Building Connected Communities of Care-The Playbook For Streamlining Effective Coordination Between Medical And Community-Based Organizations

317 Pages·2020·5.743 MB·\317

by  Keith Kosel (Editor), Steve Miff (Editor)

Building Connected
Communities of Care
The Playbook For Streamlining Effective Coordination Between
Medical And Community-Based Organizations
.
Taylor & Francis
(
Taylor & Francis Group
http://taylorandfrancis.com
Building Connected
Communities of Care
The Playbook For Streamlining Effective Coordination Between
Medical And Community-Based Organizations
Keith Kosel, PhD • Steve Miff, PhD
Parkland Center for Clinical Innovation
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742
© 2020 by Parkland Center for Clinical Innovation
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Library of Congress Cataloging-in-Publication Data
Names: Miff, Steve, author. | Kosel, Keith, author.
Title: Building connected communities of care: the playbook for streamlining effective coordination
between medical and community-based organizations / Steve Miff and Keith Kosel.
Description: Boca Raton: Taylor & Francis, 2020. | Includes bibliographical references and index.
Identifiers: LCCN 2019049400 (print) | LCCN 2019049401 (ebook) | ISBN 9780367800062
(paperback; alk. paper) | ISBN 9780367819231 (hardback; alk. paper) | ISBN 9781003010838 (ebook)
Subjects: MESH: Community Health Services—organization & administration | Community
Health Planning—organization & administration | Community Integration | Social Work
Classification: LCC RA966 (print) | LCC RA966 (ebook) | NLM WA 546.1 | DDC 362.12068—dc23
LC record available at https://lccn.loc.gov/2019049400
LC ebook record available at https://lccn.loc.gov/2019049401
Visit the Taylor & Francis Web site at
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and the CRC Press Web site at
http://www.crcpress.com
Contents
The Call to Action ....................................................................................xv
Foreword .................................................................................................xvii
Preface ......................................................................................................xix
Contributors ..........................................................................................xxiii
About the Authors .................................................................................xxv
List of Commonly Used Abbreviations ..............................................xxix
1 Playbook Overview ......................................................................1
Playbook Purpose .......................................................................................2
Guide to Playbook Terminology ................................................................3
The Six Tracks for CCC Implementation ....................................................3
CCC Roles and Responsibilities ..................................................................7
Timeline to Implement a CCC Model.........................................................9
Resource Acquisition and Preparation Phase .......................................10
Phase 1: Build the CCC Framework .....................................................10
Phase 2: Initial Implementation ............................................................11
Phase 3: Broader Community Implementation ....................................11
2 The Readiness Assessment ........................................................13
Readiness Assessment Requirements .......................................................14
Requirement 1: Identify Target Clinical/Behavioral Health
Conditions .............................................................................................15
Requirement 2: Identify Social Needs That Impact Clinical
Outcomes or the General Health of the Population ............................16
Requirement 3: Describe the Client/Patient Profile That Would
Be Targeted by a CCC ...........................................................................17
Requirement 4: Describe the Organizations and Potential
Users (Staff) of a CCC ...........................................................................18
v
vi ◾ Contents
Requirement 5: Identify Functionalities Required and Develop
CCC Use Cases ......................................................................................19
Readiness Assessment Methodology ........................................................20
Milestone 1: Obtain Data through Research, Surveys,
Interviews, and Focus Groups ..........................................................21
Milestone 2: Generate a List of Gaps for Prioritization ....................21
Milestone 3: Document Use Cases ...................................................22
3 Governance Track ......................................................................27
Introduction to the Governance Track .....................................................27
Roles and Responsibilities .........................................................................28
Requirements for Successful CCC Governance ........................................30
Requirement 1: Secure CCC Resources and Initial Commitments ......31
Milestone 1: Create the CCC Value Proposition ...............................31
Milestone 2: Select CCC Partners and Secure Early Commitments ...31
Key Documents for Requirement 1 ..................................................33
Requirement 2: Choose Your Governance Model ...............................34
Milestone 1: Identify Governance Requirements .............................35
Milestone 2: Analyze Funding Documents to Identify
Governance Parameters and Ensure Compliance ............................37
Milestone 3: Obtain Partner Commitments Not Previously
Obtained during the Readiness Assessment ....................................38
Key Documents for Requirement 2 ..................................................38
Requirement 3: Set Up the Formal Governance Structure ..................39
Milestone 1: Draft and Finalize Governance Documents ................39
Milestone 2: Create Workgroups .......................................................42
Key Documents for Requirement 3 ..................................................44
Requirement 4: Define an Aligned, Comprehensive CCC Strategy .....45
Milestone 1: Establish CCC Target Goals and Evaluation Periods ...45
Milestone 2: Define CCC Measures of Success ................................46
Milestone 3: Define the CCC Evaluation Framework
Supervisory and Advisory Support ...................................................55
Key Documents for Requirement 4 ..................................................57
Requirement 5: Select Clinical Programs..............................................58
Milestone 1: Prioritize the Clinical Needs Based on the
Estimated Impact of Interventions on the CCC Goals .....................58
Milestone 2: Identify and Define the Clinical CCC Interventions ...59
Milestone 3: Select the Clinical and CBO Participant Sites ..............61
Milestone 4: Identify Champions for Each Site ................................63
Contents ◾ vii
Requirement 6: Formalize Participation Agreements and Begin
Implementation of the Governance Plan .............................................64
Milestone 1: Establish All Necessary Agreements ............................64
Milestone 2: Implement Policies and Procedures Required by
Governance Documents ...................................................................65
Milestone 3: Develop a Publicity Plan to Publicize Successful
CCC Implementation Efforts .............................................................65
Milestone 4: Develop Ongoing Maintenance and Sustainability
Plans. ..................................................................................................66
Key Documents for Requirement 6 ..................................................67
Requirement 7: Define a Strategy and General Requirements for
