, 2015.
61 Dubard CA, Cockerham J, Jackson C. “Collaborative accountability for care transitions: The Community Care of North Carolina Transitions Program.” North Carolina Medical Journal. 2012. 73(1): 34-40. Available at http://classic.ncmedicaljournal.com/wp- content/uploads/2012/01/73106-web.pdf. Accessed 8-17-2015.
62 Ibid.
63 Ibid.
64 Dubard CA, Cockerham J, Jackson C. “Collaborative accountability for care transitions: The Community Care of North Carolina Transitions Program.” North Carolina Medical Journal. 2012. 73(1): 34-40. Available at http://classic.ncmedicaljournal.com/wp- content/uploads/2012/01/73106-web.pdf. Accessed 8-17-2015.
65 Ibid.
66 Ibid.
36 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM References
67 Ibid.
68 Ibid.
69 Ibid.
70 North Carolina Detect. “Background.” Available at http://www.ncdetect.org/about/background. Accessed 4-7-2016.
71 Ibid.
72 DEEDS Writing Committee. “Data Elements for Emergency Department Systems, Release 1.0 (DEEDS): A Summary Report.” Academic Emergency Medicine. 2008 5(1): 185-193. Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.1998. tb02607.x/pdf. Accessed 4-7-2016.
73 North Carolina Detect. “Background.” Available at http://www.ncdetect.org/about/background. Accessed 4-7-2016.
74 North Carolina Interviewee #11. Interview conducted by Megan Miller. August 4, 2015.
75 North Carolina Disease Event Tracking and Epidemiologic Collection Tool. “Background.” Available at http://www.ncdetect.org/ about/background. Accessed 8-20-2015.
76 North Carolina Legislative Statutes.“130A-480. Emergency Department Data Reporting.” Available at http://www.ncga.state. nc.us/enactedlegislation/statutes/html/bysection/chapter_130a/gs_130a-480.html. Accessed 8-17-2015.
77 North Carolina Health and Human Services. “Electronic Health Record (EHR) Meaningful Use Requirements. Available at http:// epi.publichealth.nc.gov/cd/meaningful_use/syndromic.html. Accessed 4-7-2016.
78 Ibid.
79 North Carolina Interviewee #11. Interview conducted by Megan Miller. August 4, 2015.
80 North Carolina Interviewee #5. Interview conducted by Lisa Dulsky Watkins, MD. July 22, 2015.
81 North Carolina Interviewee #6. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
82 North Carolina Interviewee #11. Interview conducted by Megan Miller. August 4, 2015.
83 North Carolina Interviewee #6. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
84 North Carolina Interviewee #11. Interview conducted by Megan Miller. August 4, 2015.
85 North Carolina Interviewee #6. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
86 North Carolina Interviewee #5. Interview conducted by Lisa Dulsky Watkins, MD. July 22, 2015.
87 North Carolina Interviewee #7. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
88 Community Care of North Carolina. “The Community Care of North Carolina Toolkit.” Available at http://commonwealth. communitycarenc.org/default.aspx. Accessed 8-19-2015.
89 Community Care of North Carolina. “Module 7: Creating an Informatics Center and Accountability/Feedback.” Available at http://commonwealth.communitycarenc.org/toolkit/7/default.aspx. Accessed 4-7-2016.
90 Ibid.
91 Ibid.
37 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM References
92 Ibid.
93 Ibid.
94 Community Care of North Carolina. “Truth in Numbers.” Available at https://www.communitycarenc.org/informatics-center/. Accessed 8-19-2015.
95 Dubard CA. “A population-based perspective on the care of complex patients: Knowing when to intervene.” Presented at UNC Cancer Outcomes Research Seminar. 2015. Available at http://unclineberger.org/outcomes/files/20150414-slides-breakfast- seminar-annette-dubard. Accessed 8-24-2015.
96 North Carolina Interviewee #8. Interview conducted by Lisa Dulsky Watkins, MD. July 28, 2015.
97 Community Care of North Carolina. “Truth in Numbers.” Available at https://www.communitycarenc.org/informatics-center/. Accessed 8-19-2015.
