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.