Second Forum on Health Care Management & Policy November 28 30, Discussion Report. Care Management

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1 Second Forum on Health Care Management & Policy November 28 30, 2012 Discussion Report Care Management Thomas G. Rundall Henry J. Kaiser Emeritus Professor of Organized Health Systems School of Public Health, University of California, Berkeley, CA, USA Federico Lega Professor Bocconi University, Milan, Italy Walter C. Kopp President Medical Management Services San Anselmo, CA, USA 1

2 The following report summarizes the round table discussion about care management at the Second International Forum on Health Care Management & Policy in Hamburg, Germany November 28 29, What is care management? Care management is an evolving concept that refers to a set of evidence-based, integrated clinical care activities that are tailored to the individual patient and ensure each patient has his or her own coordinated plan of care. Care management is closely related to the concepts of care coordination and case management, but it typically involves a broader array of activites than is usually seen with efforts to coordinate care or implement case management. Care management not only seeks to manage care intelligently when patents show up for treatment, it seeks to identify patients who need care and bring them into the system before their illness becomes serious and their care becomes expensive. Care management programs also attempt to educate patients about how they can best manage their own health and engages them with data about their health. Effective care management requires that physician practices, hospitals and other care providers implement technologies and develop capabilities to enable them to manage patient care. These typically include: Work process redesign to implement new activities and workflows that increase patient engagement, improve staff productivity, and optimize efficiency Population management, including the ability to identify patients with common clinical conditions on which to focus secondary prevention and early treatment efforts Health information technologies including electronic health records (EHR), disease registries and reporting systems to facilitate data capture, patient tracking and outcomes review Clinical decision support within a comprehensive EHR to effectively make use of best practices and evidence to help guide care efficiently and effectively Coordination tools including an interoperable EHR connecting primary, specialist and hospital-based physicians and patient portals that enable patients to access informaton and communicate with physicians offices 2

3 In addition to these practice-based capabilities, effective care management is enabled by a number of activities specific to an individual patient. Patient engagement including relationship building, exploring patient s needs and values, education, collaborative goal setting and care planning to engage patients and their families in their own care and to support self-management Assessment of the patient initially, periodically and at points in time when the course of the patient s disease changes; assessment should include the patient s clinical condition, feasibility of completing various interventions, preferences and readiness to engage in self-management and treatment Planning an individualized care plan that balances best practices for managing the targeted condition(s) with feasibility and patient preferences in a way that optimizes outcome; the plan should be periodically reviewed and adjusted as necessary. Provision of services required to implement the care plan, including arranging referrals and follow-up Coordination of services provide by using the practice-based tools and capabilities described above to communicate and coordinate with the patient and other caregivers to ensure that the care plan is implemented safely and efficiently The potential benefits of care management are improvement in population health, improvement in patient s experience with their care (including the quality of care), and reductions in medical costs associated with avoidable use of hospitals and emergency rooms, use of ineffective care practices, and patient non-compliance with care plans. What are common barriers to effective care management? There are several interrelated barriers to effective care management, including: Physician and patient behavior patterns that perpetuate fragmented care Payment incentives that reward primary care providers (PCPs) for only treating patients who present with an illness and fail to reward PCPs for managing the population of patients they serve Fee-for-service payment systems that reward providers for duplicative, unnecessary and avoidable services Primary care practice models that make inefficient use of PCP s time and make little use of nurse practitioners, patient coaches, navigators and case managers and other physician extenders Lack of coordination between PCPs, specialists, the hospital and follow-up care providers after hospitalizaton For most care management initiatives, the principal challenge is finding effective ways to change physician and patient behavior. In most developed countries the institutionalized form of medical practice is characterized by a high degree of physician autonomy, weak communication among health care providers, and a reactive approach to patient care. Similarly, the institutionaized patient role is one of passive acceptance of medical 3

