Advanced Models of Primary Care: Care Management Plus pilot and dissemination
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1 Advanced Models of Primary Care: Care Management Plus pilot and dissemination Presented by David A. Dorr, MD, MS; Oregon Health & Science University, Funded by The John A. Hartford Foundation, Intermountain Healthcare, the National Library of Medicine, and AHRQ August 10th, 2009
2 CARE MANAGEMENT PLUS: BIOGRAPHICAL INFORMATION Intermountain Healthcare Medical Group has a successful medical home program in Utah with redesigned HIT + embedded care managers; OHSU has dissemination phase, training over 75 clinical teams. Pilot with 4,700 patients, 72 doctors, 7 primary care clinics (+ 6 control clinics) Patient population: 5% of most at-risk older adults and patients with complex chronic illnesses. Duration : 6 years ( + 2 for dissemination) Timeline Completed Phase 1: Intermountain led redesign HIT & Care Manager role in 7 clinics 2: Controlled trial Strong outcomes: cost, quality, utilization 3: Review / Revise Training + IT for widespread use 4: OHSU led dissemination, implement in 75 teams Landmarks Care Management Plus : a proven medical home model for high need, high cost beneficiaries 1
3 Care Management Plus: MODEL DESIGN Our Model Dissemination Community Health Plan(s) Government Payment Usual productivity % of pay P4P Care Coordination Connection to resources / IT support Referral - For any condition or need - Focus on certain conditions 4 have adopted Pay for service, coordinator, monthly fee Care management Care manager - Assess & plan - Catalyst - Structure Technology - Access - Best Practices - Communication Working with FQHCs Medicaid Evaluation - Ongoing with feedback - Based on key process and outcome measures active patients per care manager Health IT EHR + Care coordination tracking / population management / tickler Flexible Scheduling Care managers had easier access, direct telephone + own schedule 24/7 Access Yes, through a combination of sources Performance Evaluations Monthly and ondemand reviews 2
4 Care Management Plus: RESULTS Health outcomes Cost savings / Productivity Reduced hospital admissions: Absolute reduction in patients with complex illness 4.5% at one year; 8.7% at two years; reduction in all patients 2.9% at two years. Increased Guideline Compliance: 24-42% increased compliance for diabetes, depression. Reduced mortality: Absolute reduction of 2.8% at 1 year and 3.4% at two years Total Savings: For patients with complex illness, estimated savings in Medicare $163k per practice with cost of $90k. Savings per patient: Decrease of $640-$1650*per patient per year Increased productivity: 8-12% increase in work Relative Value Units per physician Satisfaction Patient / Families: a life-saver, the reinforcement was wonderful, they really care, [CM] gives me more time... and answers Physician/ Nurses: I am working smarter, not harder, Patients are less anxious, care more consistent, team is stronger, Wish I had these skills years ago, [Computer tools are] an absolute godsend Deaths: 6.5% died in CM+ and 9.2% in control at 1 year; 13.1% died in CM+ and 16.6% in control at 2 years. Hospitalizations: Complex illness including diabetes: 1 year CM+ 21.2%, Control 25.7%; 2 years 30.5%; control 39.2%; all: 31.8% vs 34.7% at 2 years (-2.9%); * Higher is for patients with 1+ hospitalization per year. Peer-reviewed references available online at 3
5 Dissemination : to more than 75 clinical teams OHSU (7 teams) PeaceHealth (11) Intermountain (16) Klamath Open Door Colorado Access (16) HealthCare Partners Daughters of Charity (5) Care Management Plus : a proven medical home model for high need, high cost beneficiaries 4
6 Care Management +: DISSEMINATION AND ADVICE FOR FUTURE MODELS Care Manager Nurses or social workers best, although multiple options for small clinics Training individual and team essential: core competencies e.g., care of older adults, prioritization, behavioral / motivational interviewing, and assessments. Health IT Proactive, meaningful use for care coordination: populations, reminders about care plans, summaries, performance measurement Technical assistance is critical : need to enhance use of HIT to be successful in the clinic. Use to measure implementation of components: in our 75 teams, we found 73% of components adopted. Reimbursement Reimbursement is critical to effective, sustainable models; for example, Pay for proactive care: care coordination calls, goals, motivational interviewing, education Per member per month with sustained usual care At-risk patient populations should be targeted, but not exclusively Care Management Plus : a proven medical home model for high need, high cost beneficiaries 5
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