Slide 1: Next up in ongoing conversation to strengthen integrated care coordination model
One Care Implementation Council
Tuesday, December 8, 2020
Slide 2: Timeline of recent IC focus on care coordination
•	December 12, 2017 IC meeting
o	BCIL and NILP on role of LTS-Coordinators (LTS-C)
•	January 9, 2018 IC meeting
o	MassHealth presents amendment to the three-way contract on LTS-C
•	February 13, 2018 IC meeting
o	CCA and Tufts present on LTS-C
•	June 11, 2019 IC meeting
o	CCA & Tufts present on Care Coordination 
•	July 9, 2019 IC meeting
o	IC’s plan for following up with CCA and Tufts
•	September 10, 2019 IC meeting
o	IC presents a plan to follow up with CCA and Tufts on Care Coordination
•	October 9, 2019 IC meeting
o	Care coordination round robin with IC members and the plans  
•	November 12, 2019 IC meeting
o	CCA and Tufts present further information on care coordination, respond to questions from the IC
•	December 10, 2019 IC meeting
o	Second discussion on non-medical transportation and care coordination with CCA and Tufts
•	October 13, 2020 IC meeting
o	Dr. Richard Antonelli presented to the IC how care integration and care coordination services can improve care quality and outcomes
•	CCA presents CCC and Tufts presents Cityblock
Slide 3: Purpose: continue dialogue on how care coordination works from the consumer perspective
•	Rationale:
o	One Care (OC) provides medical, behavioral health, LTSS, SDOH and other services to people with complex care needs
•	Of particular importance - a high percentage of OC members with behavioral health needs
•	The success of OC is contingent on member: 
o	Understanding the “OC model”
o	Having a trusting relationship with their care coordinator (and other care team members)
o	Holding the lead role in determining contents of care plan and care goals
o	Receiving the services and care team support needed to achieve goals
Slide 4: Quality of Care and Financial Information
•	Data on quality of OC is outdated:
o	One Care Enrollee Assessment and Long Term Supports Coordinator Reports have not been available to the council since 2016. 
o	Mental Health Recovery Measure (MHRM) & One Care Quality of Life (QoL) Survey Reports have also not been available since 2016. 
o	One Care Annual Evaluation Reports have also not been available since 2016.
Slide 5: Example of integrated whole person-centered care coordination
•	Care coordinator communicates with dentist about members oral health needs
•	Care team identifies the need for member to receive periodontal work
•	Dentist submits claim for periodontal work for One Care member to plan
•	One Care member receives notification of denial of request for periodontal work.
•	Simultaneously, care coordinator receives notice of denial of request.
•	Care coordinator contacts member and dentist about filing an appeal.

Slide 6: A care plan
Note: The following is presented in table form.

Row 1
Goal: What is action contributing to?
•	Complete necessary genetic testing
Action: What needs to be completed?
•	Lab orders will be placed for ### Test
Who: Who is responsible for completing action?
•	Genetics - Dr. Bodamer
When: What is the timeline that the action needs to be completed?
•	One month
Contingency: If there is an issue or barrier, what are next steps?
•	Parents should contact Dr. Bodamer’s office (123-456-7890) if unable to complete testing within one-months’ time

Row 2
Goal: What is action contributing to?
•	Maintain stable blood sugar
Action: What needs to be completed?
•	Test blood sugar 3 times per day and control with small, frequent meals
Who: Who is responsible for completing action?
•	Parents, with guidance from Endocrinology and Nutritionist
When: What is the timeline that the action needs to be completed?
•	Daily, beginning immediately and to continue until reassessed at next Endocrinology appointment
Contingency: If there is an issue or barrier, what are next steps?
•	Blood sugars between XXX and XXX should be reported to Dr. Example’s office (123-456-7890). If a sugar is over XXX, parents will bring patient to the nearest Emergency Department

Row 3
Goal: What is action contributing to?
•	Take medication for epilepsy as prescribed
Action: What needs to be completed?
•	Order for medication will be sent to Longwood Galleria
Who: Who is responsible for completing action?
•	Neurology, with follow up phone call by Nurse Jane Doe
When: What is the timeline that the action needs to be completed?
•	RX to be started no later than 3/7/2020 and should continue until next appointment unless otherwise noted
Contingency: If there is an issue or barrier, what are next steps?
•	Please call Nurse Jane Doe if any problems arise with the prescription at 123-456-7890

