Implementing Care Management for Complex Patients in Primary Care Best Practices from Successful Programs
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1 Implementing Care Management for Complex Patients in Primary Care Best Practices from Successful Programs Clemens Hong MD, MPH Maine Community Care Teams Summit November 14, 2013
2 Health Care Costs Concentrated in Sick Few Distribution of health expenditures for the U.S. population, by magnitude of expenditure, % 5% 10% 22% Annual mean expenditure $90,061 50% 50% 65% $40,682 $26,767 97% $7,978 Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey.
3 3 Using complex care management teams to improve patient care and reduce costs One proposed solution to address healthcare cost problem Specially trained multidisciplinary, complex care management teams Goals Maintain/improve functional status & self-efficacy chronic disease & health system navigation Reduce costs by eliminating unnecessary testing and reducing need for acute care services
4 4 Limited knowledge - effectiveness of CCM o Evidence of effectiveness of primary care-integrated, CCM remains limited Most demonstrate improvement in quality or reduction in acute care utilization BUT effect on net cost reduction is less consistent o Nonetheless, growing consensus that this approach can be highly effective o Universally adopted by Accountable Care Organizations There is a dearth of information to guide implementation of these programs
5 Challenges for CCM Programs: Drops in Potential Potential opportunity Identification Engagement Finding opportunities for improvement Intervention Adapted from J Eisenberg JAMA Realized improvement Poor performance at any point along this pathway reduces program effectiveness
6 Aim & Research Questions Aim o To identify key operational attributes of successful primary care-integrated, complex care management (CCM) programs Overarching research questions o What are the core operational attributes and best practices of successful primary care-integrated, CCM programs? o How must successful primary care-integrated, CCM programs customize for specific populations or contexts?
7 Study Design & Methods Semi-structured, key informant interviews and review of program materials Site selection: literature review, expert steering committee, & snowball sampling o Inclusion criteria: Primary care-integrated CCM program Existing data on performance/success Ongoing operation Analysis: 2 independent reviewers identified themes
8 Domains of Study Program Context & Control Team Structure Patient Selection Scope of Work & Key Tasks Patient Engagement Integration with Primary Care & Other Providers Integration of Information Technology Care Management Team Training 8
9 PC-CCMP Location Payer Aetna 49 sites nationally Aetna Medicare Atlanticare Special Care Center Atlantic City, NJ Atlanticare-self-insured Camden Coalition Camden, NJ Medicaid Care Management Plus Oregon Medicare CareOregon Oregon Medicaid Community Care of North Carolina North Carolina Medicaid The Everett Clinic Everett, WA Medicare, Commercial Fletcher Allen VT Blueprint CHTs Burlington Vermont All payer Geisinger ProvenHealth Navigator NE/Central Pennsylvania Multipayer Genesys HealthWorks Flint, Michigan Commerical & uninsured GRACE Indiana Medicare, Dual eligible Guided Care Baltimore Medicare Health Quality Partners Eastern Pennsylvania Medicare, Commercial King County Care Partners Seattle, WA Medicaid MGH CMS Demonstration Boston, MA Medicare NY Health & Hospitals New York City Medicaid SoonerCare Choice HMP Oklahoma Medicaid Sutter Care Coordination Program Northern California Multi-payer 9
10 Program/Population Utilization/Cost Admit / Readmit Quality ED Use Cost Quality Provider Experience GENERAL TREND QOL/ Patient Experience Aetna's Medicare Advantage Provider Collaboration Program --- AtlantiCare Special Care Center Camden Coalition Care Management Plus CareOregon Health Resilience Program (for Health Share of Oregon) Community Care of North Carolina - Community Care of the Sandhills The Everett Clinic Fletcher Allen - Vermont Blueprint Community Health Teams --- Geisinger ProvenHealth Navigator Genesys HealthWorks Health Navigator Geriatric Resources for Assessment and Care of Elders (GRACE) Guided Care --- Health Quality Partners King County Care Partners Massachusetts General Hospital Care Management Program New York City Health & Hospitals Chronic Illness Demonstration Project = Oklahoma SoonerCare Choice Health Management Program 10
11 Program' Mortality' Admit/' Readmit' ED' Utilization' Outcomes! Cost'of' Care' Provider' Experience' Patient' Experience' Quality'of' Care' QOL/' Functional' Status' General'Trend'!'!!!' "' "' "' "'!!! Aetna s Medicare PCP ""!!!!!!! "! ""! "! ""! Atlanticare SCC ""!!!!!!! "! "! "! ""! Camden Coalition ""!!!!!!! ""! ""! ""! "! Care Management Plus!!!! "!!! "! "! "! ""! Care Oregon ""!!!!!!! ""! "! "! "! Community Care of NC ""!!!!!!! ""! ""! "! ""! The Everett Clinic ""!!!!!!! "! "! "! "! Fletcher Allen VT Blueprint CHTs ""!!!!!!! ""! "! "! "! Geisinger ProvenHealth Navigator =!!!!!!! "! "! "! "! Genesys HealthWorks ""!!!!! ""! ""! "! "! ""! GRACE!!!!!!! "! ""! "! "! Guided Care =!!! "!!! "! "! "! ""! Health Quality Partners!!!!!!!! ""! ""! "! ""! King County Care Partners!!!!!!!! ""! "! "! ""! MGH CMS Demonstration!! ""!! "! "! " ""! NY Health & Hospitals ""! ""! "" ""! "! " ""! SoonerCare Choice HMP ""!!!! "! "! " ""! Sutter Care Coordination Program ""!!!!! ""! ""! " ""!!
