Clinical Care Team Transformation Strategies

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imgres-1 Toolkits

Information Exchange Online Toolkit (CHCS)

This toolkit provides resources to assist organizations in managing patient information exchanges between the various providers involved in a clinical care team. It also offers examples of state behavioral/physical health coordination consent forms.

imgresArticles and Briefs

Integrating Health Care and Social Services: Moving from Concept to Practice

This brief, prepared by Bailit Health Purchasing and the Robert Wood Johnson Foundation, examines practical approaches that state agencies might employ to better integrate social services and health care delivery.

Organizational Factors Affect Safety-Net Hospitals’ Breast Cancer Treatment Rates

The primary objective of this study presented in AcademyHealth was to identify key organizational approaches associated with underuse of breast cancer care in nine New York City area safety-net hospitals. The study concluded that at safety-net hospitals, underuse of needed cancer therapies is associated with organizational approaches to track and follow-up treatment. Findings provide varying approaches to safety nets to improve cancer care delivery.

Strengthening the Oral Health Safety Net

Funded by the DentaQuest Foundation, this initiative is a partnership with the National Association of Community Health Centers and Massachusetts League of Community Health Centers. The partnership is working with 15 state Primary Care Associations and over 100 Community Health Centers to strengthen local and state oral health programs.

Community Care Teams: An Overview of State Approaches

The paper was produced by the Center for Health Care Strategies and the State Health Access Data Assistance Center (SHADAC) with support from the Center for Medicare & Medicaid Innovation (the Innovation Center). This resource paper provides information on Community Care Team programs in several states and includes: An overview of core program features, key elements of governance models, approaches to financing and reimbursement, considerations for workforce requirements, and examples of health informatics models to support CCT initiatives.

Developing Care Management Programs to Serve High-Need, High-Cost Populations: Insights from the health care transformation task force

The Health Care Transformation Taskforce published this white paper, which provides information on the building blocks of care management; reviews case studies of Task Force member care management programs, and lessons learned and important areas for improvement.

Interdisciplinary Care Teams for Medicare-Medicaid Enrollees: Considerations for States

This brief published by the Center for Health Care Strategies was developed through support from The Commonwealth Fund and The SCAN Foundation. The technical assistance brief describes key interdisciplinary care teams (ICTs) considerations and explores how eight states – Idaho, Massachusetts, Minnesota, New Jersey, New York, Rhode Island, Virginia, and Washington – addressed these issues.

Overcoming Challenges to Teamwork in Patient-Centered Medical Homes: A Qualitative Study

This Commonwealth Fund article describes a study of medical practices recognized as patient-centered medical homes found that a team approach to primary care was fostered by: delegating more of physicians’ nonclinical tasks to other staff; soliciting staff input on workflow modifications and feeding back data to the team; expanding the roles of medical assistants and nurses; and holding regular team “huddles.”

Safety Net Integration: A Shared Strategy for Becoming Providers of Choice

This scholarly article provides insight into strategies to promote care integration in the safety net. The researchers interviewed safety net hospital and health center leaders from five US cities to understand specific strategies implemented by their organizations.

Forging Community Partnerships to Improve Health Care: The Experience of Four Medicaid Managed Care Organizations

This issue brief from The Commonwealth Fund establishes the drivers, goals, and challenges of forging community partnerships from the perspective of four Medicaid managed care organizations.

Innovation in the Safety Net: Integrating Community Health Centers Through Accountable Care

This article from The Commonwealth Fund offers evidence to support the value in partnerships between accountable care organizations and community health centers.

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety- Net Patients: A Randomized Controlled Trial

This scholarly article documents the effects of implementing a patient navigator program in a safety net hospital on hospital readmission rates.

Improving the Care of Dual Eligible Patients in Rural Federally Qualified Health Centers: The Impact of Care Coordinators and Clinical Pharmacists

This scholarly article investigates the impact of care coordinators and clinical pharmacists in rural FQHCs on care for patients covered by both Medicare and Medicaid. The study indicates that investments in care coordination and clinical pharmacy review can significantly reduce hospitalization and harmful polypharmacy in this patient population.

