High Desert Medical Group Connections for Life Program Description

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1 High Desert Medical Group Connections for Life Program Description POLICY: High Desert Medical Group ("HDMG") promotes patient health and wellbeing by actively coordinating services for members with multiple or complex chronic conditions. The Connections for Life program fills this role by helping patients access needed resources. Operating within HIPAA regulations, eligible members are proactively identified by PCP or specialist referral, interdisciplinary team review of urgent/ emergent care cases, claims data, hospital discharge data, and pharmacy data when provided by the Health Plan, in addition to data collection through the UM process (i.e. prior-authorization, concurrent review). Enrollment is voluntary. PURPOSE: The Connections for Life program consists of three main components, Communications for Life, Caring for Life, and Choices for Life that yield a multidisciplinary, continuum-based approach to health care delivery that proactively identifies populations with, or at risk for, chronic medical conditions. Using this team approach, Connections for Life emphasizes prevention of exacerbations and complications; and increases focus on patients' and family caregivers' roles, needs and goals. This is accomplished by supporting the physician-patient relationship, developing a plan of care, and facilitating health care communications across all settings. The three components of the program have multidisciplinary team meeting on a weekly basis, and the meetings also include a representative from the acute case management program as well. On an as needed basis, a clinical social worker, social services designee, and/ or respiratory therapist also attend the weekly team meetings. 1. Communications for Life: Promotes patient health and wellness through regular telephonic communication with HDMG patients who qualify or potentially qualify for the Caring for Life program. The Communications team contacts patients who have low level acuity/ complexity monthly as identified by their initial screening. This initial screening consists of an Activity of Daily Living questionnaire and a combined social history/ abbreviated medical history review. 2. Caring for Life: Actively manages those patients identified with needs for high intensity of service integration and with associated high resource utilization. These patients are identified by recent hospital admissions, emergency room visits, or recurrent visits for exacerbations of chronic disease. Case management interventions are aimed at resolving barriers to care, achieving healthy outcomes by adhering to accepted national standards and care recommendations, facilitating regular access for scheduled care and health maintenance, and assistance with addressing urgent care needs when necessary. Targeted areas include but are not limited to patient education to promote understanding of each of their disease processes and symptom awareness, medication safety, and advanced care planning. 3. Choices for Life: Serves the special needs of patients with critical or terminal conditions as they experience the reality of a life limiting disease. The mission and vision of Choices For Life is to empower patients and their families to make choices related to their disease processes, to support them as they experience the reality of a progressive life-limiting disease, and to provide comfort and support to patients and their loved ones with the help of a dedicated team of healthcare professionals trained in the delivery of Palliative and Hospice care. Patients and their families are encouraged to discuss and make decisions in advance about CQC Complex Care Management Toolkit Resource Shared with permission from High Desert Medical Group 1

2 their preferences for treatment when an illness begins to affect their quality of life. The Choices for Life team assists patients to prepare Advanced Directives. The Choices For Life program includes education regarding Hospice care. Hospice is a special type of care for patients with life-limiting diseases. Additionally, the case management team coordinates all non-hospice related care and works closely with the hospice team to see that patient needs are met. Other Choices For Life services include but are not limited to providing tools for maintaining independence, information for long-term care, clinical, social, and supportive needs. Connections for Life Program Goals: Manage patients with multiple and/or complex medical problems by providing a single point of contact available 24 hours a day Encourage collaborations with all health care team members during various transitions of care settings Promote prevention by appropriate utilization of routine health maintenance Prevent unnecessary hospitalizations of members Facilitate compliance with requested and/ or needed therapeutic services. Population: Target patient populations eligible for active case management include but are not limited to members who have had hospital admissions (or readmissions), repetitive Emergency room or Urgent care visits for same diagnosis or chronic disease related issues. Specifically identified chronic disease groups include but are not limited to cancer, spinal injuries, serious trauma, acquired immunodeficiency syndrome (AIDS), diabetes mellitus (DM), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), asthma, coronary artery disease (CAD), and chronic kidney disease/ end stage renal disease (CKD/ ESRD). The goals of the program are to capture those patients at highest risk for complications by either intrinsic or extrinsic factors (e.g. severity of disease, co- morbidities; non-compliance). Enrollment: To facilitate timely and appropriate enrollment into the program, multiple avenues are available. Referrals are generated from the Health Plan, hospital discharge planners, utilization management, primary care providers, specialists, claims or encounter data, pharmacy data, and member (selfreferral). Patients are contacted by Case Manager or Connections team staff and educated about the programs, and their opportunity to enroll. Enrollment is voluntary and consent is recorded in the EMR. The patient is permitted to voluntarily disenroll from the program at any time. Caring for Life and Communications for Life Process: The Communications for Life team serves multiple contact roles with our patients. An initial list of patients gathered by UM and insurance/ billing diagnoses, and utilization of inpatient services is the pool for potential enrollment. These patients are contacted and provided with education about the program, and given opportunity to enroll. Provided they consent to enroll, the staff then goes through initial questionnaires: ADL and a social history/ abbreviated medical history. Based on the answers to this initial screen, patients are then retained in the Communications for Life program (and rated Level I- lowest acuity/ complexity) or noted to need further review by the supervising RN. In addition to these initial contacts from pool of patients, the Communications for Life team makes regularly monthly to all the level I acuity patients. If the patients have new symptoms, demonstrate CQC Complex Care Management Toolkit Resource Shared with permission from High Desert Medical Group 2

