1. QCCP Care Coordination Training
DAY 1

2. Trainers & CAI
Welcome

3. Housekeeping Restrooms Lunch/Breaks Parking Lot Emergencies
Training Packets

4. Activity: Introductions

5. Agenda: Day 1 Welcome, Housekeeping, & Introductions Health Home Model
What is Coordinated Care?
Understanding the Clients We Serve
Social Determinants of Health
Health Literacy
Roles and Responsibilities of Care Coordination
Care Coordination: Tasks and Competencies
The Importance of Care Coordination
Pros & Cons

6. Training Objectives
Describe the design and importance of the Health Home model, the concept of social determinants of health and the care coordinator’s role within the healthcare system
Utilize effective communication skills when engaging clients

7. Training Objectives
Identify the stages of change and apply OARS skills as a way of supporting the process of behavior change
Demonstrate ability to organize and record client information in a clear, concise and objective way.
Describe effective crisis management and practice stress management, self-care and boundary setting

8. Group Norms Respect/Risk Openness/Ouch Participation/Pass
Education/Energy
Sensitivity/Safety

9. What Are The Characteristics Of The Clients You Serve?

10. Video: Eye To Eye: Dr. Harold Freeman (6:14)
Video found here

11. Overview & Importance
Health home Model

12. Health Home: History & Goals
Patient Protection and Affordable Care Act (ACA) of 2010 (P.L ) Section 2703
Goal to ultimately reduce costs and improve health for the highest needs/highest users of services among Medicaid beneficiaries

13. Chronic Care & ER
Chronic diseases are a major contributor to health care costs
Poorly managed chronic conditions may become acute conditions
Financial Cost

14. Health Home: Organization
Organizations are designated as Health Homes by DOH
Adult and Children’s Health Homes are separate
Health Homes make referrals to Care Management Agencies & build provider networks
Service Providers must have agreements with HH to refer

15. Overview Affordable Care Act
Centers for Medicare and Medicaid Services
New York State Department of Health

16. PRIMARY & COMMUNITY PROVIDER NETWORKS
Overview
Health Home
• Administrative Services
• Network Management
• HIT Support/Data Exchange
Downstream Care Management Agency
Delivers Care Management Services
PRIMARY & COMMUNITY PROVIDER NETWORKS

17. What is a Health Home? What a Health Home isn’t…
A physical place
A medical home
What a Health Home is…
Care Coordination service delivery model
Coordinated medical & behavioral health care

18. What Is The Health Home Supposed To Do?
Assure access
Improve health outcomes
Reduce preventable hospitalizations and emergency room visits
Promote use of health information technology
Avoid the use of unnecessary care
Prevent adverse health outcomes

19. Ultimately, Health Home is designed to reduce costs and improve health for the highest needs/highest users of services among Medicaid beneficiaries

20. Who Is Eligible For Health Home Services?
Individuals who:
Have Medicaid AND
Have either two chronic conditions OR a single qualifying condition AND
i.e. HIV/AIDS or Serious Mental Illness/Emotional Disturbance
Meet Appropriateness Criteria

21. “Chronic Condition”
According to the Affordable Care Act, “eligible individuals with a “chronic condition” includes:
A serious mental health condition
A substance use disorder
Asthma, diabetes, heart disease, HIV/AIDS
Obesity as defined by a Body Mass Index (BMI) over 25

22. Appropriateness Criteria
Individuals meeting the Health Home eligibility criteria must be appropriate for Health Home care management
Assessing whether an individual is appropriate for Health Home services includes determining potential risk and current experience

23. Appropriateness Criteria
Probable Risk for Adverse events
e.g., death, disability, inpatient or nursing home admission, mandated preventive services, or out of home placement
Inadequate social/family/housing support, or serious disruptions in family relationships
Inadequate connectivity with health care system

24. Appropriateness Criteria
Does not adhere to treatments or has difficulty managing medications
Recently been released from incarceration, placement, detention, or psychiatric hospitalization
Deficits in activities of daily living, learning or cognition issues
Concurrently eligible/enrolled, along with either their child or caregiver, in a Health Home

25. Social Determinants of Health (sdoh)
What are they?
Social Determinants of Health (sdoh)

26. Let’s Look at this Case Study: Rosa Diaz

27. Social Determinants of Health
“The social determinants of health are the conditions in which people are born, grow up, live, work and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, social norms, social policies, and political systems.” World Health Organization (WHO)
. Social Determinants of Health are
mostly responsible for “health inequities”

28. Social & Community Context
SDOH
Health & Health Care
Neighborhood
Social & Community Context
Economic Stability
Education
Finances/Income
Insurance Status
Language
Neighborhood
Education/Literacy Level
Culture

