Ohio Health Quality Improvement Plan

Appendix IV — Co m m e n t s f r o mStatewide Or g a n iz a t io n sOhio Association of Area Agencies onAgingThank you for the opportunity to comment on the OhioHealth Quality Improvement Plan as it relates to thestrategy entitled Patient-Centered Medical Home. TheOhio Association of Area Agencies on Aging (OAAAA)supports this strategy as a central focus area in home andcommunity-based case management and waiver services.For over thirty years, Ohio’s Area Agencies on Aginghave been a leader in the long term care industry by beingcommitted to meeting the chronic care needs of a growingaging population. Area Agency on Aging 10B (AAA 10B)has been in the forefront of advancements in improvingconsumer care and we highlight their excellent work as anillustration of coordinating care across various segments ofthe health care system.AAA 10B has utilized an approach and integrates caredelivery with the initial assessment which transitionsto case management with continuous, comprehensive,coordinated care, as a partnership between consumers andtheir health care team. The medical home will emphasizescoordinated and/or integrated care across all elements ofthe complex health care system; enhance access to makeit easier for members to contact their personal health careteam; improve quality and safety by promoting prevention,proactively managing chronic illness, engaging members intheir care, and using our electronic systems for support.AAA 10B has partnered with 7 regional hospitals andlocate Long Term Care Nurse Consultants on eachcampus. This initiative began in 2000 to effectuate theshift in focus toward a more comprehensive, holisticcare and incorporates the characteristics associated withboth lower costs and better outcomes. In the last 2 years,AAA 10B has provided long term care consultant visitsto 5000 individuals per year with plan development forcommunity arrangements to meet their chronic care needs,with enrollment in a program or receipt of other communityservices. This coordinated care is across all elements ofthe member’s community, including the physician, hospitalteam, nursing home, home health agencies, and othercomponents of a complex health care system—includinghealth information exchange to assure the indicated care isattained when and where it is needed.AAA 10B enhances clinical staff skill set in order tomitigate the impact of risk factors for members at highrisk of nursing facility placement. AAA 10B has workedclosely in partnership with SummaCare MedicareAdvantage Plans and are actively pursing other health plansfor the integration of health plans with our communitybasedbenefits in order to promote community-based care isintegrated and coordinated, in addition to quality and safetyas hallmarks. AAA 10B’s partnership improves enhancedaccess to dual members by system advances and newcommunication options between partners.Additionally, AAA 10B conducts a weekly caremanagement interdisciplinary team (CMIT) meetingwhich includes a physician with geriatrics specialty,staff care managers, staff Clinical Nurse SpecialistSupervisor, and representatives from the communitythat may include hospice, direct care providers, adultprotective services, local housing coordinators, and visitingpharmacists. CMIT aligns efforts for integrated caredelivery and mitigates the community resources with thehealth system for productive interactions which improvemember’s functional and clinical outcomes. The member’sprimary care physician collaboration occurs throughcommunication from the team meeting discussion andwritten updates. Member outcomes that occur from theresult of the CMIT care conference may be arrangementsto referrals to physician specialists, revision of AAA 10Bcare plan services, housing relocation assistance, outpatientutilization, chronic disease management training, andaccessing medical care appropriately and timely with theinvolvement of the case manager.Finally, AAA 10B continues to add clinical staff to bolsterour proficiency in managing chronically impaired olderadults. Building on our addition of our PASSPORTClinical Nurse Specialist AAA 10B began the initiativeof adding Registered Nurse High Risk Care Managers tohelp our most vulnerable members better manage prevalentmedical risk factors to minimize the risk of permanentnursing facility placement.Ohio Association of Health PlansThe Ohio Association of Health Plans (OAHP) appreciatesthe opportunity to participate with other stakeholders,through HQII, to discuss strategies for creating a highquality,cost-effective, high performing health system inOhio. I commend all those that participated in the processand the time many dedicated to capture their input anddevelop the final document. I believe this has been a35