3 progression in their symptoms (by answers to their disease specific questionnaires), or have other questions/ concerns, the issues are either directly tasked to the Case Manager (automated in the EMR), or if outside the purview of the regular questions are brought to the case manager, RN supervisor, or medical director for further review. Lastly the Communications team makes regular follow up calls to all Communications for Life patients who are seen in the Urgent Care setting. These phone calls are entered into the patient's EMR and are thus available to all team members and providers for review as indicated. Weekly and monthly reports are generated to track the phone calls. Program specific patient satisfaction surveys are sent out as described below under the 'Evaluation' heading. The population of Level I patients is also monitored for other objective quality measures including bed days and admissions per thousand, and per member per month expenditures. This is done on a monthly basis. From here, the remaining tasks are completed by the Caring for Life Case Managers and supervising staff (see below *). *For new referrals, the supervising RN or medical director review the case history as indicated and assign the patient to a case manager. At this time a complexity score questionnaire reviewing high-risk medication/ medication classes and diagnosis summary by body system are completed as is the remainder of the intake process. Based on their score, the patient is labeled a level I (moderate risk) or level III (highest risk). The case manager is able to review the case and increase a patient's level based on new information, changes in health status, or other factors. This is discussed at the weekly interdisciplinary team meetings. However, a patient is not permitted to be 'down-graded' a level without the case being reviewed directly by the program medical director or supervising RN in the director's absence. Case Management includes assessment of the following: Initial health assessment including cognitive status, and condition specific issues Documentation of medical history and medications Assessment of activities of daily living and life planning activities Evaluation of cultural, Jingoistic and religious needs/ preferences Evaluation of caregiver resources Evaluation of available benefits Identification of barriers to meeting goals or compliance with CM plan Development of a CM plan including long- and short-term goals for all level II and level III members Development of a schedule for follow up and regular communication with member Development and communication of self-management plan for member Process for assessment of progress on member's CM plan Goals, frequency of contact, and interventions are dependent upon the patient's acuity level. 1. Upon receipt and review of referral, the case manager will initiate contact with the patient within 72 hours of the case being assigned. (Receipt and review of referral by supervising RN or medical director is 48 hours or less.) With goal of completion of the enrollment process in 5 business days. Tracking of turn-around time from receipt of referral to completion of intake is updated weekly. 2. Completion of the enrollment process encompasses ADL screen, complexity score, CQC Complex Care Management Toolkit Resource Shared with permission from High Desert Medical Group 3