4 prescriptions and advice and heavy reliance on technologically-based treatment for medical conditions. The care management approach seeks to transform medical practice structures and work patterns and more fully engage patients in maintaining their health and ameliorating health problems. The existing patient care structures and behaviors are difficult to change. A related barrier in most health systems is the physician and hospital payment system, which typically rewards episodic, fragmented care through fee-forservice or other productivity-based payment methods. Many of the care management activites identified above are not reimburseable under most pubic and private health insurance plans. However, there is a growing effort in the United States and some European countries to implement bundled payment, capitation, value-based purchasing, specific payments for care management activities and other payment reforms that will support care management. Why is pressure increasing on clinicians and managers in health systems to improve care management? Health care systems in most developed countries are struggling to control health expenditures. The OECD countries spend on average 9.5% of GDP on health care. The Unites States spends more on health care than any other nation: $8,322 per person per year, or about 17% of GDP. But health expenditures in other countries are increasing as a percentage of GDP and are straining public budgets. The Netherlands, France, Germany, Canada, Switzerland, Denmark and Austria currently spend 11-12% of GDP on health care. Research over the past two decades has documented that a substantial portion of health expenditures is due to medical errors, avoidable hospital admissions and emergency room visits, duplicative or unnecessary medical tests and patient noncompliance with drug prescriptions and behavioral recommendations to reduce risk factors such as obesity. Increasingly public and private payers of health care services employers, public and private health insurance plans and individual patients are demanding delivery and payment reforms to reduce the cost of care, especially those expenditures that are avoidable through managing care and more fully engaging patients in maintaining their health. Another source of pressure on the clinicians and managers in health systems to improve care management is the growing awareness that the quality of care in most health systems is not as good as would be expected given the amount of money spent in the health care sector. The frequency with which clinicians commit medical errors in hospitals, fail to provide recommended care to patients in amubulatory settings and allow patients to fall through the cracks during care transitions are just some of the systemic quality problems that have been identified. Effective care coordination can help to integrate care and prevent poor outcomes that give rise to avoidable hospital admissions and readmissions. For example, in the United States 20% of hospitalized Medicare beneficiaries are readmitted within 30 days; more than 33% are readmitted within 90 days. Research suggests that a substantial proportion of readmissions can be prevented with evidence-based care in the hospital combine with comprehensive dischanrge planning, supportive transitions in care, and timely primary 4

5 care. With reduce readmissions, it is estimated that that the nation can save $12 billion annually in the Medicare program alone. What are promising examples of effective care management practices? Care management programs have been in existence in some health systems for a long time. But, as the pressure to manage care has increased. More heath systems are implementing either comprehensive care management programs or programs to management care for specific diseases that pose particular challenges. The Kaiser Permanente Care Management Institute has been in existence since 1997 and partners with physicians, other clinicians, organizational leaders and patients to design and implement new approaches to patient care management that are consistent with six guiding principles: 1. Keeping members at the center 2. Harnessing technology 3. Care coordination 4. Applying evidence-based care 5. Measuring results 6. Spreading successful practices The Commonwealth Fund recently published three case studies of care management programs to reduce hospital admissions and readmissions among chronically ill and vulnerable patients: the Cinncinnati Children s Hospital Medical Center s Asthma Improvement Collaborative; the UCSF Medical Center s Heart Failure Care Management Program; and the Visiting Nurse Service of New York s Choice Health Plans. Another example is John Muir Health in the Northern California region of the U.S., which implemented a comprehansive care manaement program duirng The overarching goals of the program are to (1) create an organizational structure that effectively facilitates an integrated care management process; (2) initiate a Patient Centric model of care; and (3) create care processes by disease condition that will be followed across the continuum of care. The operational objectives of John Muir Health s Care Management Program include: Reducing emergency department visits Redirecting patients to the optimal site of care Providing palliative care as necessary Establishing routine medication reconciliation Improving discharge planning at admission, including identifying patients with a high rsk of readmission Improving care management of high-risk individuals Establishing a transition-of-care process Reducing avoidable hospital readmissions Improving communication among PCPs, specialists and patients 5

6 What organizational structures are recommended to support care management? The organizational capabilities and tools identified above (work process redesign, population management, health information technologies, clinical decision support, and communication tools) are crucial to establishing an effective care management program. Each of them will require some type of supportive organizational structure with clinical and non-clinical staff dedicated to the development and maintenance of each respective capability. In most cases, health care organizations that implement a care management program will also implement changes in their organizational design and reporting relationships in order to provide adequate organizational oversight and support for the new program. Of course, the needs of each health care organization and the population it serves must be assessed to determine the package of organizational structures that will be needed to support care management. In the case of John Muir Health, durng the roll-out of its care management program several organizational changes were implemented that support the new program: All care management functions were reorganized to report to a new Senior Vice President of Care Coordination and Integration A comprehensive patient risk stratification process was adopted to identify the proper resources for individualized patient care Alternative care settings were created, including an ambulatory care center Care planning across the continuum was coordinated, in large part through the implementation of a new electronic medical record Other organizations may need to develop even more supportive structures to sustain their care management efforts over time. Conclusion Improving health system performance in developed countries requires pursuing what Dr. Don Berwick and others have referred to as the triple aim: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Patient care management provides health systems with an effective approach to achieveing these aims. 6