1 MODULE 11: Developing Care Management Support In this module, we will describe the essential role local care managers play in health care delivery improvement programs and review some of the tools and processes that can be used to support them. This module will demonstrate the value community-based care managers bring to medical homes and provide examples of the processes and tools that care managers use to support population management activities at the practice setting. The role of the case manager When deciding how best to support implementation of the medical home/chronic care model in North Carolina, the architects of Community Care knew care management interventions would be one key to our program s success. We were convinced of the value of interventions not only by local primary care providers (PCPs) but also by national experts (including Dr. Ed Wagner of the MacColl Institute for Healthcare Innovation and Group Health Cooperative of Puget Sound) and through the examples of integrated delivery systems like Intermountain Healthcare in Utah and Geisinger in Pennsylvania. When we launched Community Care, one of our goals was to provide wrap-around support to medical homes and primary care physicians (PCPs) as they managed high-cost, high-risk patients and patients with chronic conditions. While we could have contracted with vendors from outside the community to provide care and disease management services, we chose to build a network of local professionals who worked with the communities in which they lived. We knew the kind of support we wanted to provide would require the in-depth understanding of a community that only comes from living and working in it, day after day. Our care managers are immersed in the towns, cities and counties they serve, allowing them to: Develop positive relationships with the medical homes and the PCPs caring for the patient(s). Develop positive relationships with community agencies and other local resources providing services and support to the Medicaid population. Find community resources and organizations and understand their impact on the health care delivery system for Medicaid patients. (For instance, care managers would need to
2 Page 2 of 17 understand how health-focused community groups could influence the availability of mental health services for pediatric and adult patients). Visit patient homes, when appropriate, to perform medication reconciliation, assessments and more. Work with practices and their staffs to integrate system design changes so that evidencebased practice guidelines can be implemented. Communicate face-to-face with patients and their families and/or caregivers. To support care managers and help ensure their success, Community Care created a number of tools and systems that can easily be adopted by similar programs around the country. Our population management approach In Community Care s approach to population management, we work holistically, looking at the entire target population to identify, implement and evaluate management strategies. In doing this, we emphasize the different responsibilities that health care professionals and organizations have to their patient populations: informing enrollees about their health, sharing resources and expertise to address medical and social needs, and providing and coordinating needed health care services. Managing a population involves not only the delivery of physical health care services it also requires providers to address social, mental and community issues that may impact health and medical care. Simply put, care management recognizes the social and environmental factors that affect population health. As part of our care management approach, Community Care works to: Increase access to health care services. Increase access to appropriate community resources. Increase the health status of the enrolled population. Analyze the health care needs and experiences of the enrolled population. Define subsets of the population that may require and benefit from care management support and interventions. Develop care management initiatives and supports. Utilize and organize community resources to best serve the population.
3 Page 3 of 17 Track and evaluate program performance. Adjust program initiatives accordingly. Care management, which is outcome-focused, monitors the population and service delivery system using meaningful information. Over the years, Community Care has implemented and integrated care management strategies that address chronic diseases, evidence-based best practice guidelines, chronic care, pharmacy management, emergency room utilization, prevention and health promotion, transitional support and high-cost/high-risk patients. The challenge for a successful care management program is determining which subsets of the enrolled population will benefit from the care management interventions, as the most severely ill patients may not benefit from intense care management. For instance, a patient with end-stage renal disease is likely already receiving support and services from his or her renal dialysis center in coordination with primary and specialty providers. Identifying those who will benefit most from your program s services is an ongoing process. An effective population management approach builds on the patient self-management component through member education and care management support. When used successfully, this approach equips individuals with chronic conditions with the ability to manage more effectively their diseases, gradually lowering the percentage of high-risk and high-cost patients in the population. Care management goals and objectives The overall goals of care management are: (1) to optimize the patient s ability to take care of himself or herself; and (2) to identify and coordinate needed resources and support. Through care management, we: Improve access to needed services. Educate patients on the benefits of a medical home and the best use of the health care delivery system. Advocate on behalf of the patient and family. Apply best practices for disease management initiatives. Negotiate appropriate behaviors and set goals with patients to achieve best outcomes. Provide education, support and resources tailored to the individual s need.
4 Monitor patient compliance and outcomes and follow up as needed. Module 11: Care Management Support Page 4 of 17 Redirect repeat emergency department (ED) patients to appropriate service delivery settings. Collaborate with other service providers. Participate in the PCP-led health care team. Coordinate services across providers and delivery settings. Meet care and service requirements for specific populations. Document care management interventions and follow-up efforts. At Community Care, there are five components of care management: Patient identification and comprehensive assessment: We identify patients through direct referrals, by mining administrative claims data (e.g., risk stratification tools, frequent hospital and emergency room admissions), through screenings and assessments, and through chart reviews that identify gaps in care. Developing an individualized care plan: The health care team including the care manager, primary care provider, patient and family/caregiver agree on goals in a care plan. Care coordination: The care manager ensures the patient s care plan is implemented, communicating and coordinating across providers and delivery settings. Care manager interventions are identified and documented. Reassessment and monitoring: We monitor the patient s progress toward goal achievement on an ongoing basis, adjusting care plans, as needed. Outcomes and evaluation: The care manager uses the quality metrics (discussed in Modules 7 and 10), assessment and survey results, and utilization of services to monitor and evaluate the impact of interventions.
