CCNC 101 What is CCNC? An overview of structure and operations

CCNC is:  People  Knowledge  Technology

CCNC is:

Evolution of a CCNC 1983: DMA & ORH partner to reduce ER use in Wilson county 1983: Pilot expanded to 12 counties in : Twelve-county program named Carolina Access, launched by Governor Jim Martin 1991: HCFA (now CMS) approves statewide expansion & $3 PMPM 1999: ORH begins contracting with local Networks; DMA joins later 2006: Central nonprofit organization (“N3CN”) created to apply for Medicare Duals demonstration 2008 : N3CN directed to manage ABD population 2010: N3CN assumes responsibility for clinical/technical assistance 2013: DMA contracts with N3CN; N3CN contracts with 14 Networks and 1,800 practices to centralize accountability 4

Company Structure CCNC, Inc.NCCCN, Inc. CCNC Services, Inc. NC HIE, Inc.

Company Structure CCNC, Inc.NCCCN, Inc. CCNC Services, Inc. NC HIE  Parent corporation for “family of companies  Match expertise and resources with emerging opportunities  Diverse, experienced Board of Directors  Seek innovative ways to carry out the core mission

Company Structure CCNC, Inc.NCCCN, Inc. CCNC Services, Inc. NC HIE  Decade+ of practical data analytics and “what works” in Medicaid  Statewide population health management for 1.3 million people  Provider – led, community-based  Replicates “best practices” and brings them to scale

Company Structure CCNC, Inc.NCCCN, Inc. CCNC Services, Inc. NC HIE  Provides products and services to stakeholder partners  Exports NC’s proven approach to other states  Generates private investment in technical infrastructure  Deep expertise generates additional resources to support mission

Company Structure CCNC, Inc.NCCCN, Inc. CCNC Services, Inc. NC HIE, Inc.  Centralized, neutral hub for data from multiple sources.  Lets providers exchange and analyze health data electronically  Improves the quality, safety and efficiency of healthcare statewide.

Primary Care Capacity 10

11 Large Health System Owned 344,655 Other (RHC, LHD, other) 96,226 Provider-led ACO’s 73,887 Independents 644,602 FQHC 100,800 Other Hospital Owned 120,869 Unenrolled 355,413 Who provides medical homes for NC Medicaid recipients? *Numbers represent estimated number of members enrolled in each type of practice (total member months divided by 10).

Bubbles show inpatient admissions of patients enrolled in practices controlled by the large healthcare systems. Cross-System Traffic

NC HIE, Inc.  27 participating NC hospitals  600 clinic sites  Onramp for “safety net” clinics like FQHC  Secure, affordable access to comprehensive patient health data

Awards and Recognition US Senator Richard Burr Presents Healthcare Leadership Council’s national Wellness Frontiers Award, 2013 Press release from Harvard University’s Ash Institute announcing 2007 Innovations Award

Key Initiatives Project Lazarus – Statewide chronic pain and drug overdose prevention program Pregnancy Medical Home Pregnancy Medical Home – reducing pre-term births, improving prenatal care Children’s Health Accountable Care Collaborative – 3-year CMS Innovations grant to improve care for children with complex conditions.

Peer-reviewed research Cuts Hospital Readmissions  20% reduction in readmissions for patients in the transitional care program.  12-month readmission rates consistently lower for participants within each level of clinical severity.  For every six interventions, one hospital readmission avoided – strong ROI

 Significant savings for 169,667 non-elderly, disabled Medicaid recipients  $184 million savings in about 5 years  Higher per-person savings for patients with multiple chronic conditions. Peer-reviewed research Cuts Program Costs

National Model for What Works 18  Community-based, physician-led medical homes coordinate care across health systems  Managed through 14 local, non- profit networks, ~1,800 practices & 6,000+ providers  Population Health Approach: Case management and medical home capacity building  Goal: Ensure patients receive optimal care, avoid unnecessary utilization and reduce costs  Health informatics target at-risk beneficiaries and high-impact care settings  Use of data to drive performance and standardization across networks  Medicaid savings achieved in partnership with doctors, hospitals and other providers  100 percent of savings remain in state

