Community and Clinical Integration Program
The Community & Clinical Integration Program (CCIP) is comprised of a set of care delivery standards and technical assistance that is intended to enable Advanced Networks and FQHCs to deliver care that results in better health outcomes at lower costs for Medicare, Medicaid, and commercial plan enrollees. CCIP participants will receive free technical assistance, as well as peer support through a Learning Collaborative. Entities that participate in CCIP will be expected to advance their capabilities for all populations, regardless of payer.
The CCIP standards are intended to build on existing medical home and care coordination programs in Connecticut. They are based on local and national best practices that have been shown to improve health care outcomes, improve health equity, and reduce costs.
The three core standards focus on:
Comprehensive care management: The standards establish a person-centered process for identifying and managing the care of individuals with complex health care needs, including using multi-disciplinary comprehensive care teams. They will enable medical homes more effectively identify individuals who will benefit from comprehensive care management, engage those individuals, and coordinate services by using an expanded care team that includes community-based service and support providers.
Health equity improvement: Part 1 of these standards focus on continuous health equity gap improvement including analytic capabilities to routinely identify disparities in care, conduct root cause analyses to identify the best interventions, and develop the capabilities to monitor the interventions. Part 2 specifies an intervention that uses a community health worker to address an identified equity gap.
Behavioral health integration: These standards incorporate best-practice processes to identify unidentified behavioral health needs in the primary care setting. This program seeks to bolster the ability of providers to perform these functions while optimizing existing resources. The standards establish a process for identifying individuals with unidentified behavioral health needs and addressing the need.
Technical assistance for three additional elective voluntary standards will be available to participants that are interested in improving care in the following areas:
E-Consults: E-consults is a telehealth system in which primary care providers consult with a specialist reviewer electronically via e-consult prior to referring an individual to a specialist for a face to face non-urgent care visit. E-consult provides rapid access to expert consultation. This can improve the quality of primary care management, enhance the range of conditions that a primary care provider can effectively treat in primary care, and reduce avoidable delays and other barriers (e.g., transportation) to specialist consultation.
Comprehensive Medication Management (CMM): This intervention is intended to improve care for patients with complex therapeutic needs who would benefit from a comprehensive personalized medication management plan. CMM is a system-level, person-centered process of care provided by credentialed pharmacists to optimize the complete drug therapy regimen for a patientís given medical condition, socio-economic conditions, and personal preferences. The model depends on pharmacists working collaboratively with physicians and other healthcare professionals to optimize medication use in accordance with evidence-based guidelines.
Oral Health Integration: These standards provide best-practice processes for the primary care practices to routinely perform oral health assessment with recommendations for prevention, treatment and referral to a dental home.
CCIP is a companion initiative to the Advanced Medical Home (AMH) Program. The AMH Program targets capabilities at the level of the individual primary care practice, while CCIP targets capabilities at the level of the clinical network or organization (e.g., Advanced Network or Federally Qualified Health Center). Primary care practices that are not currently NCQA PCMHs can apply to the AMH program and receive 15 months of free technical assistance and support to achieve PCMH capabilities.