Impact of a Chronic Care Coordinator Intervention on Diabetes Quality of Care in a Community Health Center

This scholarly article evaluates the impact of chronic care coordinators on diabetes care quality within six community health centers. The chronic care coordinator intervention in this study yielded some improvement, but requires some modification.

Addressing Patients’ Social Needs: An Emerging Business Case for Provider Investment

This report from The Commonwealth Fund offers a financial argument to support the need for health care providers to address patient’s social needs. It also provides strategies for health care organizations to achieve this goal.

Disease Management of Early Childhood Caries

This report explores the effectiveness of a disease management (DM) program for early childhood caries. The DM clinical protocol included a caries risk assessment tool (CAT), in-office and at-home care management, and other tools. The results from this analysis indicate that a risk-based DM approach may improve health care quality and patient outcomes. Safety net oral health providers can use this report to improve care for early childhood caries.

Cost Effectiveness of a Disease Management Program for Early Childhood Caries

This report investigates the cost-effectiveness of a disease management (DM) program for early childhood caries. The study concludes that the DM program is cost-effective and may reduce overall health care costs. Safety net oral health providers may use this report to financially justify a DM intervention for early childhood caries.

DentaQuest Institute Safety Net Solutions

Safety Net Solutions is a DentaQuest Institute program that seeks to provide care management assistance to safety net dental programs. This report outlines the SNS model and its impact, as well as provides lessons and recommendations based on efforts from 2006- 2011. Safety net providers may use this report to improve their dental programs.

Clinical Integration Across Settings

imgres-1 Webinars

State Innovations: Oral Health Integration in Statewide Delivery System and Payment Reform

This webinar from the Center for Health Care Strategies, made by possible by the Washington Dental Service Foundation, explored the range of approaches to oral health integration that states are considering in the areas of: (1) Medicaid benefit design and expansion; (2) practice-level oral health reforms; and (3) statewide delivery reform models.

imgres-1 Toolkits

Integration Strategies Toolkit

This toolkit provides various examples of innovative models integrating physical and behavioral health care. The resources are categorized into the following topic areas: physical/behavioral health integration, appropriate emergency department use, and innovations for integrating depression treatment into primary care.

imgresArticles and Briefs

CommunityRx: A Population Health Improvement Innovation That Connects Clinics To Communities

AcademyHealth offers The CommunityRx system, a population health innovation, combined an e-prescribing model and community engagement to strengthen links between clinics and community resources for basic, wellness, and disease self-management needs in Chicago.

Strengthening Integration Of Health Services And Systems

Integration of health services and systems constitutes the fourth Action Area in the Robert Wood Johnson Foundation’s Culture of Health Action Framework, which is the subject of this article from AcademyHealth. This Action Area conceives of a strengthened health care system as one in which medical care, public health, and social services interact to produce a more effective, equitable, higher-value whole that maximizes the production of health and well-being for all individuals.

National Oral Health Innovation and Integration Network

This collaborative grew out the Strengthening the Oral Health Safety Net (SOHSN) partnership. Funded by the DentaQuest Foundation, this initiative engaged partners like the National Association of Community Health Centers (NACHC) and the National Network for Oral Health Access (NNOHA), supporting their work to strategically build capacity to promote oral health on behalf of safety net providers across the country.

Medicaid Expansion: Driving Innovation In Behavioral Health Integration

The blog from HealthAffairs presents case studies from two provider systems that illustrate some of the innovative approaches that are improving the quality of behavioral health care at safety-net institutions.

Promising Practices to Integrate Physical and Mental Health Care for Medi-Cal Members

This brief from the Center for Health Care Strategies describes promising practices to improve collaboration across systems, and to provide a more seamless experience of care for beneficiaries. These insights, while gleaned from California, can inform physical and mental health care integration in other states as well.