98 North Carolina Interviewee #4. Interview conducted by Lisa Dulsky Watkins, MD. July 22, 2015.
99 North Carolina Interviewee #9. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
100 North Carolina Interviewee #10. Interview conducted by Lisa Dulsky Watkins, MD. July 31, 2015.
101 North Carolina Interviewee #7. Interview conducted by Lisa Dulsky Watkins MD. July 27, 2015
102 Community Care of North Carolina. “CCNC’s New Approach For Targeting the Most Impactable Patient.” Available at http://surveygizmolibrary.s3.amazonaws.com/library/12181/CCNCPriorityPopulationsInformation.pdf. Accessed 8-23-2015.
103 North Carolina Interviewee #8. Interview conducted by Lisa Dulsky Watkins, MD. July 28, 2015.
104 North Carolina Interviewee #4. Interview conducted by Lisa Dulsky Watkins, MD. July 22, 2015.
105 North Carolina Interviewee #8. Interview conducted by Lisa Dulsky Watkins, MD. July 28, 2015.
106 North Carolina Interviewee #3. Interview conducted by Lisa Dulsky Watkins, MD. July 17, 2015.
107 North Carolina Interviewee #6. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
108 North Carolina Interviewee #3. Interview conducted by Lisa Dulsky Watkins, MD. July 17, 2015.
109 North Carolina Interviewee #4. Interview conducted by Lisa Dulsky Watkins, MD. July 22, 2015.
110 Ibid.
111 North Carolina Interviewee #3. Interview conducted by Lisa Dulsky Watkins, MD. July 17, 2015.
112 North Carolina Interviewee #9. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
113 North Carolina Interviewee #3. Interview conducted by Lisa Dulsky Watkins, MD. July 17, 2015.
114 North Carolina Interviewee #6. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
115 North Carolina Interviewee #10. Interview conducted by Lisa Dulsky Watkins, MD. July 31, 2015.
116 North Carolina Interviewee #9. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
117 North Carolina Interviewee #10. Interview conducted by Lisa Dulsky Watkins, MD. July 31, 2015.
38 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM References
118 North Carolina Interviewee #6. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
119 North Carolina Interviewee #7. Interview conducted by Lisa Dulsky Watkins MD. July 27, 2015.
120 Ibid.
121 Ibid.
122 North Carolina Interviewee #10. Interview conducted by Lisa Dulsky Watkins, MD. July 31, 2015.
123 North Carolina Interviewee #8. Interview conducted by Lisa Dulsky Watkins, MD. July 28, 2015.
124 North Carolina Interviewee #4. Interview conducted by Lisa Dulsky Watkins, MD. July 22, 2015.
125 Ibid.
126 Patient-Centered Primary Care Collaborative. “Community Care of North Carolina.” Available at https://www.pcpcc.org/ initiative/community-care-north-carolina-ccnc-0. Accessed 8-20-2015.
127 Ibid.
128 Ibid.
129 Ibid.
130 North Carolina Interviewee #2. Interview conducted by Lisa Dulsky Watkins, MD. July 6, 2015.
131 North Carolina Interviewee #6. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
132 North Carolina Interviewee #5. Interview conducted by Lisa Dulsky Watkins, MD. July 22, 2015.
133 North Carolina Interviewee #8. Interview conducted by Lisa Dulsky Watkins, MD. July 28, 2015.
134 North Carolina Interviewee #6. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
135 Dubard CA, Jacobson Vann JC, Jackson CT. “Conflicting readmission rate trends in a high-risk population: Implications for performance measurement.” Population Health Management. 2015. 18(5): 351-357. Available at http://www.ncbi.nlm.nih.gov/ pubmed/25607449. Accessed 8-17-2015.
136 Ibid.
137 North Carolina Interviewee #7. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
138 Jackson CT, Trygstad TK, DeWalt DA, DuBard CA. “Transitional care cut hospital readmissions for North Carolina Medicaid patients with complex chronic conditions.” Health Affairs. 2013. 32(8): 1407-1415. Available athttp://content.healthaffairs.org/ content/32/8/1407.full.html. Accessed 8-17-2015.
