Connected Care Program

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1 Connected Care Program

2 Pennsylvania Counties Served by UPMC for You and Community Care Erie Crawford Warren McKean Potter Tioga Bradford Susquehanna Wayne Mercer Lawrence Beaver Forest Venango Jefferson Clarion Butler Armstrong Indiana Elk Cameron Clearfield Lycoming Clinton Centre Union Snyder Mifflin Juniata Wyoming Sullivan Lackawanna Luzerne Columbia Monroe Montour Carbon Northumberland Northampton Schuylkill Lehigh Pike Allegheny Washington Westmoreland Cambria Blair Huntingdon Perry Cumberland Dauphin Lebanon Berks Bucks Montgomery Greene Fayette Somerset Bedford Fulton Franklin Adams York Lancaster Chester Philadelphia Delaware Counties Served by UPMC for You Connected Care Pilot location Counties Served by Community Care Counties Served by UPMC for You and Community Care 2

3 Member Stratification Members identified from Medical & Behavioral Health claims data and stratified into 3 Intervention levels based on services utilized Designed to ensure members receive the right level of health plan outreach, consistent with their behavioral and physical health needs Re-stratification performed monthly to identify new members and those who are at high-risk High BH/PH & High PH/Low BH High BH/ Low PH Low BH/Low PH Members will not be moved down to a lesser level of stratification during the project 3

4 Stratification Criteria for High Behavioral Health Needs: Care in a state hospital or diverted from a state hospital Multiple admissions or readmissions to various levels of care Authorization for in-home services, diversion or acute stabilization, clozapine or methadone services, or targeted case management Criteria for High Physical Health Needs: Three (3) or more Emergency Department visits within the past three months, or Three (3) or more inpatient admissions (for any diagnosis) in the past 6 months 4

5 Member Identification: Medical Assistance From July 1, 2009 to September 30, ,375 73% 121 3% 1,101 24% Tier 1 High PH/High BH and High PH/Low BH Tier 2 High Behavioral / Low Physical Health Needs Tier 3 Low Physical / Low Behavioral Health Needs Total Medical Assistance Members Identified = 4,597 5

6 Connected Care Initiative to improve the connection and coordination of care for those with Serious Mental Illness among health plans, PCPs, and behavioral health providers in outpatient, inpatient and ED care settings. Based on Patient Centered Medical Home model with integrated care team and care plan to address all medical, behavioral, social needs. Partnership between: Center for Health Care Strategies (CHCS) Department of Public Welfare (DPW) UPMC for You Community Care Behavioral Health Allegheny County Department of Human Services 6

7 Extensive Planning Process Extensive analysis of federal and PA law related to privacy/confidentiality restrictions Feedback from a consumer advisory group Strong emphasis on member recovery goals Communication with PCPs and Behavioral Health Providers Data exchanges Staff work flow between care managers 7

8 Connected Care - Key Components Integrated Care Coordination: All members linked to a medical home Identify providers seen by member Integrated care management team supporting providers through: Holistic PH/BH care plan Education and support for member selfmanagement ED and inpatient discharge coordination Facilitating and tracking PH/BH visits and recommended tests or treatments Data infrastructure / information exchange to support care coordination Coordination by a lead care manager 8

9 Connected Care - Key Components Coordination of care in provider offices: 11 sites have additional care coordination support in provider offices: 4 will have co-located physical and behavioral health services in the same office 7 have Practice-Based Care Managers who are UPMC for You staff working with high-volume PCP practices 9

10 Connected Care - Key Components Integrated care plan: Care plan viewable by staff from both Health Plans. Community Care Integrated care team meetings which include input from: PCP Pharmacist PCP/BH providers Member and/or their care givers Health Plan Staff: Medical directors Nurses including those placed in high-volume practices Social workers Pharmacist Network staff BH Provider Patient UPMC for You 10

11 Pharmacy Management and Provider Notification Pharmacy Adherence Initiatives Notify PCP and/or prescribers for: Members on atypical antipsychotics who have a gap in filling their prescription (less than 75 days supply in the 90 day period) Notification if a claim for glucose screening has not been received in past 12 months for members filling antipsychotics Non-compliance in filling other medications that treat chronic conditions 11

12 Connected Care - Key Components Consumer Engagement: Using providers to help inform members of the program Letters sent to members describing the program Members eligible for a $25 member incentive for seeing their PCP Navigator / Personal Wellness Advocate: Lead Care Manager Health Risk Assessment Tool: Designed to identify behavioral, medical, social, health education needs and lifestyle risks Coaching for lifestyle risks like smoking, diet, and exercise Encouraging substance abuse screening by PCPs 12

13 Connected Care - Key Components Improved Discharge Planning: Essential to optimize outcomes and reduce avoidable readmissions Real-time hospital admission and discharge notification Coordinated by the Integrated Care Team Ensure member clearly understands what to do and everything is in place for follow-thru with the care plan Key Components of discharge plan: Timely post-discharge follow-up appointments Identify care giver support needs Symptom response plans to manage care post discharge Medication reconciliation 13

14 Care Management Activities July 1, 2009 to September 30, 2009 Of the 4,597 Medical Assistance members identified: Enrollment: 97 members agreed to enroll and signed consents to share information 94 members agreed to enroll, but do not want to share their information 95 members have declined 208 were unable to be reached Staff are actively outreaching to an additional 1,032 members Care Plans: 1,526 integrated care plans have been started Inpatient and Emergency Room notices to providers (utilization tracking as of August 2009): 568 ED visits 176 inpatient admissions 14

15 Preliminary Observations Staff are seeing the value of not working in silos. Care coordination is being integrated. Integrated Care Team meetings identifying valuable information related to the medical and behavioral health services the member has received, gaps in care, and their medication profile. Medical and behavioral health providers are seeing the value of the work of the integrated team, particularly with their challenging patients. Daily inpatient reports providing an opportunity for staff to visit the members that we have not been able to find while in the hospital to improve engagement and care coordination. Locating members is still a challenge. 15

16 Next Steps Continue to foster the communication and improve work flows between UPMC for You and Community Care staff. Further development and management of the integrated care plans. Use providers to help educate members on the program and engage them in the program. Do more provider education on the program and how it may support them in managing their members with SMI. Further develop the implementation plan for the Wellness Navigators. 16

17 Questions? Contact information: John Lovelace President UPMC for You UPMC Health Plan Two Chatham Center Pittsburgh, PA

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