Quality Indicators for Physical and Behavioral Health Care Integration

Although the integration of physical and behavioral health services has been shown to improve outcomes and reduce spending, it has failed to take hold. In a JAMA Viewpoint, Commonwealth Fund–supported authors say that the missing link to increased adoption of this model may be quality measures for assessing and rewarding well-integrated care.

Creating Connections: An Early Look at the Integration of Behavioral Health and Primary Care in Accountable Care Organizations

This Commonwealth Fund report explores how ACOs are approaching the integration of behavioral health into primary care by showcasing two models of behavioral health and primary care integration. The two ACOs vary in their approach to integration as well as in other characteristics.

Strategic Guidance: Practical Approaches for Engaging Employers in Community Alliances

This brief highlights employer engagement insights from collaboratives that are currently part of the Aligning Forces for Quality (AF4Q) program. This brief also offers several ideas for community collaboratives to consider in assessing the mix of employers in their region and matching their own products or services with the types of employers most likely to value them.

Using Medicaid Resources to Pay for Health-Related Supportive Services: Early Lessons

CHCS conducted interviews with state officials, community providers, and national experts to identify how these Medicaid programs are determining the appropriate scope of supportive services and incorporating them into their state plans. Drawing from these interviews, this brief provides practical state case studies to help inform supportive service payment strategies within accountable care organizations, health homes, community health teams, accountable communities for health, and other value-based delivery system reforms.

Improving Health Care Quality and Equity: Considerations for Building Partnerships Between Provider Practices and Community Organizations (A4FQ) 

Given the day-to-day hurdles many patients face, practices can benefit from strategic partnerships with community organizations that can help support patient needs. This brief outlines considerations for practices looking to develop partnerships with community organizations.It mainly addresses practices that may have limited experience with community engagement, but that seek to form relationships that can help them improve the quality or equity of their care.

Articles and Briefs

Surprise out-of-network doctor bills are much more common than we thought

In a recent Health Affairs article, the Commonwealth Foundation conducted their periodic survey of eleven countries to see how access issues might have improved or worsened. Even with the passage of the Affordable Care Act, more people in the United States had a cost-related barrier to accessing care in the United States than any other comparable country.

Previous Medicaid Expansion May Have Had Lasting Positive Effects On Oral Health Of Non-Hispanic Black Children

In this study published in the December 2016 edition of Health Affairs, authors examined the effects of a historic expansion in Medicaid eligibility on the adult oral health of those who gained eligibility as infants. The authors used data from several years of Behavioral Risk Factor Surveillance System (BRFSS) surveys and a sample of adults born between 1979 and 1991. Findings conclude that expanded Medicaid coverage geared toward pregnant women and children during their first year of life was linked to better oral health in adulthood among non-Hispanic blacks.

Oregon/California Learning Exchange (Or/CaX)

Nearly 100 safety net leaders attended the Oregon/California Learning Exchange (Or/CaX) held in Oakland on March 29, 2016 to learn about pioneering care delivery transformation efforts taking place in each other’s communities. A morning panel session discussed the two states’ experiences with FQHC Alternative Payment Methodology (APM) demonstrations, and the afternoon was packed with “Bright Spot Breakout Sessions” and “Office Hours”, where participants learned about specific innovations and care delivery models being tested and implemented in peer organizations. The convening was organized in partnership with the Oregon Primary Care Association and Blue Shield of California Foundation.

The ACO Conundrum: Safety-Net Hospitals in the Era of Accountable Care

Safety net hospitals do not have a long history of participating in ACOs. This Bailit Health Purchasing brief, based on interviews and experiences within safety net hospitals, explores why and what can be done to meet ACO challenges.

Key Elements to Consider in ACO Agreements

This action brief from the Health Care Transformation Task Force outlines areas providers and administrators should consider when joining or establishing an Accountable Care Organization.

Key Payer and Provider Operational Steps to Successfully Implement Bundled Payments

This Bailit Health Purchasing brief provides an in-depth review of the operational steps health plans and providers are taking to be successful under bundled payment.

