Pamela Tropiano, RN, CCM, BSN, MPA. CareSource

Transcription

1 Annual Education Conference September 30 October 3, 2012 Orlando, FL 1.7 Creative Case Management Pamela Tropiano, RN, CCM, BSN, MPA Senior Vice President, Health hservices CareSource

2 Mission: The CareSource Heartbeat Making a difference in the lives of underserved people by improving their health care Visioni CareSource Management Group will be an innovative leader in the management of quality public sector health care programs 1

3 CareSource Non profit, mission driven Medicaid/Medicare SNP plans Began Ohio s first mandatory Medicaid managed care program in 1989 Ohio is second largest Medicaid HMO in US 925,969 total Ohio members 24,000 contracted Ohio providers 1,050 employees URAC accredited for health plan and health call center since 2005 NCQA accreditation ti in process on site review 8/2012 Headquarters Based in Dayton, Ohio with regional offices in Cleveland, and Columbus 2 Recent partnership/alliance with Humana

4 CareSource Model Member Features: Enhanced benefits, no copays Member incentives CareSource 24 nurse triage service Care Management continuum Community based marketing program Consumer councils Provider Features: Enhanced physician reimbursement, PCP incentive program Low hassle approach to medical management Best practice administrative efficiencies Technology investments 3

5 CareSource Strengths Non-profit model 23 years of Medicaid managed care experience Service orientation for members Focus on Quality Improvement through outcomes measurement Provider partnerships; hassle free medical management Operational model is characterized by efficient transaction processing Strong financial performance Regulatory relationships 4

6 Our Health Services Department Quality Improvement Pharmacy Fully integrated Behavioral Health program Care Management Care 4 U Medical Management Dental Disease Management Health and Wellness CareSource 24 Care Management Support Services Navigators 5

7 A Game Changer for our Care Management Program Why the change? Plans have advocated for a change - Be careful what you wish for Ohio Department of Jobs and Family Services (ODJFS) verified that a small percentage of members driving costs (Hot Spotters) Old Model (largely telephonic) Percentage of members participating (high risk) = 1.6% Staffing ratio 1: members New Model (community based) 1% of total membership (high risk) ~ 8,500 members Staffing ratio 1:25 members 1 face to face contact per quarter (~2,800/month) Care Transition activities increase Low/Medium risk care management age e requirements change 6

8 What Exactly Does this Team Do? Utilizes a team approach of nurses, social workers, navigators, and other health care professionals Integrates the Case Management Society of America and the American Association of Managed Care Nursing Standards of Practice and the Harold P. Freeman Patient Navigation model Coordinating member s health care needs through the care continuum Creating efficiencies Working with internal and external customers to meet member needs Focus on quality outcomes, regulatory and accreditation requirements 7

9 What Exactly Does this Team Do? Previously, heavy telephonic care management model with on site staff only at high h volume, high h risk facilities How do we take all of the components of our model, change the focus to the community, preserve the specialty programs, and keep our eye on quality, accreditation, and compliance? How do we retain existing staff and add new staff? 8

10 9 Creating the New Model: Intensive Teamwork Weekly intensive team planning and implementation sessions Cross functional collaboration (IT, Data, HR, Facilities, Finance, etc.) Staff survey Heavy reliance on member data Documents, documents, documents Work plans Timelines Approvals (programmatic and budget)

11 Result: Care Continuum Management at a Glance

12 A Culture Shift to Community Based High Risk Care Management A multidisciplinary team approach composed of: - RN Case Managers, Social Workers, Patient Navigators, Medical Management PCCs, Care Management Support Specialists, PCPs and Specialists, Community Providers, Members/Caregivers - Each team is led by an RN Care Manager who assumes the primary responsibility of coordinating all components of the case management NCQA compliant complex case management program Company wide education and re-training for care management staff - community focus 1

13 A Culture Shift to Community Based High Risk Care Management Create innovative partnerships and collaboration - Care Coordination Centers located regionally throughout the state with multiple teams within these centers Take these partnerships to new levels Reduce the care coordination duplicated efforts Share key information - health plans have a different view Learn from the positive outcomes experienced by our on site CM s - decrease in ED utilization, improved member satisfaction Improved staff satisfaction 12

14 Patient Navigators Dr. Harold Freeman initiated and developed the first Patient Navigation program in Harlem in 1990 to reduce disparities in access to diagnosis and treatment of cancer, particularly among poor and uninsured people Patient Navigation has since evolved to include the timely movement of an individual across the entire healthcare continuum including prevention, detection, diagnosis, treatment and end-of-life care 13

