Slide 1: CCA Care Coordination Update
Commonwealth Care Alliance
Slide 2: Topics to Cover
•	Care Coordinators
o	Types of coordinators
o	Visits
o	Turnover
o	Responsibilities
Slide 3: Visit Types
•	Care Partner: RN/BH
o	Telephonic or virtual visits
o	Fully remote staff, never on-sight or in-person
o	Email for communicating with members

•	RN or CHW Hybrid
o	Hybrid
o	In person or telephonic visit based on member preference or need
o	Some telephonic or virtual visits
Slide 4: In-Home Visits
Note: the visit details below are shown in two overlapping circles with the in-person visits in the connected portion of the circles.
•	Visit by care partner
•	In-person visits
•	Visit by member any member of care team 

Slide 5: Care Partner Turnover
Note: the following monthly percentages are shown in a line graph on this slide. The trend line starts at approximately 2.60% in January 2022 and ends at 2.00% in September 2023.

•	22-Jan	1.40%
•	22-Feb	3.47%
•	22-Mar	0.69%
•	22-Apr	4.20%
•	22-May	3.55%
•	22-Jun	2.11%
•	22-Jul	2.70%
•	22-Aug	2.74%
•	22-Sep	2.68%
•	22-Oct	2.67%
•	22-Nov	2.72%
•	22-Dec	4.10%
•	23-Jan	1.37%
•	23-Feb	0.00%
•	23-Mar	1.38%
•	23-Apr	3.47%
•	23-May	2.13%
•	23-Jun	2.08%
•	23-Jul	0.68%
•	23-Aug	1.96%
•	23-Sep	3.40%
Slide 6: Community RN Turnover
Note: the following monthly percentages are shown in a line graph on this slide. The trend line starts at just over 4.00% in January 2022 and ends just under 4.00% in September 2023.

•	22-Jan	12.40%
•	22-Feb	5.56%
•	22-Mar	2.94%
•	22-Apr	0.00%
•	22-May	8.82%
•	22-Jun	0.00%
•	22-Jul	2.56%
•	22-Aug	4.55%
•	22-Sep	4.44%
•	22-Oct	0.00%
•	22-Nov	0.00%
•	22-Dec	2.13%
•	23-Jan	0.00%
•	23-Feb	6.25%
•	23-Mar	8.89%
•	23-Apr	0.00%
•	23-May	6.82%
•	23-Jun	11.36%
•	23-Jul	2.38%
•	23-Aug	4.65%
•	23-Sep	2.50%
Slide 7: Care Partner Role
•	Fully telephonic
o	Nurse or Social worker
o	Work from home, geography not considered
•	Hybrid, panels 
o	Work some telephonic, some in the community
o	Nurse for high and medium risk members
o	Community health worker for low-risk members
•	Both have access full in-community care team
o	Nurses, Nurse practitioners or physician assistants
o	Social worker
o	Community health worker
o	PT/OT
Slide 8: Care Partner Responsibilities
•	Routine member outreach
•	Coordinating with LTSC for services and community support
•	Engaging with member to meet medical and behavioral goals
•	Care plans
•	Updating PCP
•	Assist in closing gaps in care, i.e. mammogram screening, diabetic follow up
Slide 9: Care Partner Staffing
•	Currently have 6 Care Partner role open that we are actively recruiting 
•	Do not track the differences in turnover, based on licensure
•	The reported turnover rates includes CP who moved to other roles within CCA, not necessarily left the organization
Slide 10: Care Partner by Geography

•	MA, 75%
•	NH, 6%
•	FL, 5%*
•	ME, 2%
•	RI, 2%
•	Others, 9%*

* Staff lived in MA when hired and moved during COVID
Slide 11: Care Partner and Care Team Interaction
•	Care partners and clinical team huddle daily
o	Discharges
o	ED visits
o	Escalated needs
o	Follow up

•	Team meetings weekly
o	Readmissions
o	Challenges with community services
o	Member concerns needing full team input
Slide 12: How the Care Team Works With Providers
•	Staff update the PCP after a hospitalization or a change in status.
o	Can be phone calls or secure messaging through their medical record
•	Update on member medical or behavioral health status
•	Request for community services
•	Request for DME/supplies
•	Can assist with setting up appointments
•	Work with the PCP to close care gaps (mammograms, colonoscopies)
Slide 12: Matching Member Needs and Preferences to Care Partner
•	Primary reason for choosing a care partner
o	Member preference for visit type (in-person/virtual/telephonic)
o	Licensure based on member need, risk
•	Secondary reasons, when possible
o	Member language preference, when possible
o	Align to PCP office, when possible