For years, states have been dedicated to improving healthcare access for Medicaid recipients, with patient-centered medical homes (PCMHs) being a key focus. The Affordable Care Act (ACA) of 2010 further empowered state Medicaid programs to establish health homes. These health homes are designed to better coordinate a comprehensive suite of services for Medicaid beneficiaries managing chronic health conditions. Tennessee seized this opportunity, launching both a PCMH program to address primary care needs for all Medicaid beneficiaries and a health home program, known as Tennessee Health Link (THL), aimed at coordinating behavioral and physical health services for those with significant behavioral health needs. Tennessee’s PCMH program began in January 2017, closely following the THL program which started in December 2016.
TennCare, Tennessee’s Medicaid agency, recognized that for both PCMH and THL providers to be truly effective, they needed access to detailed information about their patients’ service requirements and the care they were receiving. However, Tennessee’s statewide Health Information Exchange (HIE) had been discontinued in 2012, leaving a void in readily available data. There was no existing system to transform raw data into actionable insights that providers could use to improve patient care. To bridge this critical gap, TennCare developed a Care Coordination Tool Tennessee, often referred to as CCT. This innovative tool aggregates data from various sources to equip PCMH and THL providers with the necessary information to effectively manage the primary and behavioral health needs of their Medicaid patients. This article delves into the details of this care coordination tool tennessee, drawing upon research and interviews with TennCare officials.
Understanding the Care Coordination Tool (CCT)
The care coordination tool tennessee is a sophisticated, cloud-based application designed to consolidate and present crucial patient data to healthcare providers. It pulls information from multiple key sources:
- Medicaid Claims Data: Information on services billed to Medicaid.
- Encounter Data from Managed Care Organizations (MCOs): Data from TennCare’s contracted MCOs, capturing service utilization.
- Immunization Data: Data from the Tennessee Department of Health’s (TDH) statewide immunization information system (TennIIS).
- Admissions, Discharges, and Transfers (ADT) Data: Real-time updates from hospitals, obtained through data exchange partnerships with the Tennessee Hospital Association (THA), East Tennessee Health Information Network (etHIN), and Community Hospital Systems (CHS).
By compiling this diverse data, the care coordination tool tennessee provides providers with a holistic view of their patients’ healthcare journey. This comprehensive perspective helps identify gaps in care and facilitates timely interventions. Crucially, the CCT accelerates the notification process for hospitalizations and emergency department visits, enabling providers to promptly arrange transitional care and follow-up appointments.
Specifically, the care coordination tool tennessee offers the following types of information:
- Patient Demographics and Panel Information: Names and demographic details of Medicaid beneficiaries assigned to a provider’s patient panel.
- Clinical History: Claims-based clinical data, including medication history, diagnoses, and records of past provider visits, derived from claims and encounter data.
- Hospital and Emergency Department Activity: Real-time ADT information from emergency departments and hospitals, keeping providers informed about patient events.
- Immunization Status: Immunization records for children under 2 years old and those aged 9-13, ensuring up-to-date vaccination information.
- Performance Metrics: Each provider’s performance data on quality measures that are linked to PCMH and THL value-based payments, allowing them to track their progress.
- Care Alerts: Proactive alerts that flag “past due” services needed by patients, such as mammograms, post-hospital discharge follow-ups, or updates to personalized care plans.
Participation in the care coordination tool tennessee is optional for providers in the THL and PCMH programs. However, it offers a significant advantage by providing a unified platform to leverage near real-time data. This data empowers providers to directly see the impact of their efforts on key quality and efficiency metrics that determine performance-based payments. (Detailed information on payment structures can be found in TennCare’s PCMH and Health Link operational manuals).
The Power of Multiple Data Sources in Tennessee’s Care Coordination
“Reach out to providers early…find out their wishlist. What is it that would help them take care of their patients better?”
—TennCare representative
The care coordination tool tennessee was specifically designed with PCMH and THL providers in mind. Its primary strength lies in offering a single, consolidated source of patient information, even when patients are enrolled across different MCOs. The CCT equips providers with the data necessary to understand their patients’ primary care needs, track services delivered by other providers, and stay informed about hospital and emergency department ADTs, among other critical data points.