15 Patient Navigators Innovative model - providing work for the unemployed and staffing for the community based model Hiring from the community they will serve - You ll know one when you see one Community members trained as part of the care management team to assist members in coordinating community services As directed by the RN Case Manager, part of the care management team, Patient Navigators provide one-on-one guidance and assistance to individuals as they move through the healthcare continuum 14

16 What is the value of Patient Navigation? Increase access to care Identify changes needed to decrease barriers to care Enhance access to services and quality of care for all populations Improve the quality of care Improve coordination of high-quality, compassionate care Increase patient satisfaction Improve outcomes Increase retention, diagnostic and treatment resolution rates Reduce mortality in cancer and other chronic diseases Reduce costs Improve organizational efficiencies, preventing lost revenue and ultimately providing revenue to the facility Improve patient care, which may result in cost savings to the healthcare system Enhance community relationships Increase sharing of resources both within the organization and with community organizations Create greater community trust t in the organization 15 15

17 Community Based High Risk Care Management Identification John Hopkins University ACG software combines medical, behavior health, and pharmacy claims, creating clinically relevant categories as well as risk scores for our members Health Risk Assessments, Referrals or data from providers, practitioners, internal staff, members or members caregivers are evaluated using key indicators to identify members with potential high risk care management needs Identification of members considers not only cost, but impactability and engagability 16

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19 The Care Transitions Program Bridge To Home: Contact each member having a hospital or skilled nursing facility confinement within 14 days of discharge Adherence to scheduled d primary/specialty i care follow up care Medication reconciliation and education Identification of potential member gaps in comprehension or understanding of discharge instructions or changes in the member s medication regime post discharge Assessment and identification of member educational needs with a focus on member self-management and knowledge of the member s individual triggers and individualized care treatment plan 18

20 Level 1 Bridge to Home Members at low risk for complications, readmission or having uncomplicated needs Members identified will receive an automated telephone call and asked to respond to questionnaire focused on identifying unmet needs - transfer to care manager if needs identified Level 2 Members at higher risk of complications after discharge, have more complex discharge needs requiring care coordination, or have complex or multiple diagnoses making them more likely to experience a readmission or other unplanned transition. Members will receive an automated telephone call with a more detailed questionnaire. If needs identified, will be enrolled in our Low Care Management program. 19

21 Bridge to Home Level 3 For those members who have been identified d as needing a higher intensity of care coordination At higher risk due to their medical and/or behavioral health issues, social factors for recurrent avoidable or unplanned hospital and emergency department utilization Members receive more frequent contact t by the Bid Bridge to Home team, using the Coleman Care Transitions Intervention model Select members will receive in home care transitions coordination though our high risk community based care management program or through partnership with community providers 20 Area Agency on Aging (AAA) Health Care Access Now (HCAN) Community Health Access Project (CHAP)

22 Care4U CSP (Coordinated Services Program) - ODJFS approved lock in program Dedicated, specialized care management for members with substance abuse disorders Care manager offers ongoing supportive care to members and their support system including prescribing physicians and links the member to appropriate resources in the community Focus is to: increase the member s treatment participation and retention decrease # of prescribing physicians maximize use of appropriate services improve drug-related d outcomes Team approach is used along with integration of a comprehensive network of services 21

23 ODJFS Monitoring Semi-annual monitoring of overall high risk care management rate of population p (1%) - Review of MCP s high risk care management program structure - Program evaluation: improvement in the first year for the population receiving intense care management interventions: ED visit rate Hospitalization rate Overall medical costs Different methodology for outcomes measurement for NICU babies 2

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25 24 Clinical Tools Clinical Practice Registry and Member Profile

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27 Ohio Enhanced Care Management Timeline Model RRT approval/pds and policy review and revision Resource Guide Completed Begin transition of old model members Existing Staff Placement SOP Review / Revision CCA Design for Phase II Existing Staff Training Dr. Freeman Visit/ PNI Training SOPs Completed Hiring and Staffing for Community Care Centers Training Complete transition of old model members Model fully operational Cleveland #1 Member Provider Dayton Cleveland #2 Cincinnati and Columbus #2 Navigators Communication Cleveland #2 Community Community Orient/Start Nov Plan Initiated Navigators Care Centers Care Center 28 Orient/Start Jan 9 Initiated Initiated Enhanced Model Road Show (All Staff Kickoff 10/27) Dayton and Cleveland #1 Community Care Centers Initiated Columbus #1 Community Care Centers Initiated Member Provider Communication Plan developed RFA due 26

28 Contact: Pamela Tropiano, RN, CCM, BSN, MPA Senior Vice President, Health Services p com 27

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