29. SDOH: Health Implications
Inadequate screening for diseases
Less preventive care
Delayed diagnoses
Late or inadequate treatment
Higher risk of death, illness & injury
Unhealthy behaviors

30. Health Literacy

31. Health Literacy

32. What is Health Literacy?
“Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”

33. What is Health Literacy?
The degree to which an individual has the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions

34. A “Health Literate” Person is Able to:
Read, understand, and use:
Assess
Health information: medication instructions, education materials, nutrition labels, insurance costs and benefits
Registration forms, patient rights, informed consent
Public health alerts or campaigns
Validity of available health information from non-medical sources
The best health plan for themselves and their family based on costs and benefits

35. A “Health Literate” Person is Able to:
Describe:
Calculate
Symptoms or health concerns
Changes in health status
Medication doses

36. The National Survey Of Health Literacy found:
Use a table to calculate an employee’s share of health insurance costs for a year
Read a pamphlet and give 2 reasons for a screening test
Read a prescription label and determine time to take meds
Read instructions and identify what is permissible to drink before a medical test

37. Health Literacy in New York City:
The percentages of people who do not have basic literacy in:
Manhattan
25%
Queens
46%
Staten Island
14%
Brooklyn
37%
Bronx
49%

38. The Big Disconnect
Only 12% of Americans have a proficient level of health literacy, but our health care system generally caters to this 12%.
Do you take the same tablet twice? Do you take it the medication 10 days? Or do you take one table at day until you reach 20 day?
What is a deductible? Is that a discount? What is a co-pay? What is an office visit? I thought this was a clinic?
What is influenza? What is the difference between influenza and flu? What is prolonged? What is a complication?
What is ambulatory care? What is specialty care? What is primary care?

39. The Big Disconnect
Medication Instructions: “1 tablet, by mouth, twice a day, 10 days, for a total of 20.”
Insurance/Billing: “Your health plan doesn’t require that you pay a deductible, but your co-pay will be what is indicated for the office visit on your insurance card.”
Do you take the same tablet twice? Do you take it the medication 10 days? Or do you take one table at day until you reach 20 day?
What is a deductible? Is that a discount? What is a co-pay? What is an office visit? I thought this was a clinic?
What is influenza? What is the difference between influenza and flu? What is prolonged? What is a complication?
What is ambulatory care? What is specialty care? What is primary care?

40. The Big Disconnect
Immunization Recommendations: “While it isn’t clear whether people with HIV are susceptible to a more severe case of the flu than others, studies show that HIV-positive people tend to have higher rates of complications from influenza than others and more prolonged cases of flu and flu symptoms, so it is recommended that people living with HIV get a flu vaccine every year.”
Signage: “Ambulatory Care”
Do you take the same tablet twice? Do you take it the medication 10 days? Or do you take one table at day until you reach 20 day?
What is a deductible? Is that a discount? What is a co-pay? What is an office visit? I thought this was a clinic?
What is influenza? What is the difference between influenza and flu? What is prolonged? What is a complication?
What is ambulatory care? What is specialty care? What is primary care?

41. What is the Impact of Limited Health Literacy?
People with low health literacy…
People with low health literacy have more difficulty:
Navigating the healthcare system
Finding providers
Completing forms (registration, consent, billing)
Filling prescriptions
Sharing health information with providers
Enrolling in insurance

42. What is the Impact of Limited Health Literacy?
People with low health literacy…
People with low health literacy:
Use preventive services less
Use emergency rooms more
Have a higher incidence of chronic diseases
May have more difficulty with disease management
Have more difficulty taking medication properly
Increase health care costs $50 billion to $73 billion annually

43. Activity: The Newest Vital Sign

44. Activity: The Newest Vital Sign

45. What Can We Do?

46. BE AWARE OF RED FLAGS…

47. Health Literacy RED FLAGS
Difficulty explaining symptoms
Use excuses to avoid reading (e.g. “I forgot my glasses.”)
Lots of papers folded up together-important, unimportant, and expired
Missed appointments
Difficulty explaining how to take medications
Take overly long or refuses to fill out forms.
Know the red flags

48. ACTIVELY ASSESS…

49. Bring Up the Topic “How far did you go in school?”
“A lot of people have trouble reading things they get from the doctor because of all the medical words. Is it hard for you to read the things you get here at the clinic?”

50. Assess health literacy with four simple questions

51. Assess Health Literacy with Four Simple Questions:
“Do you like to read?” Or,
“How happy are you with the way you read?”

52. Assess Health Literacy with Four Simple Questions:
What is the best way for you to learn new things?

53. Assess Health Literacy with Four Simple Questions:
How confident are you to fill out medical forms by yourself?

54. Assess Health Literacy with Four Simple Questions:
How often do you have problems learning about your medical condition because of difficulty understanding written information?

