Care Management: Reducing Risks. Project ECHO Consultation. Amy J. Khan, MD, MPH. Mia McCallum-Crawford, RN

Transcription

1 Care Management: Improving Health & Reducing Risks Project ECHO Consultation February 19, 2015 Amy J. Khan, MD, MPH Lisa Moreno, RN Mia McCallum-Crawford, RN

2 Objectives 1. Consider patient factors and social determinants that effect treatment adherence and care quality 2. Identify opportunities to improve clinical effectiveness and health outcomes 3. Describe care management services and role in supporting primary care 4. Review Nevada s Health Care Guidance Program goals, services and impacts 2

3 Treatment Challenges Patient Realities Over 1/4 of all Americans have multiple (2+) chronic conditions; nearly 3/4 of elderly persons have multiple chronic conditions Multi-morbidities Makes managing diseases more complex Inconsistencies Conflicting diagnoses, medical advice and drug information Function - Impacts activity, productivity and risk for new illness Social Factors Socioeconomic and environmental issues also complicating Anderson. Chronic Care: Making the Case for Ongoing Care;

4 Social Determinants Redux Risks for poor health impact health care and outcomes Poverty Low levels of literacy Limited English proficiency Minimal social support Poor living i conditions Limited community resources These have direct and significant ifi impacts on avoidable hospital readmissions, treatment compliance and drx adherence. Health Affairs

5 Managing Multi-morbidity Considerations Patient Preferences Incorporate patient preferences into medical decision making Guideline Limitations Consider medical evidence Shared Decisions Informed in the context of risks, burdens, prognosis, treatment complexity & feasibility Balanced Actions Optimize benefits and quality of life while diminishing harm Patient welfare Consider social, educational and economic factors, genetics and environment Disease severity and consequences assess co- occurring conditions; similarities, differences, priorities Parsimonious care Determine options, consider compliance; most efficient and effective J Am Geriatr Soc 2012 and ACP Ethics Manual, 6 th Ed 5

6 Flight training, planning and risk management Insight on potential of care management to improve outcomes Flight training involves teaching the student pilot the physical aspects of flying an aircraft. Flight planning involves producing a flight plan and includes 2 safety aspects - fuel calculation and air traffic control compliance; also minimizing flight cost by choice of route, height and speed, and by loading minimum necessary fuel. Risk management focuses on being more aware of potential risks in flying, how to identify those risks, and how to manage them successfully. FAA Handbook,

7 Care Management Activities - Overview Care Coordination assures patient s care plan harmonization across health care team to optimize quality, outcomes and efficiency; intermittent or ongoing Case Management provides personalized support to persons with ongoing needs related to clinical or social services; ADLs; food, housing and social support; ongoing relationship with helper Utilization Management pertains to the health care system s approach for managing use of services and resources by patients; provided by provider, payer and/or administrative services entity The Technical Assistance Collaborative, Inc., Boston, MA 7

8 Care Coordination Multi-Disciplinary Care Teams Support Patients & YOU! Care managers can consist of: Registered nurses Social workers Pharmacists Behavioral health specialists Dietitians/nutritionists Non-clinical staff Modalities: phone, mail, text, t , portal, website, face-to-face, monitoring devices, etc. 8

9 Post-Discharge Interventions Coordination, Support, Readmission Reduction Begins while patient is in or released from hospital, ED or other acute/chronic setting Supports care continuity and transitions Performs medication/supply reconciliation Coordinates appointments; verifies understanding and supports care needs Confirms self-management skills Educates on red flags for readmission and accessing nurse advice resources 9

10 Case Management Key Elements 1. Promotes wellness, healthy behaviors and function 2. Encourages health literacy and compliance to care plan 3. Involves patient as an informed participant in health 4. Endorses collaboration among patient, family and provider 5. Supports patient in timely and appropriate use of resources Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual s and family s comprehensive health needs through communication and available resources to promote quality cost effective outcomes. -- Case Management Society of America 10

11 Patient Engagement Comprehensive Assessments Gaps in care Immediate needs/barriers Current services Health conditions and meds Embedded screening tools Transportation access Housing/home environment Informal and caregiver support Social support, including cultural and ethnic orientation Food, security and lifestyle 11 Mental health and depression Wellness and physical activity Quality of life Advance directives/poa Cognitive abilities Personal goals Substance use Sensory impairments Interpersonal relations Functional status

12 How are care management services provided? Case Management and Care Coordination 12

13 Integrating Care Management Services Critical Communication and link with Provider Communication via: Phone Fax Electronic medical record Health info exchange Secure portal Support the provider s treatment t t plan Act as extension of the provider Collaborate and confirm: - Post-assessment summaries - Shared Care plans - Clinical alerts - Pi Priority it patients t and care gaps - Care coordination needs - Patient t health profiles or face sheets 13

14 Nevada's Care Management Organization (CMO): Health Care Guidance Program CMO Funding through CMS 1115 waiver Five-year demonstration project McKesson awarded contract Value Options- Behavioral Health sub-contractor Launched June 1, 2014 Program Goals Improve quality of care Improve health outcomes Improve patient/member satisfaction Improve value/reduce avoidable costs 14

15 Who is Eligible to Participate The Health Care Guidance Program Serves Total NV Medicaid Enrollment 575,329 (100%)* Medicaid Fee for Service Enrollment 174,738 (30%) HCGP Enrollees with qualifying conditions capped at 41,500 (7%) *As of Dec 2014 Participation is mandatory 15

