The 1115 Medicaid Waiver allows for funding of Delivery System Reform Incentive Payment (DSRIP) projects that increase access to health care services, increase the quality and cost-effectiveness of care, increase patient satisfaction and enhance the health of the patients and families served.  The Community Care Collaboration (CCC) has 15 approved DSRIP projects.

This newsletter details two of these DSRIP projects that are expanding needed services for the CCC population: Patient Navigation and Paramedic Navigation.  

Comprehensive System Navigation DSRIP Project

There are three areas of effort in the project:

• With its stakeholders, the CCC will develop system-wide, evidence-based standards and protocols for primary and specialty care navigation programs. Elements of the standardized approach will include outreach, patient navigation and follow-up, and health education and information tailored to the patient's condition and needs, all delivered in a culturally and linguistically appropriate manner.
• The CCC will substantially expand post-enrollment navigation services provided to new Medical Access Program (MAP) patients. Calls to explain MAP benefits and system navigation to new program participants are now made in evening hours, at times more convenient for the customer. 500 new MAP enrollees received this call in DY3; in the next two DSRIP program years, an additional 1750 enrollees will receive the service. The CCC will launch and test a new program for CCC patients who use regional Emergency Departments for non-emergent conditions. Within 72 hours of leaving the Emergency Department, eligible patients will be contacted by a navigator who will establish a connection to a primary care home and schedule an appointment as appropriate. Additional services that may be provided by these navigators include goal-setting, disease state awareness, health literacy assistance, pharmacy management, and linkages to social services.

Work Progress Update

The year-old CCC Navigation Workgroup is charged to advance the work of the DSRIP navigation projects, and develop comprehensive navigation services for the Integrated Delivery System (IDS).  On July 9th, at a CCC-hosted Rapid Design Session, representatives from CCC partners and other community-based organizations, crafted the CCC's Patient Navigation Principles. The following principles were adopted to describe the purpose of navigation programming within the CCC and IDS:

• Connect, coordinate and follow up for services in a timely manner.
• Partner with the person to guide them through the continuum of care.*
• Provide culturally and linguistically appropriate support with an awareness of individual needs and sensitivities.
• Educate and connect people to appropriate levels of care, community resources and available coverage.
• Promote the health and wellbeing of the person at all contacts.

*Continuum of care is a concept involving an integrated system of care that guides and tracks patients/individuals over time through a comprehensive array of health services spanning all levels of intensity of care including, health social and behavioral care

The CCC Navigation Workgroup is now determining what these principles might look like in action. To facilitate this, the CCC conducted its first CCC Patient Navigator training to introduce these principles, along with community tools and navigation resources to front-line staff from various community clinics and agencies. This meeting allowed for two-way communication between front-line staff and the CCC leadership team to discuss ideas, perspectives, and priorities for navigation in Travis County.

The CCC is also developing an implementation plan for the Patient Navigation IT infrastructure and is continuing its ongoing efforts to expand benefits education to our MAP population.

In DY4, we expect to start expanding navigation ability and services as we continue to build infrastructure, and support our community partners in their work!

Community Paramedic Navigation DSRIP Project

Project Description.  With this project, the CCC has expanded the Community Health Paramedic (CHP) program currently operated by Austin Travis County Emergency Medical Services (ATCEMS). The expanded CHP project provides short-term care management and patient navigation services to un- and under-insured Travis County residents with multiple chronic conditions and frequent recent ED utilization.

Specific services provided by paramedic staff will vary according to patient needs, but may include: vital sign assessment; medical screening; home safety assessment; prescription drug assessment, access to a pharmacy and needed prescription refills; establishing appointments for patients with no existing care provider; direct transportation service or arrangement for transportation to medical appointments; behavioral health screening and navigation to appropriate behavioral health services providers. Further, the expanded program allows CHP staff to provide certain medical services to patients in the home as governed by care protocols developed by the program's Medical Director.

Work Progress Update

The ATCEMS Community Health Paramedics (CHP) have been working hard to identify and reach out to provide navigation services to the DSRIP eligible population.  Last week, the team met its DY3 milestone of enrolling 100 new MAP patients!

Additionally, EMS data staff have been working with the team at the Integrated Care Collaborative (ICC) to integrate the CHP patient care plan into the regional Health Information Exchange.  For each patient in their care, community paramedics create a care plan to document patient needs and attempts to connect them with services.  Just recently, only the CHP team could access and utilize the care plan information.  Now that the care plan is a part of the patients' ICC records, other providers are able to use that information to offer informed care regardless of service location.

Now that all DY 3 milestones have been met, the team is turning its attention to DY 4.  Two new paramedic staff will be hired, and processes will be streamlined to make administrative workflow more efficient, allowing the team to enroll 500 new patients next year.