Presentation is loading. Please wait.

Presentation is loading. Please wait.

QCCP Care Coordination Training

Similar presentations


Presentation on theme: "QCCP Care Coordination Training"— Presentation transcript:

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


Download ppt "QCCP Care Coordination Training"

Similar presentations


Ads by Google