Best Practice in Cross-System Care Coordination Conferences

Practice experts strongly recommend an interdisciplinary approach to care coordination to meet the complex needs of older adults with chronic physical and mental health comorbidities who are also poor. These adults are likely to participate in Medicaid- funded long-term services and supports in the community or in care facilities. The majority are dually eligible for Medicare. Their healthcare costs are among our nation’s highest. Older Medicaid beneficiaries with complex needs are more likely to experience iatrogenic events within health and long-term care settings and to experience earlier mortality when compared to those who are not poor or who have fewer complex needs. Care coordinators often seek to better understand the needs of these complex individuals and to effectively collaborate within and across systems. Although interprofessional collaboration is recognized as best practice, there is currently insufficient evidence to fully support cross-system team building interventions in non-acute healthcare settings. The prevailing biomedical model with its embedded hierarchies often disincentivizes true cross-system collaboration and fails to adequately address the intersections between the individual’s own goals of care, treatment adherence, and socioeconomic risk factors. Despite prevailing understanding that a team of nurses, social workers, community partners, and others are necessary to support both individuals and primary care providers throughout the care coordination process, it can be difficult to ensure that all voices are heard and have a platform to contribute to information-sharing and decision making. Interdisciplinary cross-system care coordination conferences represent an innovative partnership under the umbrella of Oregon’s coordinated care organization service delivery model that allows multiple participants to jointly develop a person-driven plan of care. Specifically, a state-mandated memorandum of understanding stipulates that health plan partners participate with local Medicaid long-term services and supports staff to co-facilitate interdisciplinary cross system care coordination conferences for mutually identified complex individuals and to include those individuals whenever possible. Since their inception in 2015, these conferences have been shown to significantly decrease emergency department visits, inpatient admissions, and associated costs. Care conferences that include both health and social needs planning can also promote person-driven care, create more targeted care plans, increase the quality of care and increase work satisfaction. These collaborative sessions highlight the expertise of all team members, clarify team member roles, and distribute leadership among all the participants. This session, presented jointly by the long-term care innovator agent responsible for initiating and pioneering ICCCs in Multnomah County, Oregon, and an RN health plan partner will describe the process with an emphasis on lessons learned and evidence-based practice specific to collaborative team building across systems. Learning outcomes will focus specifically on establishment of joint metrics, identifying individuals to bring to care conferences, facilitating an interdisciplinary group discussion with a person-driven focus, creating a shared care coordination plan, maintaining confidentiality, and tracking outcomes. There will also be an opportunity for interactive learning and for participants to consider how this model compares to what is available or what could be developed within their own systems.