4 education of patient re Connections for Life program, patient consent to enroll, past medical history, medications review, setting of a minimum of 2 goals, plan for interventions based on goals, and plan for next follow up contact. The lists below are inclusive, but not limited to the noted items. Contact frequency, and expected staff responsibilities are outlined as follows: Level I: These patients are followed by the Connections team unless there is an acute change in their status, or a noted change in their regular monthly disease-based symptom questionnaire. Level I staffing shall include non-licensed personnel. Contacted a minimum of lx per month. Follow-up by case manager if there are changes in disease status Follow-up after urgent care, emergency visit, or hospital admission Level II: These patients are followed regularly by a designated Case Manager (LVN or RN). Contacted by Case Manager a minimum of twice (2x) monthly and 24/7 availability for urgent needs Health education to patient and caregivers as indicated, including promoting self-management Conduct medication reconciliation Assist with life planning Coordinate care with PCP and specialists, including facilitation of access Facilitate case conferences Home visits as needed Identifies and facilitates access to community resources and social services Increased support and care coordination during transitions in care If urgent care needed, facilitate access and care coordination Level III: These patients are followed regularly by a designated Case Manager. The itemized list for level III patients is the same as Level II with the noted exception of contact frequency. Contact Frequency is a minimum of 4 times (4x) per month, typically lx week. Transitional Case Management: An additional component of the Caring for Life team is a Transitional Case Manager (LVN or RN). The role of this person is to contact patients (with the exceptions of routine OB, and mental health, and under 65years of age orthopedics hospitalizations) who have had ER visits or inpatient stays to assess and assist with their post-hospitalization needs. Additionally, s/he may evaluate if the patient is a candidate for the Connections for Life program and offer the service if the patient is amenable and has the appropriate needs. This case manager follows any given patient for up to three (3) months. At that time or earlier, a determination is made if the changes in status are chronic or if the patient has returned to baseline. If the change is chronic and the patient is appropriate for CFL, then an ADL screen and complexity score are completed and a referral is entered so they can be assigned a long term case manager. This component serves to screen patients who are not enrolled but who are in transition from acute care setting back to home and may or may not improve over the short term... Discharge: Discharge criteria from Caring for Life include but are not limited to: Enrollment in hospice or palliative care, CQC Complex Care Management Toolkit Resource Shared with permission from High Desert Medical Group 4

5 Death of patient, Loss or change of insurance coverage, Relocated out of area, Patient no longer willing to participate in program, or Condition improved/ stabilized. Condition improved/ stabilized' is defined by risk factor criteria based on the chronic disease for which the patient is enrolled. The patient demonstrates by behavior, medication usage, claims history for his/ her chronic illnesses that he/she bas an understanding of disease processes, an awareness of symptoms, shows compliance with treatment recommendations, and thus has a reduction in emergent and inpatient service utilization over a specified interval of time (E.g. one year, 18 months). The patient's PCP is then notified that the patient is a candidate for disenrollment in the program and given the rationale for this recommendation. Provided the PCP concurs, the patient is then notified of the plan for disenrollment. Choices for Life Policy: To provide Palliative and Hospice care to patients who meet admission criteria. Care is provided by HDMG Choices for Life team consisting of physicians, case managers, social workers, and contracted Hospice agencies. Purpose: to produce a patient centered approach to care and to achieve the best quality of life for patients through relief of suffering and control of symptoms while remaining sensitive to personal, cultural, and religious values and practices. The Choices team is made up of Palliative Care Medical Director, nurse manager, and case managers. It is augmented by additional physicians on an as needed basis for support in following patients in residential settings, on-call and vacation times, Note- referring to 'patient/family' for Choices program serves as patient may or may not be cognitively intact, and thus may have a medical decision-maker designated, typically a family member. Care Venues: HDMG clinic Convalescent Nursing Facility Board and Care Facility Patient homes Palliative and Hospice Care Procedure: Admission guidelines include but are not limited to: 1. Patients/members with life limiting illnesses and an expected prognosis of 12 or fewer months for Palliative care and 6 or fewer months for Hospice care. 2. For Palliative care- does not meet Hospice Criteria for one or more of the following reasons: patient/ family have not accepted life-limiting diagnosis and prognosis patient/family is not amenable to ceasing aggressive therapies primary care physician is uncertain that patient's prognosis meets criteria 3. For Hospice care: published hospice criteria regarding diagnosis of life-limiting illness, with terminal prognosis within a6 month window. Referral procedure: 1. Provider (e.g. PCP, Specialist, hospitalist) assesses patient 2. If patient meets guidelines, a referral for Choices is generated within EMR and automatically CQC Complex Care Management Toolkit Resource Shared with permission from High Desert Medical Group 5

