5/3/2013

1

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

5/3/2013

2

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

5/3/2013

3

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.

5/3/2013

4

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

5/3/2013

5

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

5/3/2013

6

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

5/3/2013

7

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