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Core NCCC Products

Barriers to Integration
In this 20-page issue brief, the NCCC identifies major goals for achieving chronic care integration, discusses barriers to achieving these goals, and concludes with specific recommendations for government, payers, and philanthropic collaborations to remove integration barriers and dramatically improve the delivery of chronic care services. Download

Care Strategies for Managing High-Risk Individuals
Managing the care of high-risk individuals in primary care settings is a challenge for all healthcare providers. Developed with support from Arthur Andersen, this 502-page toolbox contains a compilation of survey information obtained from NCCC members regarding strategies to better manage care. Use this toolbox to

  • Understand current programs and strategies used by leading healthcare organizations to manage care for high-risk individuals in primary care settings
  • Develop best practice methods and management strategies

The compiled NCCC-member site survey results include program descriptions, communication samples, and cost-saving results. The tool also includes a categorization of the survey responses (e.g., by type of program, target population, incentive strategy), an analysis of the information and findings, and a framework to understand the various programs.

A copy of the Risk Identification Guide is also included in this toolbox. This 79-page guide describes a conceptual framework and processes for screening patients into risk categories in order to direct those at highest risk for adverse outcomes to appropriate interventions.
Download Risk Identification Guide - Part 1
Download Risk Identification Guide - Part 2
Download Risk Identification Guide - Part 3

Chronic Care Management-A Toolbox for Action
Chronic Care Management-A Toolbox for Action, written and developed by Mary Jane Osmick, M.D., Medical Director at Crozer-Keystone Health System, documents an integrated health system's five-year journey in developing and implementing cross-continuum chronic care management programs.

The 581-page book presents three introductory chapters about chronic care management, followed by a practical six-phase model designed to help others improve their chances for success. Supporting chapters discuss "drivers" of success or failure including functional health literacy, end-of-life concerns , learning styles, cultural competency, and optimal team functioning. Reporting templates, checklists, and measurement tools to assist practitioners in program development are included in the toolbox.

Although a great deal has been written about chronic care management from an academic standpoint, much less information is available to practitioners who wish to develop or improve their own programs. This book will become the practitioner's step-by-step guide for chronic care management programs-from the first meeting of the planning committee, through years of successful ongoing patient care.

Chronic Care Network Development in Rural Areas
The foundation of the NCCC's work is the development of chronic care networks (CCNs). A chronic care network is a person-centered, systems-oriented approach to managing care across time, place, and profession, using integration, disability prevention, and managed care financing methods to serve a common group of people with chronic conditions. The creation of CCNs in rural areas poses unique challenges. This 16-page issue brief explores the challenges of, as well as the strategies and approaches to, effective rural CCN development. Download

Congressional Resource Guide on Chronic Care
Healthcare reform initiatives to improve care for people with serious and disabling chronic conditions must be grounded in a solid understanding of the problems of people with chronic conditions and a sense of urgency about the personal and public impact of this problem as we enter the twenty-first century. Toward this end, the NCCC has developed the Congressional Resource Guide on Chronic Care to educate Congress and other key policy officials on issues related to chronic diseases and disabilities.

This 459-page toolbox includes a wealth of information, from chronic disease prevalence rates and costs to principles for quality, cost-effective care for people with chronic conditions. It is intended to help policymakers understand the relationship between the nature of chronic disease and the need for a systems approach to healthcare delivery and financing. Here are a few of the tools included in this toolbox:

  • Statistics on chronic disease in America, including prevalence rates and costs
  • A profile of federal programs serving people with chronic conditions
  • Principles for high-quality, cost-effective care
  • Barriers to integration of healthcare services for the chronically ill
  • Case studies illustrating the impact of our current fragmented healthcare system on consumers and providers
  • A public policy agenda for the next century to improve care for the chronically ill
  • A chronic care resources list

The Elements of Integrated Care Management
While all NCCC members are working to improve their ability to provide integrated care management, each site is at a different state of evolution, serving different populations under a different set of structures. Despite this variation, NCCC members have come to a consensus on defining the basic elements of integrated care management. These elements are described in this 8-page issue brief. Download

Extended Care Pathways-A Practical Tool
One strategy that the NCCC advocates to improve the integration of chronic care services is extended care pathways (ECPs), which are standardized approaches to multidisciplinary care of individuals with particular diagnoses. An ECP is a set of policies and procedures that providers use to address a specific disabling chronic condition over time and across the full continuum of care.