6 sent to Nurse Manager of Choices program. 3. Patient's records are reviewed for appropriateness for enrollment. If patient clearly suitable by chart review only, patient/ family is contacted, and Case Manager is assigned. 4. If it is uncertain patient is appropriate for services, patient is evaluated by Choices program provider for clinical evaluation. This evaluation occurs within 3 business days of referral. If appropriate, then case manager is assigned. 5. CM then facilitates completion of enrollment paperwork, advanced directives for care, and patient is assigned to Hospice agency or Palliative care services either in home, residential, or in-patient settings as indicated by care needs. CM notifies PCP of enrollment to program. Provision of Care Services: The Choices for Life program has contracts with several local/ regional Hospice care agencies. Eligibility for services is verified monthly. Care is provided directly by the assigned agencies. Palliative care services are provided by agency or directly by HDMG clinic with oversight by Palliative care medical director. For those that are receiving care by agency, Choices team attends regular interdisciplinary team (IDT) meetings (2-4 x/month) at each of the designated agencies. Regardless of from where/ whom the patient receives services, patient rosters are reviewed each week by the team. The Choices team updates any new needs, changes in status, disease progression, and assesses the patient for continued need of services, and appropriateness for level of service provided. Case Managers assist with plan of care, and record it in chart. Chart is marked Palliative/ Hospice care in EMR by automated alert and on paper charting of agency or care facility. Physician reviews patient medical records at residential facilities to verify that care plan is appropriate for goals and that patient continues to qualify for this level of care, Palliative medical director reviews charts on a monthly basis, recording findings in chart. Palliative care physicians see patients on an as-needed basis at the various locations. Discharge Guidelines: 1. Patient may progress from Palliative care to Hospice level care 2. Patient no longer meets Palliative care or Medicare hospice care criteria respectively for their enrollment; 3. Patient/ family no longer agree to palliative care philosophy. Note: patient/ family are then offered Caring for Life program (voluntary enrollment- see above). 4. Patient condition stabilizes and/ or symptoms have been under control with minimal risk of decline (again, patient/ family are offered services of Caring for Life) 5. Patient is no longer a full risk member of HDMG Evaluation of Choices Program: 1. Patient surveys are sent out at regular intervals, and to each patient/ family unit for program specific review. Additionally, the assigned agencies also utilize their own patient satisfaction surveys. Complaints about services with specific agencies or specific care providers with in an agency are tracked. 2. Length of services along with standard deviation is tracked for the program and compared to national averages for other Palliative/ Hospice care agencies. Average length of services is tracked monthly. In this instance, length of services increasing typically reflects an increase in benefit to the patient. 3. Total enrollment is also tracked and compared to national averages based on population needs of the group. Referral sources are tracked. Both of these allow the program to target resources to better provide services in populations which may have been previously overlooked. When CQC Complex Care Management Toolkit Resource Shared with permission from High Desert Medical Group 6

7 these areas are identified, further education of providers, support staff, and community are reiterated to provide better patient education and understanding of the program. Evaluation of Connections for Life Program: CFL Specific Patient satisfaction surveys are sent out to patients at regular intervals as follows: Level I patients: twice yearly Level II and III patients: quarterly Choices patients (or family) quarterly and/ or to each patient/ family Additionally, we continually analyze patient complaints, inquiries, and comments as they arise. Medical chart review is conducted regularly. Examples of patient feedback may include information about the overall program, program staff, usefulness of educational material, improvement in quality of life, pain management, and health status. Effectiveness of Connections for Life program is measured by quantitative data across a minimum of three parameters. The following guidelines must be fulfilled for each parameter: A relevant process or outcome is identified Valid methods that provide quantitative results will be used A performance goal is set. Measurement specifications are clearly identified Results will be reviewed and analyzed through utilization data, assuring statutory and regulatory compliance If applicable, opportunities for improvement are identified A plan for recurrent measurement is developed for longitudinal tracking of maintenance of quality standards and for tracking improvements after specified interventions Examples of performance assessments include Case management effectiveness related to a specific parameter of a chronic medical condition (e.g. cholesterol measures for CAD.and DM, prescription of asthma medications, HEDIS measures) Improvement in a service measure such as inpatient days per 1000, emergency visits per 1000, and admissions per 1000, total cost per member per month Readmission rate Satisfaction with CM services. Assessment of the effectiveness of the interdisciplinary team meetings These goals are completed with support from the UM/QM team and statistical analysts with data collected by a combination of automated extraction from EMR and insurance databases. The data is used to measure against both external and internal standards and to do intra- and inter- case manager tracking. CQC Complex Care Management Toolkit Resource Shared with permission from High Desert Medical Group 7

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