TennCare leverages its Medicaid Management Information System (MMIS) as a major source of claims and eligibility data for the CCT. However, TennCare recognized the limitations and challenges of relying solely on this system. One significant hurdle is the time lag between service delivery and the appearance of that service data in claims. Another challenge reported by providers is the lack of seamless integration between the care coordination tool tennessee and their existing Electronic Health Records (EHRs). This lack of interoperability can lead to duplicate data entry, as providers may need to input the same information into both systems. These challenges can potentially hinder a provider’s ability to fully utilize the CCT to access timely and comprehensive patient information.
To overcome these data limitations, TennCare strategically forged partnerships with organizations that manage complementary data sources. The Tennessee Hospital Association (THA) became TennCare’s initial partner in 2017. TennCare contracted with THA to obtain near real-time ADT data, which is crucial for timely care coordination. To ensure comprehensive ADT coverage, TennCare collaborated with THA to include hospitals that were not already submitting data. For instance, TennCare implemented guidelines requiring hospitals to submit ADT data as a condition for receiving directed payments, previously distributed as unreimbursed hospital cost pool payments. This initiative resulted in 100% of Tennessee hospitals now contributing ADT data to the THA, creating a robust and complete dataset through this partnership.
In 2019, TennCare expanded its data partnerships by contracting with the Tennessee Department of Health (TDH). This agreement incorporated specific immunization data from the statewide immunization information system (TennIIS) into the care coordination tool tennessee. This immunization data supplements claims data to enhance the accuracy of Healthcare Effectiveness Data and Information Set (HEDIS) immunization measures. It also proactively identifies patients who are due for immunizations. Similar to the THA partnership, the TDH also benefits from this collaboration. The contract commits TennCare to working with the TDH to improve both the volume and quality of data submitted to the TennIIS registry by providers, furthering the shared goal of improving childhood immunization rates across Tennessee.
“One of the biggest draws was that live ADT feed. It helped care coordinators keep up to date with admissions, emergency department use, and discharges so that they could follow-up in real time.”
—TennCare representative
While the specific data partnerships established in Tennessee may not be directly replicable in other states, the underlying principle of leveraging diverse data sources remains universally applicable. TennCare emphasizes the importance of meticulous planning to identify the essential data elements for a care coordination tool tennessee, both at launch and for future scalability. Identifying potential data partners and the resources required to access data beyond the Medicaid agency’s direct control is also a critical aspect of thorough planning. Furthermore, cultivating mutually beneficial partnerships and establishing effective contracts are processes that require time and strategic foresight. Developing a long-term roadmap early in the development process is therefore essential for success.
Investment and Funding for Tennessee’s CCT
Developing and maintaining the care coordination tool tennessee represents a significant investment. Its implementation demanded strong leadership and the dedicated efforts of a diverse team of professionals across multiple TennCare departments. These included the chief medical office, behavioral health operations, information systems, legal, and other relevant divisions. Crucially, the development process incorporated valuable input and feedback from providers and MCOs who would ultimately be the primary users of the tool. Beyond contracts with the CCT vendor (HealthEC), THA, and TDH, TennCare also engaged information system (IS) contractors for design and implementation expertise. TennCare estimates that a core team of 15-20 individuals were deeply involved in the development, with numerous others contributing their expertise as needed.
The most substantial component of the investment is the direct cost associated with developing and operating the care coordination tool tennessee. TennCare initiated a procurement process to select the initial vendor to develop and operate the CCT, awarding the contract in 2016. The second generation of the CCT, launched in November 2020, was procured through an existing TennCare IS contractor. TennCare representatives believe that the updated CCT more effectively aligns with their vision for the tool and better addresses the evolving needs of THL and PCMH organizations.
Drawing on their experience, TennCare advises states considering developing a similar tool to prioritize vendor selection carefully. It is crucial to ensure that the chosen vendor possesses the necessary qualifications to accurately provide and process data. Inaccuracies in data can quickly erode trust in the tool’s reliability. TennCare recommends that states:
- Establish clear minimum qualifications for potential vendors and involve knowledgeable information technology staff in the vendor evaluation process.