12 Funding & Operational Control Funding o Grants o Health Systems o Payers Operational Control o 8 Delivery System o 7 Payer o 2 Joint Payer/Delivery system o 4 Regional CM Organization
13 CCM Team Structure Most lead Care Managers (CMs) are nurses (RNs) Tight vs loose team structure o Integrated multidisciplinary team à Independent CM Multidisciplinary teams address different needs: o Administrative support staff o Pharmacists o Resource specialists/social workers o Behavioral health specialists o Health coaches o Community health workers (CHWs)
14 CCM Team Structure Healthcare & Community Services Non Acute Hospice VNAs Community Agencies Pallia=ve Care and Hospice Community Resource Specialist Care Agencies Complex Care Team Substance Abuse Specialist PCP Care Manager Specialist Pharmacist Mental Health Team Financial Service Specialist Elder Service Network Transport Providers Civic Organiza=ons 14
15 1. Quantitative Patient Selection o Applying risk prediction software to claims datat o Acute care utilization focused o High risk condition focused 2. Qualitative o Referral Physician/Staff or Patient 3. Hybrid approaches
16 Effective Targeting of Care Management Population Volume ß Healthy Area of Greatest Opportunity? ß Chronic Illnesses ß Medically Complex/ High Utilizers
17 Scope of Work & Key Tasks Central task o to build relationships with patients, primary care teams & hospital/community partners Touches Twice weekly to monthly Telephonic, office, in-home Patient case load: patients per CM o Depends on training, resources, & intensity of intervention o Use of teams, risk stratification & IT enable larger case loads
18 Scope of Work & Key Tasks Comprehensive assessment & creation of care plans Care coordination With Hospitals/EDs, SNFs, Specialists, VNA, behavioral health & community-based resources Focus on Transitions of Care Health coaching/self-management support Address behavioral health needs Address social service needs Address barriers to access/care Advanced care planning Patient advocacy/activation Outpatient Specialist Care Emergency Department & Acute Inpatient Care CARE MANAGEMENT & PRIMARY CARE SNF & Rehab Care
19 19 Patient engagement Connection to primary care Face-to-face interaction Longitudinal relationships Traits of CM team members Detective skills & creative problem solving Ability to build trust Cultural concordance CHWs Motivational interviewing Sell it to patients & ensure early success Mobile workforce & technology Making the right pitch to patients is important Tailored approach at Camden Coalition 1. Reach out to patients during hospitalization or ED 2. Provide a personalized introduction, use open-ended questions 3. Once armed with specific needs of patient, can tailor presentation of services
20 Primary care integration Poor interactions with primary care were major barriers to effective CCM Recommended approaches Tight vs loose integration Embedded, high touch à off-site, low touch Enhancing integration Co-location Face-to-face interaction: accompaniment, meetings Data/EMR Access Early successes/trust building Education on CM role/benefits 20
21 Engaging Other Critical Resources Ties to inpatient facilities/eds o Communication with inpatient CMs o Communication with skilled nursing facilities o CM Team members embedded at hospital sites ED/Hospital CM Ties to community-based agencies o Home health agencies o Elder Resource Centers o Community Centers o Social Service Agencies Hospice Non-Acute PALLIATIVE# CARE#and# HOSPICE# OUTPATIENT# PHARMACY# FINANCIAL## SERVICES# Elder Service Network VNAs Community Care Agencies COMMUNITY# RESOURCE# SPECIALIST# PCP# Pa%ent# CM# MENTAL## HEALTH# Transport Providers Civic Organizations SUBSTANCE## ABUSE#
22 22 Health information technology (HIT) Little advanced care management HIT infrastructure Some risk prediction, but with limited data availability Limited population management functionality Some task assignment/ tickling ability CM tasks rarely tracked little QI functionality Limited referral tracking HIT needs for CM activities Data integration with access to real-time data from multiple data sources Real-time notification of high-risk events Advanced population management IT platforms that have: Population management functionality registry function, decision support, task assignment/ tickling ability Supports secure communication and documentation Quality/Performance monitoring
23 Training Most pair classroom didactics with on-the-job training (shadowing/mentorship) Motivational Interviewing cited as most important skill included in training often ongoing Other training elements include: Program goals Geriatric or disease specific issues Care manager role Cultural competence Care management protocols Palliative care Approaches to primary care engagement Leadership/change management/ teamwork Chronic disease self-management Use of HIT systems
24 Important concepts for ensuring efficient care management intervention Build strong relationships with patients, primary care teams, and other community care partners Continuously assess motivation & readiness for change A good CM doesn t do everything o Allocate the CM resource to high-yield activities, complement existing services, & focus on mutable issues o Use HIT infrastructure to enhance CM efficiency o Work in multi-disciplinary teams
25 Conclusion Primary Care-Integrated CCM Programs are a critical piece of national healthcare delivery transformation to improve health & reduce costs We need to address financial, operational and technical barriers to ensure widespread adoption of these programs AND ensure that we learn from past efforts at care coordination while appropriately tailoring interventions for different context & population needs
26 Acknowledgements Principal Investigator: Timothy Ferris RAs: Allie Siegel, Powell Perng, Paola Miralles Funding: Program Officer: Melinda Abrams Steering Committee: o Tom Bodenheimer o Randy Brown o Nancy McCall o Melanie Bella o Rushika Fernandopulle o Steven Kravet o Joanne Sciandra o Annette Watson * No conflicts of interest to report *
27 Questions? Contact:
28 What s Needed? Financial o Incentives to reduce unnecessary utilization and accelerate interoperable HIT development o Up-front investment in CCM infrastructure & programs Organizational/Technical o Stronger primary care o Accelerated adoption of interoperable HIT o Multi-payer alignment to promote provider integration o Technical Assistance to address implementation challenges o Regional CM structures to help smaller/rural practices o Workforce development (professional & paraprofessional e.g. CHW)
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