Each month, NACDD seeks to highlight the excellent work being done by State Health Departments across the country. This month's "I Count!" story comes to us from the Utah Department of Public Health.
In January, 2013 the Utah Department of Health convened the Health Care Systems Partnership. An important goal of the partnership was to work on a project that advances four important national health care trends: health information technology, meaningful use; patient centered medical homes and accountable care organizations (ACOs). For the first year, the partnership met quarterly to identify a theme that would be meaningful to all of them. They chose to focus on care coordination, which is multidimensional, cross-cutting and affects all four national health care trends.
The partnership has representation from all major health systems in Utah including: Intermountain Health Care, University of Utah - Health Care, Medicaid, Molina, State Division of Substance Abuse and Mental Health, HealthInsight, Summit County Health Department, Public Employees Health Program, Altius Health Plans, Association for Utah Community Health, and Utah Health Information Network. Additionally, within the Department of Health, categorical programs fully engaged include the Healthy Living through Environment, Policy & Improved Clinical Care (EPICC), Violence and Injury Prevention, Arthritis, Asthma, Cancer and Tobacco Control Programs.
The partnership worked to develop a shared understanding and principles to follow to keep themselves focused and on track. Their criteria for selecting a project to work on together included whether it: fills a gap, is measurable, is achievable, includes multiple partners willing to work together, is mutually reinforcing to current efforts, and does not duplicate current efforts. They also came to a consensus on a mutual definition of care coordination to make sure all partners and entities would be included in the process. Finally, they agreed upon principles of care coordination (based on the National Quality Forum, Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination). Partners shared additional information about current projects they are involved in to help the group identify gaps in care coordination systems and processes.
The partnership used the Centers for Medicare and Medicaid (CMS) State Innovation Model (SIM) driver diagram planning model to identify an overall aim for the project as well as primary drivers. The aim is to: increase the number of patients receiving coordinated services in primary care and/or behavioral health and the primary drivers are: processes for information sharing and communication; integrating primary care and behavioral health; identifying patients in need of coordinated care; and addressing reimbursement for defined care coordination services.
A representative from each partner organization joined a subgroup focused on the primary drivers that aligns best with their mission and work. Each subgroup reviewed and clarified the primary driver, identified secondary drivers (ie. activities and interventions), and discussed possible measures of success. They also discussed other partners to include.
Currently, the subgroups are moving forward in their care coordination areas. They are identifying projects and developing action plans that take a systemic, multilevel approach to care coordination.