- Select a vendor with proven experience working with large, multi-site organizations and handling diverse data types from multiple sources.
- If the tool is intended to generate HEDIS measures, verify that the vendor holds a National Committee for Quality Assurance (NCQA) Measure Certification.
“After you choose a vendor, set strategy immediately. The strategy should be as detailed and inclusive as possible, but general enough to grow to what you need in the future.”
—TennCare representative
- Actively solicit input from providers who will be using the tool. This can be achieved through technical assistance groups or end-user testing sessions during the design phase.
- Conduct thorough reference checks on potential vendors to gain insights into their strengths and weaknesses.
- Develop a strategic training and engagement plan for the first 12 months following the tool’s launch to ensure successful adoption and utilization.
While the overall investment in the care coordination tool tennessee is substantial, the initial CCT implementation qualified for a 90/10 federal matching fund rate under the Health Information Technology for Economic and Clinical Health (HITECH) Act. As an integral part of the Medicaid agency’s MMIS, the current HealthEC CCT receives a 75/25 federal matching fund rate. This federal funding significantly reduces the financial burden on the state. (It is important to note that while HITECH funding concluded in 2021, alternative opportunities for securing 90 percent funding for the design and development of HIE and HIT infrastructure still exist).
Evidence of Success and Improved Outcomes
A key indicator of the care coordination tool tennessee‘s success is provider adoption and utilization. As of June 2021, every PCMH, THL, and MCO in Tennessee had registered at least one staff member to use the tool, with a total of 662 registered users across these organizations. TennCare representatives report that the enhanced ADT data feed was a major factor driving provider engagement. To support users, TennCare provides ongoing monthly training sessions and personalized assistance. TennCare and its vendor have also developed a comprehensive learning library offering recorded training modules and quick reference guides. This library helps providers effectively utilize the CCT for tasks like identifying frequent emergency department users and proactively managing patient care.
However, the ultimate measure of success for the care coordination tool tennessee is whether it leads to improved cost-efficiency and healthcare quality outcomes. While definitively isolating the CCT’s impact from other factors influencing cost and quality is complex, TennCare has conducted evaluations of both the PCMH and THL programs. Agency representatives believe that these evaluations provide indications that the CCT has contributed to positive outcomes. Key findings from these evaluations include:
“There are some members THL providers cannot find. With ADT, they can locate and maybe enroll the member if they show up at the hospital.”
—TennCare representative
Although these improvements cannot be solely attributed to the care coordination tool tennessee, TennCare believes the CCT has played a significant role. By design, it assists providers in identifying care gaps and provides the necessary information to enhance follow-up care and coordination. This belief is reinforced by feedback gathered from focus groups and interviews with PCMH and THL providers. These providers consistently emphasized the critical value of the CCT for care coordination, particularly highlighting the ADT data feed. Furthermore, many providers expressed a desire for even more data integration, indicating they recognize the substantial value of the information provided by the CCT. Anecdotal evidence suggests that the information within the CCT has effectively helped providers pinpoint the specific primary care and behavioral health needs of their patients and facilitate timely access to appropriate care.
Summary and Key Takeaways
TennCare’s experience with the care coordination tool tennessee offers valuable insights for other state Medicaid agencies. It demonstrates how states can successfully develop IT tools to empower providers to improve care for Medicaid beneficiaries, even in the absence of a statewide HIE. TennCare’s success is rooted in a provider-centric approach. The agency prioritized end-user needs and preferences throughout the CCT’s development, focused on delivering accurate, near real-time data to enhance care coordination, and concentrated on providing actionable information that directly supports provider performance improvements linked to value-based payments. To achieve this, TennCare proactively sought data sources beyond the Medicaid agency’s immediate control to create a more comprehensive and timely dataset. They also cultivated a strong collaborative partnership with the state’s IS agency. Finally, access to enhanced federal matching funds helped offset the significant investment costs. The care coordination tool tennessee serves as a compelling model for other states seeking to enhance care coordination and improve outcomes for their Medicaid populations through strategic technology investments.