5 Figure 1. The Case Management Process Module 11: Care Management Support Page 5 of 17
6 Page 6 of 17 Identifying target populations To identify a target population such as asthma patients or people with co-morbidities you must first have a picture of the entire patient population. In North Carolina, we started with a two-pronged strategy. First, we performed intensive claims data analysis, studying inpatient claims by diagnosis, emergency room visits by diagnosis, high-cost patients by diagnosis, etc. Our first analysis showed that asthma was the diagnosis with the highest number of hospital admissions and emergency room visits. Once an opportunity was identified, we made sure evidence-based best practice guidelines were available to manage asthma and that we had primary care provider engagement and buy-in. With those in hand, we launched our first quality improvement initiative, focused on asthma, in We followed our asthma initiative with programs for patients with diabetes and congestive heart failure and for those who frequently visited the emergency department. These programs enabled both the networks and the medical homes to gain experience and confidence in rapidcycle quality improvement efforts and in tracking and monitoring performance and impact. For more information on this process, see Module 10 ( Designing and Developing Care Improvement Strategies ). Each quarter, Community Care creates routine case identification reports for every network and practice participating in Community Care. These reports are generated from administrative claims data and help the care managers, PCPs and networks identify potential individuals for targeted interventions. The reports include a list of patients who meet the following criteria: Identifying Emerging Asthma Patients Met modified HEDIS (Healthcare Effectiveness Data and Information Set) in most recent six months and did not meet modified HEDIS in previous year. Currently enrolled in Community Care. Is not a skilled nursing care patient. Does not have a clinical indicator/condition of asthma ruled in. Does not have COPD (chronic obstructive pulmonary disease).
7 Identifying Emerging Diabetes Patients Module 11: Care Management Support Page 7 of 17 Met modified HEDIS in most recent six months and does not meet modified HEDIS in previous year. Currently enrolled in Community Care. Is not a skilled nursing care patient. Does not have a clinical indicator/condition of diabetes ruled in. Identifying Emergency Room Patients Currently enrolled in Community Care. Made three or more emergency room visits in past six months. Enrolled in the same practice at least nine out of the last 12 months and is currently enrolled in the same practice. Is not a skilled nursing care patient. We provide care managers with pertinent patient information for individuals that are potentially high risk. An example worksheet that is obtained from claims data and provided to each community care network is provided below. The care managers can use this information to further identify potential patients that might benefit from their interventions.
8 Page 8 of 17 Patient Information Emerging Asthma Emerging Diabetes ED List Network Network Network Network County County County County Practice Name Practice Name Practice Name Practice Name Practice Code Practice Code Practice Code Practice Code Emerging Asthma (Y/N) Dual Eligible Dual Eligible Dual Eligible Emerging Diabetes (Y/N) Medicaid ID Medicaid ID Medicaid ID ED List (Y/N) Patient Last Name Patient Last Name Patient Last Name Medicaid ID Patient First Name Patient First Name Patient First Name Patient Last Name Date of Birth Date of Birth Date of Birth Patient First Name Age Age Age Date of Birth Gender Gender Gender Age Program Category Program Category Program Category Gender ABD Indicator ABD Indicator ABD Indicator Dual Eligible Case Manager Case Manager Case Manager Program Category Current Case Status Current Case Status Current Case Status ABD Indicator Medicaid Months Enrolled Medicaid Months Enrolled Medicaid Months Enrolled Community Care Months Enrolled Living Arrangement Community Care Months Community Care Months Enrolled Enrolled Patient Address Total Medicaid Cost Total Medicaid Cost Total Medicaid Cost Total Medicaid Drug Cost Total Medicaid Drug Cost Total Medicaid Drug Cost Total IP Visits Total IP Visits Total IP Visits Total ED Visits Total ED Visits Total ED Visits IP Asthma Primary Diagnosis Visit ED Asthma Primary Diagnosis Visit CA PCP Visit Total Prescriptions Asthma Maintenance Meds Short Acting Asthma Meds IP Diabetes Visit Any Diagnosis ED Diabetes Any Diagnosis CA PCP Visit Total Prescriptions Insulin or oral hypolglycemics or/ antihyperglycemics Emergent ED Visits Non-Emergent ED Visits The elements included on the case identification reports were selected with the help of network leadership and care managers, and we continue to refine the reports as we gain experience. Calling on the expertise of the care managers is essential to create reports that have meaning and that will be used in the field. The goal is to stratify the population and identify patients that will benefit from the targeted care management interventions.
