Maggi presentation(2) [Read-Only] - Oregon Public …...5/3/2013 3 The What To assure system...
Transcript of Maggi presentation(2) [Read-Only] - Oregon Public …...5/3/2013 3 The What To assure system...
5/3/2013
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Strategic Initiative Requirements
• Goal• Accountable
Coordinator
• Participating Partners
• What• When• Metrics
• CCO Requirement?• Regional Health
Improvement Plan?
• Health Disparities and Inequities
• Return on Investment• Synergy with other
Initiatives
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The What
Develop a MCH Care Coordination system incorporating:
Expansion of Nurse home visiting programs (Nurse Family Partnership, CaCoon, Maternity Case Management). Year 1
Enhancement of WIC and Oregon Mother’s Care programs to provide “one-stop-shop” care coordination and support services for low-income mothers, their children 0-5 and families. Year 2
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The What
To assure system continuity, connection with prevention services, and experienced
home visitors, nurse home visitors/care coordinators and WIC certifiers/community health workers will be
hired by public health agencies.
The What (Year 1)
Deschutes County• 1 FTE bilingual NFP nurse (covers tri-counties)
• 1FTE CaCoon nurse
• 1 FTE MCM nurse
• 1 FTE WIC certifier/community health worker
Jefferson County• .5 FTE MCM and CaCoon nurse
Crook County• .5 FTE MCM and CaCoon nurse
The What
Nurse home visitors/care coordinators promote integration of prevention services and other CCO
initiatives into primary care practices and bring their perspective back to public health.
They also will help develop WIC “one-stop” support service clinics Year 2
and provide consultation/oversight For WIC certifiers/community
health workers.
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CaCoon Care Coordination
MCM Care Coordination
Nurse Family Partnership
WIC One-Stop Support Clinic
Low birth weight (LBW) / preterm birth X X X
Breastfeeding (future) @ discharge @ 6 mos. @ 6 mos.
Immunization rates (mother/child) (child) X X (child)
Effective contraceptive use X X ?
Potentially avoidable ED and office visits X X X
Prenatal/parent tobacco use (parent) X X X
WIC participation/early prenatal care (WIC) X X X
Prenatal/child one dental visit in last 12 mos. (future) (prenatal) X X
Eligible mothers/ children on OHP X X X X
Screening/education/referral maternal/parent depression/anxiety, interpersonal violence
X X X X
Screening/referral substance use X X X
Child ASQ developmental screening/referral (future) X ?
Metrics
The ProblemLack of capacity and inadequate coordination between primary care, public health and other
prevention services is a barrier to prenatal/early childhood wellness and
life-long health.
The ProposalImprove wellness through an MCH Care
Coordination system that empowers families and maximizes their use of primary care
and prevention services.
Proposal Strengths
• Tri-county, evidenced-based Primary Prevention
• Impacts Life-long and inter-generational health
• Addresses 8 CCO requirements
• Addresses diversity and connects services to the home—right care, right place, right time
• Public Health and Primary Care Partnership
• Rated #1 initiative by the Clinical and #4 by the Community Advisory Committees
• Integrates Early Learningand Health Care Transformation
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Wellness Domains:
Physical
Behavioral
Social
Emotional
Cognitive
Wellness Domains:
Physical
Behavioral
Social
Emotional
Cognitive
Costs?
Total from all Payment Sources Phase I (12 months)
Timeframe All SourcesDMAP* Billing
Other Sources
COHC Request
Year I $495,882 $174,375 $141,296 $180,212
Year II $523,965 $174,375 $146,101 $203,489
*Medicaid funding currently outside of CCO—critical for Initiative
Request is $.36 on the dollar
Return on Investment?
Prevention of 4 preterm births/year ($46,000 ea.) pays for the project
Other savings in decreased ED visits, unplanned pregnancies, tobacco/substance use etc.
Integration of primary care and public health resources
Better Health, Better Care, Better Cost for highest risk population
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CASE STUDY
Jane is 17 with an unplanned pregnancy. She reports frequent
marijuana use, untreated scoliosis, no medical or dental
home and a history of poor school performance.
Maternity Medical Support Functions
Labor & Delivery
OR
Pediatric Medical Support Functions
NICU
Jane + Pregnancy
Primary Care Provider
Discharge
High School Refers to Nurse Family Partnership (NFP)
NFP
FamilyDental Home
enrolled in CCO
First trimester prenatal care and attended all appointments
Stayed in school
Stopped marijuana use during thefirst trimester
WIC
Depression?Domestic Violence?
Smoking & Substance CessationFamily Group
Support
Nutrition Education
Imaging
Labs
OB/Routine Prenatal
Support to Stay in School
Pediatrician
Maternity Medical Support Functions
Labor & Delivery
OB/Routine Prenatal
Imaging
Labs
Pediatric Medical Support Functions
Family
Babies
NICU
Discharge
PediatricianJaneNFP
Family Group Support
Jane delivers
Jane Delivers Twins at 36 weeks gestation
No complications
weight >5lbs;
No NICU
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Maternity Medical Support Functions
Labor & Delivery
Imaging
LabsOR
Pediatric Medical Support Functions
NICU
Discharge
Jane, Babies & Family NFP
Contraception Education
Maternal/Infant Bonding
Breastfeeding Support
Jane breastfeeds to 6 months
Babies current on well-child exams and immunizations
Babies meet developmental milestones
Jane receives treatment for scoliosis
Jane uses reliable contraception
Jane graduates from high school and enrolls in community college
Babies’’’’ father stays involved
Parenting Education
Postpartum
OB/Routine Postpartum
Primary Care Provider
Pediatrician
“Jane is much more confident and empowered
now. She advocates effectively for herself
and the girls.”
NFP nurse
Lessons Learned1. Be at the table!2. Use CCO language3. Address CCO metrics4. Stress ROI of prevention
and evidenced-based programs5. Share compelling,
local case studies