The CCNC Footprint Statewide  6,000 primary care providers  1,800 Practices  90% of PCPs in NC  1.4 million Medicaid Patients  300,000 Aged, Blind, Disabled  150,000 Dually Eligible All 100 NC Counties14 Networks Each network averages:  1.4 Medical Directors  42.8 Local Case Managers  1.8 Pharmacists  1.0 Psychiatrist

Local Network: Community Care of Wake/Johnston  155 primary care sites  Wake Faculty Practices  103,000 Medicaid  5 th largest network in population  2 Medical Directors  39 Local Case Managers  3 PharmDs  2 Psychiatrists  1 Obstetrician Embedded:  11 FTEs dedicated to WakeMed  9 Registered Nurses/SW  2 Patient Coordinators Wake & Johnston Numbers

NCCCN, Inc. Avoids Wasteful Spending Resource allocation ER admissions Patient targeting Pharmaceutical adherence Improves Care Medical home Community resources Performance data Best practices Physician-Led 6,000 primary care providers 1,800 practices 90% participation Data network National Model Innovation in American Government Award Wellness Frontiers Award Medicaid spending trends HEDIS top 10%

22 Primary Care Foundation

23 Primary Care Foundation Data to inform decisions & focus efforts

24 Primary Care Foundation Data to inform decisions & focus efforts Population mgmt: Stratify population, choose targets

25 Primary Care Foundation Data to inform decisions & focus efforts Population mgmt: Stratify population, choose targets Multi-disciplinary team: RX, Behavioral, Care Manager

CCNC Medical Home 26 Primary Care Foundation Data to inform decisions & focus efforts Population mgmt: Stratify population, choose targets Multi-disciplinary team: RX, Behavioral, Care Manager

Advanced Medical Homes A Key to Healthcare Reform 27

Networks  14 networks cover all 100 NC counties  Networks develop local solutions to community health issues  Multi-disciplinary team works at “top of licenses”  Now including community pharmacists under CMMI grant Physicians Care Managers Pharmacists Clinicians Behavioral Specialists

Networks

Shared Vision, Aligned Goals  Provider-led  Analytics-driven  Best practices  Shared protocols  Controlling costs  Improving outcomes  Vulnerable populations The CCNC Model 30 Palliative Care Transitional Care ED Management Behavioral Health Pharmacy Management Population Management Medical Home

Where are the Opportunities? 31 A Small Portion of Beneficiaries Are Responsible for a Disproportionate Share of Costs

Where are the Opportunities? 32 Patient Segmentation to Manage Risk

Population Health Management 33  Medicaid and Medicare  Aged, Blind and Disabled  Frail Elderly  Chronic Complex Comorbidities  Diabetes, Asthma, Congestive Heart Failure  Emergency Department “Frequent Flyers”  Recent Hospital Discharges  Substance Abusers Focus Resources on Where it Matters Most

$0 $1K $2K $3K $4K $5K $6K $7K $8K $9K $10K $11K $12K $13K $14K $15K $16K $17K $18K $19K $20K Patient Risk Cohort #1 Patient Risk Cohort #2 Patient Risk Cohort #3 Targeting the “Impactable”

CCNC Services Business verticals  Population Health Management  Network and infrastructure development  PCMH support  Analytics  Decision Support  PHARMACeHOME

CCNC Services  Consulting  Development  Implement and Deployment  Software Licensing Analytics Decision support Informatics and Dashboards  Business Process Outsourcing Interventions Call Centers Network Support 36

Our Products  Care Triage TM (pharmacy data analytics)  Predictive Modelling  Custom Interventions  Custom Dashboards  PHARMACeHOME  Network Development and Support 37

Questions?  For more information, please see our website at  You can also contact CCNC Communications at 38