Core NCCC Products
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
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, 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.
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
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
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
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.
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.
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
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
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
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
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).
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.
This 36-page literature review is a synthesis of findings in 13 case management topic areas.
Download
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
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
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
Download
1998/1999 Annual Forum:
Building Partnerships for Integration of Acute and Long-Term Care Services
Download
2000 Annual Forum:
Exploring Next-Generation Issues
Download
2001 Annual Forum:
Knowledge into Action: Sharing What Works
Download
2002 Annual Forum:
Pushing the Boundaries Beyond Demonstration
Download
These proceedings offer overviews of the MSHO clinical forum meetings.
Integrating Care Management, March 3, 1997
Download
Exploring Risk Identification, May 16, 1997
Download
Care Coordination Across the Continuum, September 8, 1997
Download
Fostering Culturally Competent Care, May 18, 1998
Download
Learnings from MSHO Case Experiences, September 11, 1998
Download
Utilization Benchmarks & Techniques- Frail Elders, June 24, 1999
Download
Promoting Self-Efficacy in Older Adults, September 10, 1999
Download
Synthesis of Early Learnings-Three Focus Groups, October 1997
Download Findings Report
Insights From Beneficiaries-Two Focus Groups, October 1998
Download Findings Report