16 Qualifying Conditions Among Enrollees Cerebrovascular disease, epilepsy Diabetes mellitus ESRD, chronic kidney disease Excluded Populations: CAD Dual-Eligible's Asthma, COPD, chronic bronchitis i Adoption assistance, foster care HIV/AIDS Home and Community Based Mental health disorders service Waivers (Section 1915c) Musculoskeletal system diseases Targeted Case Management (TCM) Neoplasm/tumor recipients Obesity MCO enrollees Pregnancy Nevada Check-Up enrollees (CHIP) Substance use disorder Emergency Medicaid Complex high cost conditions Long-Term Care/SNF residents 16

17 Committed to Nevada Carson City-based office Local leadership team: Executive Director Medical Director Operations Manager BH Medical Director BH Program Director NV-based care management staff Clinical and case management experience Strategically t placed staff to reach rural beneficiaries i i Statewide distribution to engage beneficiaries Familiar with medical and community resources RNs, LCSWs, Community Health Workers, and Peer Specialists 17

18 Core Program Components The Care Management Organization Will Provide Enrollee Services Provider Services Administrative Services Mailed materials, surveys, info, enrollee handbook Health Education/ Coaching 24x7 Nurse Advice Line Support Enroll into one of 8 Care Management Programs Online Health Resources Member/ ProviderLinkage Population Profiling Clinical Care Alerts Provider Outreach Provider Portal Provider Profiling Practice Improvement Clinical Guideline Info Enrollment and Disenrollment Medical Records Quality Assurance Grievances Technical Infrastructure Reporting Assist in confirming transportation, making appointments, etc 18

19 Confirming Beneficiaries Enrolled in the HCGP Noted in Eligibility Verification System as CMO CAREMGMT 19

20 Communication, Updates and Referrals Access to HCGP staff and resources Toll free number: Option #1 for members Option #2 for providers Secure fax number: Real Time Referral Form (download at NV Medicaid/DHCFP website under Care Management Organization tab) Include clinical information or updates as appropriate p 20

21 Case Study #1 Gender [F] Age [42] Speaks [English] Risk Score [H] Conditions:[Chronic Pain; Diabetes; Depression; Obesity; Substance Abuse] Care Plan Problems Member enrolled in October 2014 Pattern of frequent ED use and multiple admits for abdominal pain Chronic abdominal pain following bariatric surgery Situational depression Outstanding DME and transportation needs Interventions CHW has conducted face to face visits RN contacted provider which led to surgical intervention ention for abscess Walker and home health secured post operatively Connected with Logisticare Secured new pain management provider Outcomes DM RN & CHW working with member to prevent recurrent ED use and rehospitalization Homehealth secured following discharge Member to be joined by RN at next appointment Have engaged son for additional member support Impact: Reducing risk for ED utilization and facilitated definitive care 21 FOR INTERNAL USE ONLY/PROPRIETARY AND CONFIDENTIAL

22 Case Study #2 Gender [M] Age [25] Speaks [English] Risk Score [H] Conditions: [Diabetes, Gastroparesis, Depression, Recurrent hospital admissions] Care Plan Issues Interventions Outcomes Enrolled in July 2015 Face to face meeting Insulin changed and trial of Multiple hospital admits with CM while in hospital gastric stimulator requested Actively engaged with DM CM accompanied Strengthened patient and and BH case managers patient to endocrine provider relationship follow up Ongoing gastroparesis Avoided re hospitalization with poorly controlled Meeting with providers Accompany member to blood sugars and patient appointments Impact: Supported adherence to care plan and reduced readmission risk 12/19/2014: / Initially, no readmission for 16 weeks. Medical issues necessitated admission in Oct and Dec Gastric stimulator trial failed. DM CM coordinated with member and treating providers, and visited during hospitalization; SW CM supporting emotional health. 22 FOR INTERNAL USE ONLY/PROPRIETARY AND CONFIDENTIAL

23 Program Impacts: State of Illinois Medicaid Cost Savings and Improved Outcomes Illinois: Annual Program Savings s ($Million) Saving $300 $250 $200 $150 $100 $50 $0 $565M increase Program Year 3.5% decrease in inpatient days in net savings for the state of Illinois by delivering care management services to more than 260,000 eligible Illinois Medicaid beneficiaries 15% in influenza vaccinations 6.1% increase in appropriate usage of prescribed medications Outcomes and program savings results have been verified by the State of Illinois and were achieved over 4 program years. Percentage based results represent 4 year averages across all program eligible Illinois Medicaid beneficiaries. 23

24 Program Impacts: Blue Cross Blue Shield Plan Successful Referrals and Member Engagement 70% 60% 50% 40% 30% 20% 10% 0% Chronic Condition Management Program Participation Referred by nurse advice line 41% Standard outreach of asthmatic members referred by the nurse advice line stayed enrolled in the chronic condition management program at least 12 months, compared to only 20% with standard outreach Nurse Advice Line member transfers to integrated Chronic Condition Management programs 35% greater likelihood that members referred to a chronic condition management program by the nurse advice line vs. only mailings and outbound calls would stay enrolled 61% of diabetic members referred by the nurse advice line stayed enrolled in the chronic condition management program at least 12 months, compared to only 29% with standard outreach Source: BCBS plan analysis of members,

25 Provider Engagement is Critical Primary Care Teams drive Better Outcomes and Value Assure awareness and role in care planning Improve delivery of clinical quality targets Engage clinical leaders in optimizing care Reduce inappropriate utilization Coordinate with behavioral and other partners Identify efforts to improve care effectiveness Educate provider and spread adoption of effective best practices 25

26 Thank You! Questions? Contact Information: Amy J Khan, MD, MPH McKesson Care Management [email protected]