Developing Our Service Package(s)(insert network name and/or location)

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

• EBP – need targeting & outreach• Psychosocial• Transportation• Food• Safety – physical & social• ADRC/information – connecting

with coach• Reinforcement for good habits• DME/assistive devices• Training about accessibility• Caregiver

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

• Eyes & ears in the home (they don’t ask/don’t listen) – 10-day post-discharge

• Identify & have solutions for modifiable risk factors

• Med Rec/HomeMeds (Star Rating)

– Review after next visits – specialist vs. PCP – PharmD

• Caregiver support – spouses are on same health plan– NYUCI for spousal caregivers

• Coaching – Navigation of LTSS• Fall prevention

Network capacitySoCAL MULTI-SPECIALTY COMMUNITY CARE GROUP

Organization name Service competencies Strengths

SeniorServ Meals, ADHC, Care Mgt., CT

AAAs (Ventura, S. Diego) OAA, CM, CT, transportation

AltaMed FQHC, LTSS, Vendor Mgt., PACE, CT

St. Barnabas Korean,

Partners LTSS, Vendor Mgt, CM, CT, research/evaluation, EBP

Jewish Home Hospice/Home, CT, housing

Network capacityNew network partners to be added• St. Barnabas• San Bernardino/Riverside• Mental health services – Didi Hirsch, Winstone

Define opportunities – invite gap-fillers – primarily evolutionaryWe need definition on our rolesBranding: Describing ourselves in materials/handoutsScalability

Service value definitionResult(s) we commit to deliver

• 20% reduction in Medicare FFS readmissions– MCO/ACO– Medicaid

• Reduce ED use• Reduce falls• Reduce SNF• Reduce hospitalizations/days• Reduce adverse drug effects• More advance directives• Fewer 911 calls – more calls to

call center• Member retention

How we will measure• Data from MCO/physician

group– ED use– Hospital use– SNF/rehab; SNF/LTC– Treatment for falls– 911/Ambulance

• Data from paramedic systems• Data from HomeMeds• Client/Patient Reassessment• Pre/post vs. comparison group• % deaths in hospital

Service value definitionLevel of satisfaction we commit to deliver

• 75% accept home visit• 90% satisfaction? Don’t know.• Ask for current level of

satisfaction & set bar higher• Payer satisfaction• Post-discharge hospital

satisfaction

How we will measure

• CAHPS• IFC/Research lead

development of measures

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Service value definition

Early thoughts on possible pricing for your service package?•Cost plus shared savings•Fully loaded cost

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InsightsOur biggest insight(s) from Developing Service Packages is/are… •Building from shared current interest and building toward shared future interests

– Sharing best practices – still getting our CCTPs off the ground– Proving the value of the collaborative– Building trust; building relationships– Buying services from each other

•We need to move forward with a work group to define and formalize this – we each have visions & intentions, assumptions

•Different collaborative members will bring different opportunities to the table – as a network, at least members have right of first refusal

Action Steps• Thursday meeting with hospitals• Refine marketing materials - Reframe CCTP into SNF diversion• Define services each member provides or can access through

their networks/collaboratives – December 6 or separate call with team leads – using slides from Kathy Greenlee, June & Lynn Kellogg

• Longer term– Convene IT workgroup to come up with data sharing strategy– Pricing strategies – contract floor levels– Define geographies– Gap analysis and other members to be invited

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

• List here

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