9 Page 9 of 17 In addition to producing claims data reports that identify potential target patients, we also identify patients using the following referral sources: Primary care providers/medical homes. Discharge planners. Hospital staff in the emergency department. Departments of social services. Local health departments. Local aging agencies. Mental health providers. Other community providers. Community and organization leaders (e.g., faith leaders). The patient (him/herself). The patient s caregiver(s). Supporting the care managers and medical homes Once the Community Care program identifies a target population, our next task is supporting the care managers and medical homes. Our support includes: Educating the medical homes and care managers about evidence-based best practice guidelines. Introducing PCPs/medical homes to their care managers and providing contact information for referrals and follow-up. Providing care managers with the tools and reports to assist them in supporting patient care. Creating systematic data analysis to target patients and providers for outreach, education and intervention. Implementing a screening and assessment process. Identifying a process to monitor the patients participating in care management. Educating patients about their disease states, including medication adherence, prevention and risk-factor reduction.
10 Page 10 of 17 Ensuring follow-up with hospital discharge instructions for high-risk, high-acuity, highcost patients. Coordinating transitional support across provider and delivery settings. Assisting providers in coordinating care for the target population. Case Management Information System (CMIS) As discussed in Module 7 ( Creating an Informatics Center ), Community Care chose to build a web-based case management information system to support the needs of the community-based care managers. We considered several off-the-shelf care management products but ultimately decided to develop our own because: We wanted the ability to manage a large volume of Medicaid claims from the state s system, and most software vendors at that time, lacked experience with the Medicaid population. Making enhancements to an off-the-shelf system would have been costly and timeconsuming. We wanted a flexible system that could standardize processes across all networks but also allow for pilot initiatives at the network level. Our case management information system (CMIS) is a user-built, patient-centric software package available via secure website. Thanks to input from a group of care managers (we called them the power-users work group ), we were able to design and build a system that meets the needs of the care managers working with North Carolina s Medicaid population every day. Community Care began using CMIS as its electronic record of case management activities in 2001, with major enhancements released in 2005, 2006 and The system is currently used by 13 of the 14 networks the other network uses a hospital-based system that offers features similar to those of the CMIS. Currently, CMIS contains demographic, claims and chart audit data on more than one million Medicaid recipients enrolled with Community Care practices. The care management processes embedded in the system follow the nationally recognized nursing case management model. Care
11 Page 11 of 17 managers and other network staff maintain a single care plan that stays with the patient when he or she moves from one area of the state to another or when he or she changes medical homes and/or networks, ensuring continuity of care in care management activities. In addition, several networks share the CMIS functionalities with state organizations responsible for managing the uninsured population, giving these organizations the ability to track enrollment, eligibility and care management services. For more information on CMIS, please review a sample care plan and a slide deck that includes screenshots of the system. Community Care s Care Management Standardization Plan Community Care networks are responsible for managing their enrolled populations. To ensure continuity and quality of service across the state, Community Care central and network leadership have developed standardized processes and expectations for every Community Care participant. Standardization enables the program to share best practices among networks, establish meaningful expectations, and monitor and evaluate program activities. Community Care works with networks to establish effective methods of identifying the recipients most likely to benefit from care management interventions. Once identified, recipients who agree to participate are given a comprehensive health assessment, which documents conditions and problems, interventions, goals and other care management activities that are then recorded in CMIS. Community Care developed a Care Management Standardization Plan that provides definitions and specificity in the following: Care management priorities. Care management actions steps. Medication management steps. Components of the transitional care model. Care management intensity levels. A standardized care management plan is important for monitoring progress and success in achieving the plan s goals and objectives. The networks have common performance expectations
12 Page 12 of 17 and standardized processes that help us reach our goals for quality improvement and cost containment. An example of the types of standardized processes in place for care managers is provided in the following charts.