CCC Technology and Data Integration at Partner Sites .......................68
Milestone 1: Analyze any Funder or Sponsor Specific
Technology Requirements .................................................................69
Milestone 2: Translate the CCC Intervention Workflows and
Use Cases into Technical Requirements for the Technology
Platform. .............................................................................................70
Milestone 3: Conduct Market Research to Understand the
Range of Available Technology Platforms in the Market .................72
Milestone 4: Select the Right Technology Partner ............................73
Key Documents for Requirement 7 ..................................................75
Requirement 8: Define and Perform Quality Assurance Activities
to Ensure Intervention Integrity across the CCC .................................76
Key Roles and Responsibilities .........................................................76
Milestone 1: Define and Create Quality Assurance Processes ........76
4 Legal/Policy Track .....................................................................81
Introduction to the Legal/Policy Track.....................................................81
Roles and Responsibilities .........................................................................82
Legal and Policy Framework Assumptions ..............................................82
Legal/Policy Track Requirements .............................................................84
Requirement 1: Develop a Legal and Policy Framework for CCC
Governance ...........................................................................................87
Milestone 1: Create Legal Documents for Early Partner
Commitments to the CCC .................................................................87
Milestone 2: Complete an Analysis of Sponsor and Funder
Requirements for Governance ..........................................................88
Milestone 3: Create the Desired Governance Structure Based
on Stakeholder Interests, Funding Parameters, and State Law ........89
viii ◾ Contents
Milestone 4: Establish Remaining Legal Agreements .......................90
Milestone 5: Ensure Creation and Ongoing Implementation of
Policies and Procedures Required by Governance Documents ......92
Key Documents for Requirement 1 ..................................................93
Requirement 2: Develop a Legal and Policy Framework for the
Technology Platform .............................................................................94
Milestone 1: Determine Applicability of HIPAA ..............................95
Milestone 2: Determine Requirements for Individual Privacy
Expectations, Consents, and Authorizations ....................................98
Milestone 3: Determine Requirements for Nonclinical or
Non-CBO Partners ...........................................................................101
Milestone 4: Finalize Agreement with Technology Vendor ...........103
Key Documents for Requirement 2 ................................................106
Requirement 3: Develop a Legal and Policy Framework for the
Clinical Providers ................................................................................107
Milestone 1: Ensure Completion of Requirement 2 Milestones .....107
Milestone 2: Finalize Agreements with Clinical
Partners/Participants .......................................................................107
Requirement 4: Develop a Legal and Policy Framework for the
Community Partners ...........................................................................111
Milestone 1: Ensure Completion of Requirement 2 Milestones .....111
Milestone 2: Finalize Agreements with Community
Partners/Participants .......................................................................111
Requirement 5: Develop a Legal and Policy Framework for CCC
Program Sustainability ........................................................................114
Milestone 1: Review Sustainability Requirements for Each Track
from a Legal Perspective .................................................................114
5 Technology Platform Track ......................................................117
Introduction to the Technology Platform Track .....................................117
Prerequisites to the Technology Platform Track ....................................118
Roles and Responsibilities .......................................................................118
Requirements to Establish the CCC Technology Platform .....................119
Requirement 1: Define the Underlying Business Requirements
Supporting the Technology Platform ..................................................120
Milestone 1: Know the Partner/Participant Organizations ............120
Milestone 2: Contemplate User Factors Affecting CCC
Technology Adoption and Use .......................................................120
Milestone 3: Know the Users of the System...................................121
Contents ◾ ix
Key Documents for Requirement 1 ................................................123
Requirement 2: Determine Desired System Characteristics and
Requirements .......................................................................................124
Milestone 1: Conduct Technology Inventories at Partner Sites ......124
Milestone 2: Define the Functionalities Needed for Identified
Use Cases .........................................................................................124
Milestone 3: Align Clinical and CBO Needs with CCC
Technology ......................................................................................125
Key Documents for Requirement 2 ................................................130
Requirement 3: Define Required Application Functionalities ...........131
Functionality 1: Define Notification Requirements ........................131
Functionality 2: Define Secured Messaging Functionality .............131
Functionality 3: Define Requirements for Appointment
Calendars .........................................................................................131
Functionality 4: Define Needs for Document Storage and
Tagging ............................................................................................132
Functionality 5: Define Need for Real-Time Alerts ........................132
Functionality 6: Define Query Service Eligibility and Availability ...132
Functionality 7: Define Reporting and Analytics Functionality
Needs ...............................................................................................132
Functionality 8: Define Decision Support Needs ...........................134
Functionality 9: Define Beneficiary Registration Information .......134
Functionality 10: Define Ability to Identify and Merge Patient
Records ............................................................................................135
Functionality 11: Determine Eligibility Identification
Functionality ....................................................................................135
Functionality 12: Customize SDOH Screening Questions .............135
Functionality 13: Define Referral Needs .........................................135
Functionality 14: Determine Data Elements, Definitions, and
Requirements for a Resource Database/Referral Directory ...........140
Functionality 15: Define Required Support for Organizations
Offering Multiple Programs .............................................................141
Functionality 16: Account for Resources Outside the CCC
Referral Network .............................................................................142
Functionality 17: Support the Resource Database Updates at
Any Desired Frequency...................................................................142
Functionality 18: Define the Process for Curation and
Selection of CCC Resources for Referrals .......................................143
Requirement 4: Stand Up the Technology Platform ..........................145