139 Jackson C. “CCNC Transitional Care: It Works!” 2012. Provided by Jackson on 7-28-2015.
140 North Carolina Interviewee #4. Interview conducted by Lisa Dulsky Watkins, MD. July 22, 2015.
141 North Carolina Interviewee #2. Interview conducted by Lisa Dulsky Watkins, MD. July 6, 2015.
142 North Carolina Interviewee #3. Interview conducted by Lisa Dulsky Watkins, MD. July 17, 2015.
143 North Carolina Interviewee #9. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
39 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM References
144 North Carolina Interviewee #7. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
145 North Carolina Interviewee #9. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
146 Ibid.
147 North Carolina Interviewee #5. Interview conducted by Lisa Dulsky Watkins, MD. July 22, 2015.
148 North Carolina Interviewee #8. Interview conducted by Lisa Dulsky Watkins, MD. July 28, 2015.
148 Ibid.
150 North Carolina Interviewee #7. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
151 North Carolina Interviewee #6. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
152 North Carolina Interviewee #10. Interview conducted by Lisa Dulsky Watkins, MD. July 31, 2015.
153 Ibid.
154 Ibid.
155 North Carolina Interviewee #1. Interview conducted by Lisa Dulsky Watkins, MD. July 2, 2015.
156 Ibid.
157 Ibid.
158 North Carolina Interviewee #11. Interview conducted by Megan Miller. August 4, 2015.
159 North Carolina Interviewee #10. Interview conducted by Lisa Dulsky Watkins, MD. July 31, 2015.
160 North Carolina Interviewee #3. Interview conducted by Lisa Dulsky Watkins, MD. July 17, 2015.
161 Ibid.
162 North Carolina Interviewee #6. Interview conducted by Lisa Dulsky Watkins, MD. July 27, 2015.
163 Ibid.
164 North Carolina Interviewee #3. Interview conducted by Lisa Dulsky Watkins, MD. July 17, 2015.
165 North Carolina Interviewee #10. Interview conducted by Lisa Dulsky Watkins, MD. July 31, 2015.
166 North Carolina Interviewee #2. Interview conducted by Lisa Dulsky Watkins, MD. July 6, 2015.
167 Ibid.
168 North Carolina Interviewee #10. Interview conducted by Lisa Dulsky Watkins, MD. July 31, 2015.
169 Ibid.
170 Bonner L. “NC Legislature Approves Medicaid Privatization.” The News & Observer. September 22, 2015. Available at http://www.newsobserver.com/news/politics-government/state-politics/article36223626.html. Accessed 8-17-2015.
40 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Appendix 1 - de Beaumont Medicaid-Public Health Expert Group Members
Mary Applegate Lacy Fehrenbach* Frederick Isasi Ohio Department of Medicaid Association of Maternal and NGA Child Health Programs Carol Backstrom* Paul Jarris* NGA Barbara Ferrer* ASTHO Boston Public Health Commission Gus Birkhead* Richard Jensen New York State Department Amy Ferris The Centers for Medicare and of Health Washington State Department Medicaid Services Center for of Health Medicare and Medicaid Innovation Lindsey Browning National Association of Medicaid Lori Freeman Adam Judge Directors Association of Maternal and de Beaumont Foundation Child Health Programs Brian Castrucci Laurel Karabatsos de Beaumont Foundation Bob Glover* Colorado Department of Health National Association of State Care Policy and Financing Stephen Cha Mental Health Program Directors The Centers for Medicare and Tony Keck* Medicaid Services Center for Stuart Gordon South Carolina Department of Medicaid and CHIP Services National Association of State Health and Human Services Mental Health Program Directors Theresa Chapple Ruth Kennedy* de Beaumont Foundation Mary Beth Hance Louisiana Department of Health The Centers for Medicare and and Hospitals Harry Chen Medicaid Services Vermont Department of Health Center for Medicaid and CHIP JP Leider* Services de Beaumont Foundation Stacy Collins Association of Maternal and Laura Hanen Sarah Linde Child Health Programs NACCHO HRSA
Brian Costello Brian Hepburn Mike Maples ASTHO Consultant National Association of State Texas Department of State Mental Health Program Directors Health Services Ed Davidson ASTHO Consultant Thuy Hua-Ly Megan Miller Washington State Health Care ASTHO Lisa Dulsky Watkins Authority ASTHO Consultant Sharon Moffatt Edward Hunter ASTHO de Beaumont Foundation
41 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Appendix 1 - de Beaumont Medicaid-Public Health Expert Group Members
