Over the last two years, Care Compass Network (CCN) has conducted several Medicaid Accelerated eXchange (MAX) Series in conjunction with local health systems to redesign the way care is delivered for the state’s most vulnerable patients. In earlier article “‘Mad’ MAX Comes to the Southern Tier“, we provide further detail on the process for the MAX Series.
Cayuga Medical Center (CMC) was one of four health systems that participated in CCN’s MAX Series workshop. Through assessing the drivers of utilization specific to their system, the action team chose to focus on collaboration within community-based organizations (CBOs) such as palliative care agencies, hospice and care coordinators, with a separate focus on skilled nursing facilities.
When the action team came together for their first workshop they were “familiar with each other and familiar with working with each other to some extent but they had very different perspectives on patient care and the flow of information,” says Project Manager and MAX Facilitator, Lauren Greco. “It illustrates, in the beginning, how standardized something can seem to one person but from an overall process flow it can be very unstandardized.”
Over the course of the three MAX Series workshops the team was successful in creating and implementing a high utilizer assessment that focused on the individual, drilling down beyond medical reasons to understand why the patient is a the emergency department. As well, regular points of communication were organized between the interdisciplinary teams through a daily high utilizer huddle at rounds and a weekly round-table discussion between organizations.
Based on the drivers of utilization, the action team identified appropriate CBOs to refer their patients to and worked with them to develop a warm hand off protocol with each organization removing any barriers to connecting the patient to care. The skilled nursing facilities were provided with resources to help them understand when they should take action and bring the patient to the hospital.
Additionally, a Shared Care Plan was developed that is accessed by the care team when seeing patients that are high utilizers. The action team worked together to establish what important information would be recorded, where the document would be stored, how it would be updated and what team members would have access.
Understanding that it is rare for high utilizers to have relationships with a primary care office, the action team worked to begin outpatient care coordination, connecting the patient with a primary care office. “CMC and Cayuga Area Preferred [administrative coordinators for area primary care offices] have a close relationship. They can have a representative from the primary care facility come and introduce themselves to the patient,” shares Greco. “You then have the warm handoff and the connection has been made for the patient to use primary care as the first line of defense rather than the Emergency Department.”
The Cayuga Medical Max Series was successful in increasing a culture of collaboration. “It’s really interesting to see how the MAX Series set them up for designing programs and outlining interventions together,” says Greco. “You can see this in other cohort programs that CCN is running with Cayuga Medical Center.”