55. A Pill Bottle
A medication label is a simple tool to assess health literacy. I ask these questions: What is the name of this medicine? How much do you take? How often do you take it? Do you have refills? How many? These are the elements of literacy: prose (reading) numeracy ( numbers, calculations)

56. Use Health Literacy Universal Precautions

57. Health Literacy Universal Precautions
Steps that practices take when they assume that all patients may have difficulty comprehending health information and accessing health services.
Plain language for clear communication
Teach back method to assess understanding
Use of easy to read health material

58. Do Patients Really Understand What We Are Saying to Them?

59. Plain Language
Plain language is clear, succinct speech or writing designed to ensure the listener or reader understands as quickly and completely as possible
Tricalm

60. Common Medical Term Plain Language Rupture Break open, burst Antibody
Immunization
Hypertension
Adverse reaction
Deficiency
Cholesterol

61. Teach Back Method Teach Back can: Uncover health beliefs
Reinforce health messages
Open a dialogue with patients
Improve patient understanding of disease
Lower hospital readmission rates
Increase patient satisfaction

62. Teach Back Method
Patients should view teach back as you verifying how well you explained information - not as a test.
"I want to be sure that I did a good job explaining everything today. Can you tell me how you’re going to take your new blood pressure medicine?”
“What foods are you going to avoid while you’re taking this medicine?”
“I gave you a lot of papers to take home. Which papers are you going to bring when you go to see the eye doctor?”

63. Providing the HPV Vaccine
Teach Back Method
Providing the HPV Vaccine
This ones shorter….

64. OTHER TIPS

65. Practical solutions

66. End Your Visit with this Statement:
“I bet a lot of questions have been on your mind as we’ve talked. Tell me 1 or 2 questions you’ve been thinking about.”

67. Questions to Avoid at the End of the Visit:
“Do you understand?”
“Does that make sense?”
“Do you have any questions?”

68. Dr. Google: Internet Health Information as Reliable as Conversation at a Bar

69. Health Literacy
The capacity of professionals and institutions to communicate effectively so that community members can make informed decisions and take appropriate actions to protect and promote their health

70. Key Messages:
Health Literacy is also the capacity of health care providers to communicate effectively so community members are able to make informed health decisions.
Health care providers can use health literacy universal precautions, and Ask3 to mitigate the health literacy disconnect.
Using plain language and teach back method doesn’t necessarily add more time to patient interactions; any time added is time ultimately saved later on.

71. Remember the Wisdom of POOH

72. Acknowledgements
NYSDOH AIDS Institute, "Health Literacy in HIV, STI and Viral Hepatitis Care”, Training Manual for Health Care Professionals. August 2015

73. Health Literacy Resources

74. What’s happening in your clinics?
Here is how to find out:
The first link will tell you about your state, city or county. The second link is a calculator to help you figure out what’s happening in your clinic.

75. Lunch
Break

76. What is Care Coordination?
Critical Component of the Health Home Model
What is Care Coordination?

77. ACTIVITY: Care Coordination Video (5:10)
Northern Piedmont Community Care
ACTIVITY: Care Coordination Video (5:10)

78. Care Coordination: “The Bridge to Health"
Breaks cycle of crisis
Essential link between systems
Helps develop client stability

79. What Is Coordinated Care?
Organization of patient care activities between two or more healthcare personnel (i.e., doctors, specialist, therapist, nurses) with the goal of:
facilitating appropriate delivery of health care services
preventing duplication and miscommunication
From Agency for Healthcare Research and Quality (AHRQ), a part of the U.S. Department of Health & Human Services

80. What Is Coordinated Care?
Organizing care involves:
The marshalling of personnel and other resources needed to carry out all required patient care activities
An exchange of information among participants responsible for different aspects of care
From Agency for Healthcare Research and Quality (AHRQ), a part of the U.S. Department of Health & Human Services

81. What are Some Examples of Coordinated Care?
Shared test results
Patients helped to follow-up appointments
Patient doesn’t have to provide the same information over & over
Access to specialists is facilitated
Education about medications and illness
Help understanding doctor’s orders

82. Efficacy of Care Coordination
Care Coordination has been identified by the Institute of Medicine as one of the key strategies for improving the effectiveness of the healthcare system
The strongest evidence shows benefits with those suffering from chronic conditions
i.e., heart disease, diabetes, mental illness, stroke and depression
From Agency for Healthcare Research and Quality (AHRQ), a part of the U.S. Department of Health & Human Services

83. Competencies
Care Coordination

84. Activity: What is it? What is it NOT?
Care Coordination
Activity: What is it? What is it NOT?

85. What Are Your Clients’ Needs?

86. Activity: What do I think?
Attitudes Exploration
Activity: What do I think?

87. Activity: What’s your intro?
Engaging Your Clients:
Activity: What’s your intro?

88. DAY 1: Wrap-Up