Judith Monroe* Jeff Schiff CDC Office of State, Tribal, Local, Minnesota Health Care Programs and Territorial Support Tom Schlenker* José Montero* San Antonio Metropolitan Health New Hampshire Department of District Health and Human Services James Sprague* Robert Morrison de Beaumont Foundation National Association of State Alcohol and Drug Abuse Directors Deirdra Stockmann The Centers for Medicare and Kelly Murphy Medicaid Services Center for NGA Medicaid and CHIP Services
Karen Murphy* Hemi Tewarson The Centers for Medicare and NGA Medicaid Services Center for Medicare and Medicaid Innovation Carol Thornton Pennsylvania Department Kathleen Nolan* of Health National Association of Medicaid Safe States Alliance Directors Laura Tobler Catherine Patterson National Conference of State de Beaumont Foundation Legislatures
Harvey Perez* Monica Valdes Lupi* Washington State Department ASTHO of Health Rita Vandivort-Warren Robert Pestronk* HRSA NACCHO Kathy Vincent Patricia Portzebowski ASTHO Consultant National Association for Public Health Statistics and Information Kristen Wan Rego Systems ASTHO
John Robitscher Amber Williams National Association of Chronic Safe States Alliance Disease Directors
*previously served as representative for organization on expert group
42 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Appendix 2 - Interview Instrument
INTERVIEW INSTRUMENT
Thank you for talking with me today. This interview is being conducted as part of a series of case studies that will reflect collaboration between Medicaid and public health that have yielded (or promise to yield) cost savings to Medicaid and/or improvements to population health. Do you have any questions at this time?
I would like to read a brief disclosure statement to you. If it sounds good, we’ll get started.
Disclosure statement: This interview will last for approximately an hour. As explained to you earlier, your participation is absolutely voluntary. You can decline to answer any question, and if you wish to discontinue your participation at any time during the interview process, please feel free to do so. With your permission, we would like to record this interview. This recording will only be used to confirm our notes, and will be deleted once the project is completed. Your identity will be confidential and any reports generated from this session will include only de-identified responses. Before verbally consenting to participate in this interview, I would like to make sure that you feel you understand the purpose of this project and have had the chance to ask any questions you’d like. If you do not have any questions, with your consent, we will begin the interview, and it will be recorded. (Consent)
In the course of this interview, we will be asking you several questions about [NAME OF POLICY CHANGE] which I’ll call “policy change” for short. The questions will include how the policy change started, how implementation happened, and what the outcomes have been.
1. What is your role in your agency, and how did you come to be aware of the policy change?
2. What was the problem the policy change sought to address?
a. (Identify vision, mission and values)
3. In two or three sentences, could you summarize what the policy change was?
4. Thanks for the overview. As part of this case study, I’ll be trying to figure out when the various stages of the policy change occurred.
a. Can you outline a timeline of the process?
b. Were there any missteps identified during the implemetation process you’ve described?
i. How were they identified?
ii. How were they overcome?
43 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Appendix 2 - Interview Instrument
5. What were the mechanisms of the policy change’s implementation? The 2 areas we have already identified are engagement of partners and types of tools. If there were other mechanisms, please share them.
a. Engagement of partners
i. What external partners/stakeholders were engaged,and how? (Examples could include political, governmental and special interest groups, CMS,others.) Were they were key to the process?
ii. What internal partners and staff were engaged andprimarily responsible? Were they co-located?
b. Tools
i. What methods of communication were used? Examples include face-to-face, conference calls, webinars, shared electronic files, public meetings
ii. What kinds of policy tools were used?
