sfdph_managed care initiative
TRANSCRIPT
The San Francisco Department of Public Health: Care Coordination addressing the Social Determinants of Health
Managed Care Initiative
Lisa Catanzaro. M. Arch., MPH
MANAGED CARE MODEL
Strategic Framework
Risk Based Population Care – Chronic Disease Prevention
Program Framework Multi-Disciplinary Coordinated Accountable Health Home Care Management Across the IDS
Operational
Integrated Managed Care Operations
Clinical, Behavioral, Economic and Social Determinants of Health
(Community Care Plan – IT Intervention - Tool for managing resources)
ADDRESSING THE PUBLIC HEALTH PROBLEM
Ø Improved equity in health. Model promotes social justice. Ø Delivery system addresses
conditions in which people are born, grow, live, work and age.
Ø Build relationships: Community health Social service Faith-based organizations Local Retail and Transportation entities.
ACTIVITY DIAGRAM CARE COORDINATOR
Adapted from—Coordinating Care for Medicare Beneficiaries: Early Experiences of 15 Demonstration Programs, Their Patients, and Providers. Report to Congress. Baltimore, Maryland. Mathmatica Policy Research; 2004
Start Physician input/
sign off
Community Care Plan
Feedback Loop
Assess patient’s needs and
health status; develop goals
Develop a care plan to address
needs
Review Medications
Educate patient about condition and
self-care
Build relationships with patients, families, care
providers
• Preventive Care with PCP • Follow-up visits with BH • Visit with Specialists • Acute and Urgent Care • Substance Abuse • Housing – Living situation • Finances • Legal • Safety • Skills • Support • Meaningful Role
Monitor patient’s knowledge and
services
Intervene as needed
Feed back patient
information to Primary Care
Provider
Reassess patients and
care plan periodically
Arrange needed services
PROPOSED SYSTEM ARCHITECTURE
Data Integration
Chronic disease
management
- Primary care provider
EHR
Behavioral health
management
- Behavioral healthcare
provider EHR
Community Care Plan Mgmt/Data Warehouse
Data layer Community Care
Plan data collection. EHR
and CCMS
Report Generation
Info
rmat
ion
laye
r
Data standardization Data linking/integration Data quality assurance
- Manage care for populations across programs and systems of care - Assure timely access to care; reduce urgent emergent services - Increase quality and longevity of life - Increase self care and self management
Patient compliance and
tracking
Coordinated Case Management
System
Diagnoses Continuum of care- patients’ community
Patient History and Care Plan
Patient demographics
Health Outcomes
Population Guidelines
Bio-Psy-Social Risk Factors
Knowledge layer Community Care
Plan- disease Management
Community Resources/ Exposure
Guidelines SFDPH
CDC SAMHSA
Care Coordination and
Clinical Guidelines
Service Utilization
Data mining and Knowledge discovery Report generation Program analysis
REFERENCES
Horvitz-Lennon M, Kilbourne AM, Pincus HA. From silos to bridges: meeting the general health care needs of adults with severe mental illnesses. Health Affairs 25, no. 3 (2006): 659-669. Editor. High Users of Multiple Systems. San Francisco Department of Public Health. City and County of San Francisco. San Francisco, CA. Draft; 2013. Wise CG, Bahl V, et al. Population-Based Medical and Disease Management: An Evaluation of Cost and Quality. Disease Management. 2006; 9(1): 45 –55 Larmee AS, Levinsky SK, et al. Case management in a heterogeneous heart failure population: A Randomized Controlled Trial. Archives of Internal Medicine. 2003; 163: 809-817. Editor. Coordinated Case Management System (CCMS). San Francisco Department of Public Health. City and County of San Francisco. San Francisco, CA SFPDPH Publication; 2012. Editor. Integrated Delivery System: Care Coordination. San Francisco Department of Public Health. City and County of San Francisco. San Francisco, CA. Draft; 2013. Editor. Coordinated Case Management System. (2012). Editor. Best Practices in Coordinated Care. Report submitted to Health Care Financing Administration, Division of Demonstration Programs, Center for Health Plans and Providers. Baltimore, Maryland. Mathmatica Policy Research; 2000. McDonald KM, Sundaram V, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol.7: Care Coordination). Agency for Healthcare Research and Quality (US). 2007; 04(07): 0051-7. Editor. Coordinating Care for Medicare Beneficiaries: Early Experiences of 15 Demonstration Programs, Their Patients, and Providers. Report to Congress. Baltimore, Maryland. Mathmatica Policy Research; 2004 Institute for Healthcare Improvement. IHI Triple Aim Initiative. http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx. Accessed June 22, 2013.