Four Innovative Strategies to Help Providers Succeed Under Payment Reform

This report from the Robert Wood Johnson Foundation and prepared by Bailit Health Purchasing, LLC consolidates experiences and best practices from health care payment reform experts into four specific strategies. The strategies include target population identification, creative care management responses, understanding costs, and information support for providers.


Measuring Social Determinants of Health among Low-Income Populations: Early Insights from State Initiatives

This webinar, made by possible by The Commonwealth Fund, will explore emerging state-level approaches to measuring Social Determinants of Health (SDOH) among beneficiaries of publicly financed care. It will address: (1) the rationale for collecting SDOH data; (2) various approaches for using SDOH information; and (3) challenges and key considerations for states interested in advancing SDOH measurement efforts. The webinar will feature promising initiatives in two states, Massachusetts and Oregon, and highlight takeaways from a soon-to-be-published CHCS environmental scan that examines existing SDOH data collection efforts by Medicaid and other public agencies.

Articles and Briefs

Considerations for a National Risk-Adjustment Model for Medicaid Managed Long-Term Services and Supports Programs

This brief examines considerations in developing a nationally available risk-adjustment model for MLTSS programs. It also explores research needed to develop a robust model that predicts expected LTSS costs as accurately as possible.

Rewarding High Quality: Practical Models for Value-Based Physician Payment

In Alliance of Community Health Plans’ newest brief, Rewarding High Quality: Practical Models for Value-Based Physician Payment; they examine how ACHP members across the U.S. have launched a diverse range of initiatives to reduce costs while increasing quality of care.

White Paper: Payment to Promote Sustainability of Care Management Models for High-Cost, High-Need Patients

This paper, by the Health Care Transformation Taskforce, illustrates Task Force members’ important investments in care management infrastructure and their success with improving outcomes for high-need patients under a patchwork of payment arrangements.

Key Payer and Provider Operational Steps for Successfully Implementing Bundled Payment

This brief from the Health Care Incentives Improvement Institute provides a more in-depth review of the operational steps health plans and providers are taking to be successful under bundled payment. The findings are based on interviews with seven payers, seven providers, and one organization selected as a convener.

Aligning Higher Performance Through Shared Savings Programs

Commissioned by The Center for Care Innovations, this discussion paper focuses on shared savings programs including where providers share in upside risk or where they share in both upside and downside risk as participants in Medicaid managed care programs.

Transitioning to Episode-Based Payment

This policy brief describes how to define an episode payment and how to transition to episode payment.

Oregon’s Bridge to Value-Based Payments for Community Health Centers: A Win for Medicaid, Providers, & Patients

This article summarizes a successful attempt to embrace value-based payment in Oregon health centers. The resource highlights risk-adjustment considerations for successfully implementing an alternative payment model.

Risk Adjustment for Sociodemographic Factors

This report provides a set of recommendations for successfully including socioeconomic status, race, ethnicity and other factors in risk adjustment. The National Quality Forum developed ten specific recommendations for health care organizations to follow through an expert panel of clinicians, academics, and public health professionals.

Sociodemographic Factors Affect Health Outcomes

This is a periodically updated list of evidence and resources on the need to risk adjust performance measures prepared by America’s Essential Hospital.

Impact of Risk Adjustment for Socioeconomic Status on Risk-adjusted Surgical Readmission Rates

This scholarly article explores whether differences in surgical readmission rates in safety net hospitals vs. non-safety net hospitals are the result of care quality differences. The study results indicate that variation in readmission rates are the result of differences in patient populations and not quality. The article suggests that risk adjusting readmission measures led to changes in hospital rankings.


The 6|18 Initiative: Evaluation and Impact Measurement

This webinar includes information on: (1) expectations for active Medicaid and Public Health engagement in evaluating the 6|18 Initiative’s impact; (2) a description of CDC’s Evaluation Wheel and early effectiveness evaluation approach; (3) a brief synopsis of the Medicaid Adult and Child Core Measure Sets and quality reporting activities; and (4) a description of the methodology and results of a CDC analysis of CMS quality measure sets.