1. Regulatory/statutory (State or local? Funded?)
2. CMS/Medicaid (Waiver, and what kind? State Plan Amendment? Other?)
3. Payer alignment
6. There is commonly some kind of “course correction” over time in complex projects such as yours. Did this occur in your case?
a. Were the initial goals of the collaboration modified? If so, how?
b. Were the original strategies significantly changed? If yes, describe.
7. Evaluation
a. How did you measure outcomes of the policy change?
b. Are there any outcomes attributable to that policy change?
c. Is there funding dedicated to evaluation? If so, where does the funding come from (in-kind, etc.)?
44 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Appendix 2 - Interview Instrument
8. Sustainability
a. Is there a mechanism in place to address sustainability?
i. If so, please describe. Has it been successful?
My final questions are about extrapolating from your experience with this policy change to others. I’m going to ask you to think about missteps, and how transferable you feel this policy change is to other locales.
9. What from this process could be useful to other states or local entities considering similar approaches?
10. What was the impact of the type of policy vehicle on the implementation process?
11. In addition to the missteps identified earlier, if any, were there other things you might have done differently?
a. If so, how were they identified?
b. How were these issues overcome?
45 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Appendix 3 - Interview Data Collection Tool
Interview respondent name: Case: Interview ID #: Date: State: Note taker:
Question Helpful hints Question Summary number Use semicolons to separate Take full notes here Provide short summaries here, use distinct concepts quotation marks to indicate verbatim quotes, otherwise paraphrase.
What is your role in your agency, and Role 1. how did you come to be aware of the policy change?
Ignore role, focus on awareness
What was the problem the policy Problem 2. change sought to address?
Identify vision, mission, values
In two or three sentences, could you Summarize policy change 3. summarize what the policy change was?
Summarize policy change in as few distinct steps as possible
Can you outline a timeline Timeline 4a. of the process?
Critical. Report each step by month and year, if possible. Use numbered list
Were there any missteps identified Missteps 4b. during the implementation process you’ve described? How were they identified? How were they overcome?
Separate responses into distinct misstep identification and solution (use semicolons)
What were the mechanisms of the Mechanisms of Implementation 5. policy change’s implementation?
The 2 areas we have already identified are engagement of partners and types of tools (below). If there were other mechanisms, please share them.
46 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Appendix 3 - Interview Data Collection Tool
Question Helpful hints Question Summary number Use semicolons to separate Take full notes here Provide short summaries here, use distinct concepts quotation marks to indicate verbatim quotes, otherwise paraphrase.
What external partners/stakeholders External engagement 5ai. were engaged, and how? (Examples could include political, governmental and special interest groups, CMS, others.) Were they were key to the process?
External to home agency (could include other governmental actors)
What internal partners and staff were Internal engagement 5aii. engaged and primarily responsible? Were they co-located?
Internal to the home agency only
What methods of communication Communication methods 5bi. were used?
Options include: face-to-face, conference calls, webinars, shared electronic files, public meetings
5bii. What kinds of policy tools were used? Policy tools
Options include: Regulatory/statutory (State or local? Funded?) CMS/Medicaid (Waiver, and what kind? State Plan Amendment? Other?) Payer alignment
Did course corrections occur? Course corrections 6. Were the initial goals of the collaboration modified? If so, how? Were the original strategies significantly changed? If yes, describe
Modified goals, strategies, and tactics. Concise summaries
How did you measure outcomes of the Measure outcomes/Evaluation 7a. policy change?
Separate concrete impact measures from process measures
47 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Appendix 3 - Interview Data Collection Tool
Question Helpful hints Question Summary number Use semicolons to separate Take full notes here Provide short summaries here, use distinct concepts quotation marks to indicate verbatim quotes, otherwise paraphrase.
Are there any outcomes Attributable outcomes/Evaluation 7b. attributable to that policy change?
Yes/No, and what?
Is there funding dedicated to Funding for Evaluation 7c. evaluation? If so, where does the funding come from (in-kind, etc)?