Row 4
Goal: What is action contributing to?
•	IEP documentation request will be updated with school system
Action: What needs to be completed?
•	Required school documentation and phone call to Teacher Smith
Who: Who is responsible for completing action?
•	Neuropsychology and Teacher
When: What is the timeline that the action needs to be completed?
•	Two weeks from most recent visit: XX/XX/XXXX
Contingency: If there is an issue or barrier, what are next steps?
•	Teacher Smith should contact patient’s parents with any noticeable adverse changes in behavior or understanding

Slide 7: Questions asked of consumer members of One Care and RI duals demonstration councils
•	Round-Robin question # 1: What is the best way to measure the quality of your experience in One Care?    
•	Round-Robin question # 2:  What do you feel is missing from care coordination in One Care? 
•	Round-Robin question # 3:  What information do you need from MassHealth to help you understand your rights in One Care? 
Slide 8: Response categories
•	Care coordinators do not have the trust of members or demonstrate understanding of members unique needs
•	Workforce instability and lack of continuity of care
•	Communication is inconsistent in quality and accuracy
•	Engagement of consumers to advance quality and transparency 
•	Implement metrics that measure the quality of outcomes that reflect member values and priorities
Slide 9: Richard Antonelli, MD, MS
Medical Director, Integrated Care
Assistant Professor of Pediatrics, Harvard Medical School
One Care Enhanced Care Coordination And Integration Can It Be Measured?
Slide 10: Minimum expectations of your care coordinator
•	Create formal relationships between care team members, including you and other people you want on your care team such as family members, a PCA, Certified Peer Specialist
•	Help you build on your existing strengths and relationships with family and other supports
•	Collaborate with you and all providers in your care team, including but not limited to your medical subspecialists, nurse practitioners, physician assistants, LTS coordinators, community health workers, Certified Peer Specialists, Certified Recovery Coaches etc.
•	Communicate with you, and all your medical and nonmedical providers
•	Facilitate your transitions between different providers, hospital and home

Slide 11: Minimum expectations of your care coordinator
•	Work with you to assess your needs, establish goals and create your care team
•	Work with you to assess your needs and goals along with your care team
•	Work with you to create, implement and update a formal written plan of care that meets your language, culture, and value needs
•	Monitor, follow and respond to your needs as they change over time
•	Link you to and collaborate with community partners and resources that correspond to your needs, and when appropriate those of your family and care team.
Slide 12: Dr. Lisa Iezzoni, MD, MSc
Prof. of Medicine, Harvard Medical School
Mongan Institute
PCORI research findings: importance of consumer engagement in quality measurement and shaping of whole person-centered care
Slide 13: One Care PCORI: project aim
•	Partner with persons with significant physical disabilities and serious and persistent mental illness to develop two new approaches to assess quality of care.
•	Survey enrollees about the care they receive and overall experience in One Care. The survey asked how members manage their care and what self-direction means to them.
•	Established YESHealth - Your Experience: Speak up for better health care. Members provided information about their perceptions of care quality to a trained team of persons with disabilities who reported the information to One Care care teams with the goal of improving care by elevating consumer perspectives. 
•	How providing consumer informed and consumer directed quality information to One Care providers affects One Care quality.
•	Sought to improve the ability of One Care enrollees to manage their own health care and to recognize and report quality problem.
Slide 14: Study findings: care coordination
•	Knowledge of care planning care team was associated with members reporting
o	increased healthcare quality
o	increased control over health
•	Access to new services or equipment to live independently was associated with:
o	increased reporting improved perceptions of hope
o	overall health
o	improved quality of care

Slide 15: Potential round-robin questions
•	What internal measures do plans use to measure quality of care coordination? How are care coordinators trained to meet these measures in a whole person-centered way? How is this information shared with OC members?
•	Communication is an ongoing challenge for members. What requirements are currently in place for care plan member portals?
•	What can be done to increase plans engagement of members in IC town hall meetings e.g. robo-call technology to promote the town hall meetings?
Slide 16: Draft motions
•	Starting January 2021
•	Quality measure workgroup
o	Review current quality measures
o	Survey questions
•	Create guidelines 
o	Core measures 
o	Supplemental measure
o	Developmental
o	Developing survey questions
•	An overview of the protocols used in plan oversight

Quarterly report on
•	Trends identified from grievance and appeals data (in collaboration with MYO)
•	Corrective action plans in place and plan progress on these plans
•	Plan progress in creating, implementing and measuring health equity strategies
•	Progress of quality measure workgroup