Community-Based Care Coordination (CCC) Maturity Assessment Program Level 1. Level 2. 3. Level 4. Who/What Elements Beginning Progressing Intermediate Advanced Organization(s) LEADERSHIP Sponsoring CCC on board Many All members sponsoring organization(s) community of Transformative Providers on CCC on board services on community change board Providers board embrace Providers Community Triple Aim goals Community new models notified CCC extends engagement identified services of care to ToC & fees Community Some Goal setting Patients (pts) received Care services community Team-based, Payers coordination relationship Community services on patient-centered actuated building steering board care initiated committee in Triple Aim Payers engaged Evidence-based place goals being Business case in goals-setting care met for Learning Communications Innovative delivery accountable about or with pt models care implementing representatives anticipated new models CCC of care Local care coordinator on Triple Aim board goals measured & refined Patients Patients Appointment Risk Consumer PATIENT Primary Care POPULATION / assigned to F/U calls for stratification experience Provider PANEL MGMT PCPs high-risk pts to balance of care (PCP) panel size improved Patients assigned Results Referrals panels to PCP tracking for all tracking for high Panel Providers Specialties patients risk pts composition share Results tracking CCC cohorts maintained savings CCC cohorts CCC cohorts Appointment F/U Population identified for managed Consumer calls care through ToC experience of Referrals tracking management care Risk stratification measured to balance panel size Panel maintenance
Community-Based Care Coordination (CCC) Maturity Assessment Who/What Program Elements Level 1. Beginning Level 2. Progressing 3. Intermediate Level 4. Advanced Organization(s) sponsoring CCC Providers Community services Patients (pts) Payers LEADERSHIP Transformative change Community engagement Goal setting Team-based, patient-centered care Evidence-based care Innovative delivery models Sponsoring organization(s) on board Providers notified Community services relationship building initiated Business case for accountable care anticipated Local care coordinator on board CCC on board Providers on board Triple Aim goals identified Some community services on board Payers engaged in goals-setting Communications with pt representatives CCC Many community services on board CCC extends to ToC & fees received Community steering committee in place Learning about or implementing new models of care Triple Aim goals measured & refined All members of community embrace new models of care Care coordination actuated Triple Aim goals being met Patients Primary Care Provider (PCP) panels Specialties CCC cohorts Population PATIENT POPULATION / PANEL MGMT Patients assigned to PCP Results tracking Appointment F/U calls Referrals tracking Risk stratification to balance panel size Panel maintenance Patients assigned to PCPs Results tracking for all patients CCC cohorts identified for care management Appointment F/U calls for high-risk pts Referrals tracking for high risk pts CCC cohorts managed through ToC Risk stratification to balance panel size Panel composition maintained Consumer experience of care measured Consumer experience of care improved Providers share savings