13 Figure 2. Standardized Processes for Care Managers Module 11: Care Management Support Page 13 of 17
14 Page 14 of 17 Patients engaged in care management are defined as heavy intensity, medium intensity or deferred. Patients are deferred from care management for a variety of reasons: refusal to participate; because their conditions are already managed optimally; or because interventions are not likely to impact their health outcome or quality of life (e.g., a patient with end-stage renal disease). Care management staffing and training Each Community Care network hires staff based on the targeted quality improvement and care management initiatives it is pursuing. Most networks employ a mix of nurses and social workers, including behavioral health social workers with master s degree. A sample care manager job description is included in the Resources section of this website. The number of full-time equivalents vary somewhat across the networks, but an average AFDC (Aid to Families with Dependent Children) caseload per care manager ranges between 5,000 to 7,500 enrollees per care manager, and an average ABD (aged, blind and disabled) caseload ranges from 1,500 to 3,500 enrollees per care manager. These caseloads are assigned with the assumption that only five to 10 percent of the population will require care management at any given time. The care managers provide interventions at varying levels of intensity, some of which occur face-to-face while others are telephonic. As Community Care moved into managing more individuals with chronic and often co-morbid diseases, the networks identified additional staff skills that were necessary. As a result, networks started hiring network pharmacists in 2007 to provide the needed support for medication review, management and reconciliation (for more information, see Module 9 ( Establishing a Network Pharmacist Program ). In July 2010, Community Care hired a full-time psychiatrist to lead a mental health integration initiative, and every network is currently (October 2010) in the process of hiring a part-time or full-time psychiatrist to develop and implement behavioral health integration efforts. For Community Care practices with significant numbers of chronic care patients, networks began embedding care managers in the practices to improve the timeliness and integration of care support. Currently, over 50 care managers are embedding in primary care practices. We expect to see continued growth in the number of care managers embedded in practices and may begin embedding pharmacists and behavioral health professionals when
15 Page 15 of 17 warranted. As new areas of focus are identified, it is important to have the leadership and resources to support the implementation of new initiatives. Community Care networks want their licensed staff to practice at the top of their license, and many networks have hired non-licensed staff to support the care managers in their outreach and education efforts. Networks have also hired non-clinical personnel to provide administrative help (e.g., reminding patients about appointments and ensuring that follow-up visits to specialists are kept). Non-clinical support staff free nurses to spend time with patients and their families instead of performing administrative duties. Each network has developed an orientation and staff development process. Many of the network care managers have attended and received various care management certifications and recognitions from trainings, classes and seminars. In addition, the Community Care central program office provides regular care management training sessions and quarterly meetings for new care managers. Training curricula are developed by Community Care in partnership with the network leadership and lead care managers. In 2009, we focused on patients with co-morbidities, providing training on: motivational interviewing techniques; working with chronic pain patients and palliative care resources; setting boundaries with patients; HIPAA rules for care managers; and safety during home or community visits. These centralized meetings help standardize care manager skill sets and allow us to hire skilled trainers for a reasonable per-trainee cost. Monitoring care managers and care management Community Care monitors and evaluates the performance and activities of all care managers through CMIS. Each manager s patient activity is standardized, and networks and the central office have the ability to create parameterized queries at the patient, practice, network or care manager level. For example, Community Care can generate a report on all heavy-intensity patients at a practice or those who are served by a specific care manager. These reports enable both care managers and supervisors to examine activities and interventions on a macro level and compare progress and outcomes of interventions.
16 Page 16 of 17 The following is a list of the types of activity documented in CMIS. All of these activities can be used in queries and reports. Initial screenings and assessments. Patient care plan. Information gathered during in-person visits or telephonically. Results from chart audits, including gaps in care. Interventions and strategies used in the care management processes. Patient s progress in achieving individual goals. Case management activity (including number of patients receiving comprehensive assessments, PHQ9s/depression screening, patient self-management notebook, transitional support, pharmacy consult, medication review, home visit, education, face-toface encounters, etc.). Patients meeting priority criteria for assessment who were touched by the care manager and the intensity level of the care management activity. Percentage of patients being managed at heavy- or medium- intensity levels. Percentage of hospitalized patients who were touched by a care manager in a specified period of time. Communication gathered from other providers and resources. Needed follow-ups and reminders. Interventions are one of the fundamental components of care management. For successful intervention efforts, we suggest you support your networks and practices with care managers who can help identify and work with patients personally, increasing patient adherence and improving overall program effectiveness. Points to remember Supporting case managers, who in turn support practices, is a key to your program s success. Support can include education, tools and reports, training and coordination.
17 Page 17 of 17 Not every patient will benefit from care management. Work with your team to identify the people most likely to be impacted by the services you provide. To provide the most efficient system of care and avoid duplication of services, bring all players to the table, including primary health care providers, mental health care providers, government and local agencies, and others. Care management comprises five components: identifying and assessing patients; developing an individualized care plan; coordinating care; reassessing and monitoring; and evaluating outcomes. Hiring non-clinical staff to support clinical professionals will allow your care managers to devote their time and efforts to patients, not paperwork. Track care managers activities so you can assess progress individually, across practices, among networks and within the program as a whole.
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Oregon Standards for Certified Community Behavioral Health Clinics (CCBHCs) Senate Bill 832 directed the Oregon Health Authority (OHA) to develop standards for achieving integration of behavioral health
Our Patient-Centered Medical Home a Process, not a Click Richard Johnston, M.D. President, Medical Clinic of North Texas, P.A. Medical Clinic of North Texas, P.A. MCNT Physician Owned Primary Care Medical
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