Yes/No, and what kind?
Is there a mechanism in place to Sustainability 8. address sustainability? If so, has it been successful?
Yes/No, and what?
What from this process could be Transferability 9. useful to other states or local entities considering similar approaches?
Focus on short phrases
What was the impact of the type of Impact of policy vehicle type 10. policy vehicle on the implementation process?
Make sure it’s attributable to vehicle specifically, otherwise “No Impact attributable” is OK
In addition to the missteps identified Missteps 11. earlier, if any, were there other things you might have done differently? If so, how were they identified? How were these issues overcome?
Will be combined with codes above. Separate responses into distinct misstep identification and solution
48 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Appendix 4: Document Review Data Collection Tool
Document name: Case: Document ID #: Date: State: Note taker:
Question Question Summary number Take full notes here Provide short summaries here, use quotation marks to indicate verbatim quotes, otherwise paraphrase.
1. What was the problem the policy change sought to address? Problem
2. What was the policy change? Summarize policy change
3. What was the timeline of the process? Timeline
What were the mechanisms of the policy Mechanisms of Implementation 4. change’s implementation?
What external partners/stakeholders were engaged, and External engagement 5. how? (Examples could include political, governmental and special interest groups, CMS, others.) Were they were key to the process?
What internal partners and staff were Internal engagement 6. engaged and primarily responsible?
49 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Appendix 4: Document Review Data Collection Tool
Question Question Summary number Take full notes here Provide short summaries here, use quotation marks to indicate verbatim quotes, otherwise paraphrase.
7. What kinds of policy tools were used? Policy tools
What was the impact of the type of policy vehicle on the Impact of policy vehicle type 8. implementation process?
Is there a mechanism in place to address Sustainability 9. sustainability? If so, has it been successful?
10. How are outcomes of the policy change measured? Measure outcomes/Evaluation
11. Are there any outcomes attributable to that policy change? Attributable outcomes/Evaluation
12. About this document Document format - Web, print, other?
12a. About this document. Publicly available?
12b. About this document. Working document?
About this document. Publicity material? 12c. If so, target audience?
12d. About this document. Author and title?
12e. About this document. Other information?
50 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM Timeline
1983–1985 2001 2009–2013 2015 • DMA and ORH partnered with the • CCNC developed CMIS. • 2009: HITECH enacted. • Population Health Management study NCFAHP to develop the Wilson County found 30-day readmission rate per Health Plan, using a Kate B. Reynolds • 2009: CCNC implemented Med 1000 beneficiaries declined. Health Care Trust grant. 2004 Rec Plus. • August: CCNC network included • NC DETECT created to serve as an • September 2010: CCNC had ADT 90 percent of primary care practices 1991 early detection surveillance system. data from 28 hospitals. and serves 1.4 million Medicaid • DMA and ORH obtained a 1915(b) beneficiaries. federal waiver for PCCM operations. • June 2011: Treo Solutions analysis 2005 found CCNS saved NC nearly • September: NC governor signs $1.5 billion from 2007-2009. House Bill 372 into law enacting 1997 • $6 million from state budget was Medicaid privatization. allocated to CCNC chronic care • Spring 2011: CCNC transitional care • Carolina ACCESS implemented in 99 pilot programs. program had 91 care managers in of 100 counties. 118 primary care practices and • NC General Assembly passes 50 care managers in 48 hospitals. syndromic surveillance law mandating 1999 all EDs submit data to NCHESS. • May 2012: CMS approved NC’s • UNC Department of Emergency Health Homes SPA providing Medicine collaborated with DPH 90 percent enhanced FMAP for to develop NCEDD. 2006-2007 health home services.
• CCNC expanded service to include • August 2013: Health Affairs study the ABD and dually eligible population. stated patients enrolled in transitional care less likely to be readmitted the 2008 following year.
• CCNC transitional care program launched statewide.
• NC DETECT collected data from all NC hospitals and had population-wide data.
51 NORTH CAROLINA | TRANSITIONAL CARE PROGRAM