A tool for managing, monitoring, and evaluating care, an ECP specifies what will be done, at what particular points along a specified time scale, in order to achieve the desired outcomes. ECPs increase continuity of care, thereby improving quality and cost effectiveness. The NCCC has created a 361-page toolbox that provides next-generation strategies based on NCCC-member experience in developing, implementing, and evaluating ECPs. Second-generation issues identified include

  • Efforts/methods for training staff across multiple sites and the need for buy-in from key clinicians for ECP use
  • The difficulty of identifying relevant outcome measures and tracking them for ECPs
  • Strategies to involve clients in ECP development, use, and evaluation
  • The need for computerizing ECPs-software/hardware issues and the processes, ideas, and interim steps for connecting services without a fully integrated information system
  • Approaches to comorbidities
  • The relationship between ECPs and methods of disease management, care/case management, guidelines, protocols, quality improvement techniques, and utilization review processes
  • Effects of financing/reimbursement methods on ECP buy-in, design, and use
  • Use of the ECP as a documentation replacement for part of the medical record

In keeping with its practical orientation, the toolbox contains case studies, lessons learned, checklists, sample flow charts, and work plans.

A copy of the NCCC's 1995 Extended Care Pathways report is also included in this toolbox. NCCC members have developed and tested a number of pathways and share their learnings about ECPs in this 79-page report. Download Extended Care Pathways Report

The development of this toolbox was funded by a grant from The John A. Hartford Foundation.

Integrating Pharmaceutical Care
This toolbox is designed to allow a multi-organizational healthcare system to analyze its own progress toward integrated pharmaceutical care-across settings and facilities-according to certain guiding principles and measurable objectives. The toolbox provides a framework and lays out a suggested process for conducting a self-assessment.

This 248-page tool includes

  • A concept paper
  • A comprehensive user's guide
  • Criteria and measures for integrated pharmaceutical care
  • A patient assessment instrument
  • A scoring guide
  • References and articles

The centerpiece of this toolbox is the Criteria and Measures for Integrated Pharmaceutical Care. Working with a multi-member group of physicians, pharmacists, and administrators, the NCCC and the National Pharmaceutical Council developed these criteria and measures to define targets for healthcare organizations to use in moving toward a more integrated approach to pharmaceutical care.

Perspectives in Disability Prevention
Cheryl Phillips, M.D., an NCCC member and geriatrician, wrote this comprehensive discussion of disability prevention. In this 12-page issue brief, Dr. Phillips reviews the meaning of disability, reviews prevention strategies, discusses practitioner issues, offers provider network and client perspectives, and provides examples of disability prevention programs. Download

Population-Based Planning: Emerging Approaches for Chronic Care
Healthcare delivery systems are under severe pressure, first, to cut costs, and second, to improve the outcomes of care for defined population groups. Yet healthcare organizations are not set up for tracking and managing population groups-nor have healthcare professionals been trained to work in this way. This 20-page issue brief describes population-based planning and identifies how it can best be modified to target people with chronic conditions. Download

The Primary Care Team: Cornerstone of a Chronic Care Network (CCN)
Primary care should be comprehensive, accessible, financially responsible, and coordinated over time and place. For the chronically ill, the challenge of providing these services is best met through interdisciplinary care teams with clear leadership, designed to provide the most medically effective and cost-appropriate care that reflects client and family preferences. This 20-page issue brief explores care of the chronically ill, the role of primary care teams within systems of care, and strategies for creating CCNs to better serve the chronically ill. Download

