Developing Our Service Package(s)Florida Neighborhood Networks

Shirley, Sandra, Gabriel, Maria and Anna

Service packagesMajor services/service packages that will meet our customers’ needs:

• Save money – referred by care transition team, physician – we will do wellness and prevention assessment (nurse or clinical social worker EnhancedWellness working for the collaborative

• Patient-centered assessment –

• Coordinated model

Major services/service packages that will meet our contracting organization’s needs:

• Patient-centered assessment

• Access to Evidence-based programs – person is connected to community health worker

• Access to aging network services

• PMPM to cover services

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Network capacityCurrent network partners, capacity and strengths

Organization name Service competencies Strengths

ADRC in 3 counties History, EBP program delivery, knowledge, information and access to entire service systems

Network of providers with deep penetration

FQHCs Medical home expertise, experience with EBPs, providing clinical services, becoming geriatric center of excellenceHRSA mandate, Health IT, Medicare billing capacity

Embedded in high risk communities, building services to older adults, attracting people who need services

VA health system MOVE program – weight reduction system, hope to have VA support as benefit

Use to refer veterans to community programs

YMCA EBP delivery capacity, embedded in community, Core strength in fitness and wellness programs, 100% retention

Embedded in high risk community, capacity to influence , 60 community partners,

Aging network MTS and network of facilitators, 30 MOAs with community partners

Deliver programs in day care centers, and deliver other programs, access to large condos, name recognition

Parks and Recreation

Hospitals Link via ADRCs , id older adults

Network capacity

New network partners to be added• Medicaid opportunities, what can network partners bring• Physician groups (family practitioners) , Prestige – build

relationships , • Large clinics (Medicare Advantage) internal structure• Rand eye institute, hospital systems - current CCTP hospital

partners

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Service value definitionResult(s) we commit to deliver• 7% Reduction in ambulatory

emergency room in target population of 2+ chronic conditions at end of year one

• 7% ambulatory-sensitive admissions at end of yr one

• Achieve 25% reduction in 30-day all cause readmissions

• Achieve 7% reduction in overall medication cost

How we will measure• Partner with health plan to

determine claims utilization, control and intervention population

• Part D medication claims

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Service value definition

Level of satisfaction we commit to deliver

• 90% customer satisfaction rate based on service package

How we will measure• Entry assessment • Assessment of goals

achieved (6 months)• Satisfaction survey (6

months)

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Service value definition

Early thoughts on possible pricing for your service package• Pilot is funded by health foundation. Researcher will assist with cost analysis and identify actual savings. This will help in developing a pm/pm fee•Health plan – no cost, but needs to assist with recruitment of 600 participants and 600 control and provide access to data via secure HIT

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InsightsOur biggest insight(s) from this session on Developing Service Packages is/are… •We are on the right track (Broward and Dade)•Way of conceptualizing the pilot is moving in the direction of expanding CCTP •To date, no one has evaluated integrated package of EBPs and cost savings

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Action StepsThe action step(s) we will take in the next month to develop our service package(s) are:•Create a community road map (MI concept) •Meet with potential health plan partners to test out service package to determine their perception of the value•Projected cost for one pilot (600 people in 6 months and follow up for 6 months) builds in evaluation and delivery • 6-month intervention and 6-month follow-up

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Parking Lot (Issues for later, additional questions for speakers)

• List here

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