Wisconsin Medical Director, M.D. Of Mediapients

Transcription

1 Wisconsin Provider Expo The New Care Management Model It s Reality! Michael Jaeger, M.D. Wisconsin Medical Director

2 What We re Working To Accomplish Current state opportunities: Consistency Touch more members Maximize cost of care savings opportunities Seamless interface with other WLP programs

3 What We re Working To Accomplish New model implementation July 07-establish foundation Subsequent phased growth

4 Care Management Definition Nurses working 1:1 with members, families and providers, using behavioral change science to engage WLP members in addressing health & care coordination needs

5 Care Management Activities Member/family facing Member needs focused Empowering versus instructive

6 Care Management Activities Continued Integrated with member specific benefits Integrated with other WLP programs (UM, HMC, WBH, PBM, Health Solutions) Collaborative with physician treatment plans

7 Types of Care Management Programs Care Management: Targets members with catastrophic illnesses or conditions Advanced Care Management: Targets members predicted to be at future risk for high costs (Complex Care) Specialty Care Management: Targets members with very focused conditions (Transplant, Oncology, Bariatrics, NICU)

8 Guiding Principles Improve the lives of the people we serve Touch more members Assist with navigating the healthcare system Promote member education, self-care management Collaborate with providers Promote evidence based care Support cost of care Achieve consistency Integrate behavioral change science Incorporate use of community resources Integrate with HMC, UM, Pharmacy, WBH and other clinical programs Maintain and expand accreditation Deliver measurable outcomes

9 Shelley s Story

10 CM Model Future IDENTIFICATION Internal Referrals External Referrals Data Mining Enrollment Specialist ENGAGEMENT TRIAGE NURSE On-Site Reviewer Discharge Planner Care Facilitator Case Manager Social Worker Specialty Care Mgmt. MEASUREMENT Member Satisfaction Provider Satisfaction Case Rates & Financial Outcomes Client Reporting Provider Reporting Operations Reporting CM/Health Outcomes

11 Care Management High Level Process Flow Internal Referrals External Referrals Data Mining Referrals Toll Free CM Referral Line/ Centralized Work Queues Specialty Case Manager Enrollment Triage Nurse Onsite Reviewer Discharge Planner Care Facilitator Case Manager Social Worker

12 Live In-Bound Call Referrals To Referral Specialist WMDS Input: Call Comes Into Zone-Specific Toll-Free Care Management Program Referral Line Referral Specialist Answers Phone Find Member In System & Verify Eligibility Access Member in Contact Mgmnt. Click on member widget, verify current plan effective date & program eligibility in membership source system. Check If Member s Active In Another Nurse Telephonic Program Check MAS Toolbar to see if member is active in another program. If yes, make a not in Contact Mgmnt. Document Caller Name & Relationship To Member Document in Contact Management Document Reason For Call Add Reason for Call in Notes Area Contact Mgmnt. Explain Program & Process For Follow-Up (Based on Script) Use Referral Specialist Script Call Ends Call ends only if you are not talking to the member: If our are not talking to the member, close Contact Mgmnt. With outcome in Close Reason. Task to appropriate Triage for Follow-Up Task to Triage priority Urgent-Expedite 1 hour; Non- Urgent Expedite 24 hours. Add Contact Mgmnt. Note Document Case Action & Details * Result of Eligibility Check * Result of Check For Other Program Activity * Source/Reason For Referral * Complete Referral Specialist Survey * Complete SF12V2 or SF10 As Appropriate * Route/Tasked to Appropriate Triage Workgroup If talking to the member & they accept, complete: Contact Mgmnt. Screen with Close Reason of Acceptance. Create Provider Referral Select New Assessment CM RS Outbound & complete SF12V2 OR SF10 Be sure to mark Complete before Exit. Add Contact Note Type CMRS Live Referral with outcome in the Close Reason Selection Send Case To Triage * Inpatient Referral Turn-around is 4 hours * Unless Urgent, All Other Turn-around Times are 24 hours Criteria For Urgent Mark referral as Urgent when referral includes a request for services If Requested Call or Send to Referring Source Confirming Receipt & Sent to Triage Process Ends

13 Care Manager (CM) Process Flow WMDS Receive Referral In Task From Triage Select Member and Make Initial Call Access Auth or Provider Referral from designated Task List per priority Obtain Member s Verbal Consent To Participate in Program Transfer to CM application. Document contact phone call Tab 1 New Contact. Tab 2 Select Program Type. Document Member consent in Folder Widget at end of Enrollment line. PRE-ASSESSMENT Send Welcome ( CM Intro ) Letter (Includes Bill of Rights and Written Consent) Select Intro letter from Tab 6, generate New letters. ASSESSMENT Complete CM Assessment PLANNING Develop CM Plan (Issues, Goals & Interventions) Tab 2, Select CP from list, include all standard components and/or customize as needed. Document Outcomes under folder widget at end of line under tab 3. FACILITATION * Implement CM Plan & document all activities associated with implementation coordination * Call back member at regular intervals (as planned) * Physician Contact/Communication (per Policy) Add additional Care Plans under tab 3, Care Plans button. Task to designated Task List for date due of follow-up. Add designated Priority. Ongoing Monitoring of CM Plan Goals & Documentation of Progress (Identify Barriers & Update CM Plan As Needed) Document contact phone calls, Tab 1 follow-up calls. Document notes in CM narrative notes under Note Type appropriate to the CM process being addressed, update care plan & intervention notes, update issues and outcomes as needed No MONITORING CM Plan Goals Met? Yes *** AT ANY POINT IN PROCESS *** Enrollment Issue and/or Continued Participation Question Come Up: Member No Longer Interested In Program OR Member No Longer Eligible for Plan Coverage OR Unable to Reach After Multiple Attempts Complete Discharge Summary Document Outcomes and Case Closure Criteria Goal Outcomes are documented in Folder Widget on each issue. Select appropriate reason. Add Note from enrollment screen Type Closure & select Reason. All Issues must be completed resolved/ unresolved & reason noted in narrative note & add end date of issue. Send letter. Case Closure Closure Letter Sent (Per Policy) Process Ends

14 Data Mining Released first enterprise-wide data mining in late July

15 Next Rx Connects Integration Dedicated pharmacy support for the Care Management program Goal is to optimize member benefits while increasing use of mail order services Includes consultation with RNs, direct contact with members and providers

16 Behavioral Health Integration 3 levels of support for the Care Management program - CODA program - Referral to WBH CM programs - Consultation Working with WBH team on CODA/CM referral criteria and program handoffs

17 Member Medical History MMH is an abbreviation for Member Medical History Is an internal application for Anthem associates distributed over the Internet and accessed through the MAS Toolbar

18 Member Medical History The MMH application consists of the following screens: * Encounters * Medical Claims * Diagnosis/Conditions * Clinical Procedures * Surgical Procedures * RX * Hospitalizations * Emergency Room Visit * Eligibility History

19 MMH Diagnosis/Conditions STOP

20 MMH ER Visits Reports STOP

21 Julieanne s Story

22 Questions?

23 Wisconsin Provider Expo Thank you for joining us! Michael Jaeger, M.D. Wisconsin Medical Director In Wisconsin, Blue Cross Blue Shield of Wisconsin ("BCBSWi") underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. BCBSWi and Compcare are independent licensees of the Blue Cross and Blue Shield Association. Registered marks Blue Cross and Blue Shield Association