Risk-Sharing Arrangements Across a Continuum
This 12-page issue brief stimulates discussion of an organization's philosophical approach to risk sharing by presenting ideas about goals and issues affecting risk sharing. This document offers six models of risk sharing to illustrate different financial risk-sharing approaches. Download

Serving the Dually Eligible
People who are dually eligible for Medicare and Medicaid benefits represent a small portion of the total beneficiary population but consume fully one-third of total annual expenditures for both programs. Integration of Medicare and Medicaid benefits, services, and financing is the key to improving health outcomes and controlling costs for this population. The NCCC has developed a toolbox of resources to help providers, health plans, and policymakers better understand the needs of the dually eligible; barriers to developing a seamless, cost-effective system of care for this population; and strategies for effectively integrating Medicare and Medicaid benefits. This toolbox includes

  • Demographic and financial information
  • A status report on current efforts to integrate Medicare and Medicaid
  • Information on regulatory barriers to integration of Medicare and Medicaid benefits
  • Federal waiver authority for Medicare/Medicaid integration
  • Capitated financing plans for Medicare and Medicaid programs
  • Models for Medicare/Medicaid integration
  • Baseline capabilities for health plans, providers, and states in serving the dually eligible
  • Recommendations for regulatory reform

This 1,079-page toolbox also includes a comprehensive set of resources developed for Minnesota Senior Health Options (MSHO).

State-of-the-Art in Network Performance Measures
There are at least six measurement systems that can be used to compare healthcare plans or provider networks. These systems were all developed in the 1980s and early 1990s but for somewhat different purposes and with different primary users in mind. This 60-page publication describes these measurement systems, highlights similarities and differences between them, suggests appropriate uses, and offers directions for further development of the performance measurement field in general. Download

Minnesota Senior Health Options Resources

The State of Minnesota implemented Minnesota Senior Health Options (MSHO) in 1997 to serve people aged 65 and older who are dually eligible for Medicare and Medicaid. The NCCC has developed a number of resources for MSHO health plans and care systems that are available for dissemination.

Case Management for the Frail Elderly: A Literature Review
This 36-page literature review is a synthesis of findings in 13 case management topic areas. Download

Self-Efficacy/Self-Health Care Among Older Adults: A Literature Review
This 20-page literature review explores concepts, theories, attitudes, and goals related to self-efficacy among older adults. It also reviews programs that promote self-efficacy, evidence of effectiveness, and instruments and measures. Download

Provider Survey Report: 2000 Survey of MSHO Care Providers
This 48-page report summarizes survey findings of three different types of direct care providers that serve Minnesota Senior Health Options (MSHO) beneficiaries. The surveys of care coordinators, nurse practitioners, and physicians were intended to provide insight into the impact and effectiveness of the MSHO demonstration from the perspective of a sample set of direct care providers. Download

MSHO Annual Forum Proceedings
These proceedings provide session summaries from the annual day-long educational conferences for MSHO participants.

1997 Annual Forum:
Innovations and Issues in Clinical Integration: Improving Systems for MSHO Clients

1998/1999 Annual Forum:
Building Partnerships for Integration of Acute and Long-Term Care Services

2000 Annual Forum:
Exploring Next-Generation Issues

2001 Annual Forum:
Knowledge into Action: Sharing What Works

2002 Annual Forum:
Pushing the Boundaries Beyond Demonstration

MSHO Clinical Forum Proceedings
These proceedings offer overviews of the MSHO clinical forum meetings.

Integrating Care Management, March 3, 1997

Exploring Risk Identification, May 16, 1997

Care Coordination Across the Continuum, September 8, 1997

Fostering Culturally Competent Care, May 18, 1998

Learnings from MSHO Case Experiences, September 11, 1998

Utilization Benchmarks & Techniques- Frail Elders, June 24, 1999

Promoting Self-Efficacy in Older Adults, September 10, 1999

1997 Focus Groups: Health Plans and Care Systems
Synthesis of Early Learnings-Three Focus Groups, October 1997 Download Findings Report

1998 Focus Groups: Clients
Insights From Beneficiaries-Two Focus Groups, October 1998 Download Findings Report


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