coiin News Articles

NCCA Blog – “We try to do the right thing, at the right time, for the right person:” Team Indiana’s Approach to Care Coordination

Thursday, April 28, 2022

Team Indiana chose to participate in the National Care Coordination Academy (NCCA) to learn and share with other care coordination innovators. In this interview, Mary Ciccarelli, MD, Clinical Director for Team Indiana, discusses how participation in the NCCA assisted in her team’s journey toward expanding care coordination services across the state. Their care coordination innovations include a training and coaching curriculum for care coordinators and Care Coordination Playbooks to facilitate system navigation. This conversation has been edited for length and clarity by Candace Jarzombek, CMC CoIIN Graduate Research Fellow.

What are you most proud of achieving as part of the NCCA?

We used our participation in the CoIIN network, as well as the NCCA, as leverage in our own state to push forward conversations we were having about piloting models with Medicaid. I attribute our joining the CoIIN four years ago as the event that pushed our state to say, “okay, if we’re going to [invest in care coordination] at any time, this might as well be it.” The NCCA was another different crowbar to try to open that door. We are planning for a launch of a big demonstration project now as a statewide expansion of care coordination using COVID relief dollars. The state is preparing to invest $9 million in this over the next three years. Our state’s never done that before, and it’s an opportunity we can’t blink our eyes at.

What innovations in your care coordination model did you make as part of the CoIIN and NCCA?

Our main innovation is our care coordinator virtual coaching model. We hired a very experienced care coordinator nurse and an experienced social worker and built a first-week orientation with a five-month high-intensity training curriculum followed by a longitudinal coaching model. In the high intensity curriculum, there are weekly didactic sessions spanning 20 key content areas as well as weekly open-ended coaching sessions, for specific case discussions.

After the first six months, there are episodic video conference lectures for the statewide cohort of nurses. We try twice a year to do something face-to-face because physically being together is important in terms of the care coordinators’ ability to relationally make use of each other in the coaching sessions.

What content or resources have you developed as part of this coaching model?

We have about 30 documents called Care Coordination Playbooks that are process recommendations of how to navigate the complex systems of care across both health and social systems. For example, how do you get a wheelchair fixed through Medicaid or through an alternative source if Medicaid won’t cover it? The playbooks cover the “work around methods,” like special community resources, such as churches, who will help us. They encourage care coordinators to get to know their own community and to know which door to knock on when you have an unusual request.

At the simplest level, the Playbooks took the lengthy Medicaid provider manuals, often over 300 pages, and translate them into, “So you want to get incontinence supplies. Okay. Which plan is the patient on?  Which provider will cover that? Here’s how to do it.” The Playbooks explain the home and community-based waivers and the key choices families have to make related to them, and help care coordinators to counsel families on which choice is the right one for them at the current time. It is one of our principles that by training care coordinators, we want them to be skilled to do the right thing, at the right time, for the right person, which is more targeted and precise and hopefully yields more effective outcomes, rather than just tossing all the resources at a new team member.

What do you think is next for Indiana’s care coordination program?

It is the goal, in the three years of this expansion, to prove that we can move this model up to scale. We’ll move from 300 to 3000 covered patients over the next three years. If we can prove the model works at a scale of 3000, then we’ll plan to launch it statewide at the completion of the demonstration project. The other big innovation of this next demonstration is that we will expand beyond pediatric practices. In year two, we’ll start rolling in practices who are for adults with intellectual and developmental disability (IDD). A substantive problem in the care of children with medical complexity is their transition to adult care and the diminished access to care, or perceived diminished access, in the adult world, particularly for people with IDD.

Is there anything else you would like to share about Team Indiana’s work?

Our work in social determinants of health (SDOH) has led to a large facet of our Playbooks. We’re trying to decide at the children’s hospital level how to do general SDOH screening for everyone. However, for those with medical complexity, we feel that you have to do a deeper dive into social complexity to help you identify and modify barriers to quality outcomes. We’re currently planning to continue to use a more advanced assessment tool in that population. We hope to prove that by using an expanded assessment, we serve our families with more measurable success.