Combining Case and Care Management for Population Health

Combining Case and Care Management for Population Health Raena C. Akin-Deko, MHSA Assistant Vice President for Product Development, NCQA Karen Handmaker, MPP VP Population Health Strategies, Phytel August 28, 2013

About NCQA Our mission To improve the quality of health care Our method Measurement We can t improve what we don t measure Transparency We show how we measure so measurement will be accepted Accountability Once we measure, we can expect and track progress 2

Objectives Understanding Case and Care Management What s the difference? Why are both critical to population health management? How PCMH standards encourage both Lessons from NCQA s Recognized PCMHs Care management is harder to implement Funding is necessary for sustainability Health IT is a fundamental tool for care teams Strengthening Population Health Through the PCMH Model NCQA: Case Management 3

PCMH Transforms Practice Model for Population Health Current View 30 Patients Per Day 14 have Chronic Conditions Unknown Health Risks Visits Too Short for Coaching New Population View 2500 Patient Population 900 have Chronic Conditions 1100-1250 have Mod-High Health Risk Care Teams Leveraged by HIT Volume-Based/Episodic Value-Based/Continuous

The Definition of Care Management 5

Looks a lot like the definition for Case Management NCQA: Case Management 6

Care Management vs. Case Management Care Management Case Management

What s Your Role? (Show of Hands!) CARE Manager Low-Moderate risk patients Risks & conditions have defined guidelines Increase monitoring & improve self-care to stabilize symptoms, prevent migration Caseload: 500-1000 Focus: Close care gaps Identify health risks early Preventive treatment Increase self-care capabilities Promote healthy lifestyle CASE Manager High-risk patients Complex, high cost treatment needs Significant barriers to self/care, services Post-acute risk spikes Caseload: 50-150 Focus: Transition management Care coordination Stabilization at point of optimal recovery Cost containment Coordination of benefits 8

Costs of Uncoordinated Care Health care costs are expected to reached $4.4T in 2018 A 2010 IOM roundtable on Value and Science- Driven Healthcare 1 noted the following as drivers of health care costs: Unnecessary services Inefficiently delivered care Missed prevention opportunities Case management aims to coordinate care to mitigate these concerns 1. IOM. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Roundtable on Value and Science-Driven Healthcare. 2010. http://www.nap.edu/openbook.php?record_id=12750&page=r1

Costs of Uncoordinated Care ""Health Policy Brief: Reducing Waste in Health Care," Health Affairs, December 13, 2012. http://www.healthaffairs.org/healthpolicybriefs/

The Importance of CASE Management Case management helps patients navigate the health care system Allows for the coordination of care across the healthcare system Increases adherence to care plans and improves quality outcomes Reduces fragmentation of health care, which can occur when patients receive services from multiple settings Can reduce patient and system costs

Care Management: Look Below the Waterline Do you only focus the top 3%?

Evolution in Approach: Patient-Centered, Provider-Delivered Care Managemet Patient-Centered Medical Homes Care teams led by a clinician coordinate all aspects of a patient s care, including care planning and connections to community resources Accountable Care Organizations Provider-based organizations that are accountable for both quality and costs of care for a defined population Arrange for the total continuum of care Embedded Case Managers Geisinger ProvenHealth Navigator Community Care of North Carolina 13

NCQA PCMH Standards 14

NCQA PCMH Standards (continued) 15

NCQA PCMH Standards (continued) 16

Research supporting comprehensive care and case management approaches In hospital settings: Comprehensive discharge planning plus post-discharge support for older patients with CHF significantly reduced readmission rates 1 Operationalization of case management in daily clinical routines for inpatients reduced hospital length of stay from 7.34 days to 5.79 days 2 In the medical home: A PCMH in integrated group practice showed significant improvements in patients and providers experiences in the quality of clinical care 3 Clinical systems are associated with decreased use of inpatient and emergency care but not ambulatory care utilization in diabetes 4 Higher quality of care, reduced cost of care on some measures 5 In community-based settings: A review of available RCTs and comparative observational studies showed that community-based case management for frail elderly individuals can improve client psychological health or well-being and unmet service needs 6 17

Key Findings from Recognized Medical Homes PCMH 2011 Analysis Demographics N=1039 practices with NCQA PCMH-Recognition 71% achieved Level 3 Practice Size 2-4 clinicians (42%) 5-9 clinicians (26%) 10+ clinicians (11%) Majority (78%) serve both children and adults Practice Ownership Hospital/health plan (40%) Physician-Owned (38%) FQHC (22%) Military clinics and FQHC/CHC more likely to be Level 3 and have higher average total scores

Challenges Most challenging elements that practices must pass to become recognized: 1. Using data to support population health: Generating lists, proactively reminding patients about needed services (2D) 2. Care management: Carrying out functions such as pre-visit preparation, providing written care plans (3C) 3. Referral tracking and follow up: Giving the receiving site reason for the referral, providing electronic summaries of care, tracking referral status (5B)

Challenges (continued) Elements where less than half of practices achieved full credit: 1. Electronic access: Providing patients with electronic access to their health information; e.g., test results, medication lists (PCMH 1C) 2. Referrals: Providing referrals to community resources (PCMH 4B) 3. Agreements: Establishing and documenting agreements with specialists if co-management needed (PCMH 5B)

Areas of High Performance More than 80% of practices achieved full credit on the following: 1. Continuity: Ensuring the patients have a consistent care team (PCMH 1D) 2. Care Management: Implementing evidence-based guidelines through point of care reminders (PCMH 3A) 3. Care Management: Managing medications including (PCMH 3D): Reconciliation during care transitions Assessing patient response to medications and barriers to adherence Documenting over the counter medication and supplements

Key Findings from Survey of Recognized Medical Home Practices Surveyed practices that achieved different levels of recognition under NCQA s PCMH standards 7 N= 249 recognized practices from 23 states

Lessons from Level 3 Medical Homes: Motivation to Change Theleaders of our efforts to improve care quality are enthusiastic about their task. Our practice operations rely heavily on organized systems. Our resources (personnel, time, financial) are too tightly limited to improve care quality now.

Lessons from Level 3 Medical Homes: Health Information Technology We had already had an electronic medical record system for a couple years, and we were sort of doing internal improvements and tracking, but when we decided to do this it became really apparent that there were other functionalities of this program that we could really utilize care management functionality that was innate in the electronic medical records program that we had, but we just hadn t really branched out to do yet. - NCQA Recognized Patient-Centered Medical Home

Lessons from Level 3 Medical Homes: Team-Based Care Utilizing staff to the maximum potential of their license (e.g. standing orders) Gives physician more time to address patient concerns Empowers staff Improves relationships between physician and staff Information and skills training to clinicians and staff

Lessons from Level 3 Medical Homes: Resources Participation in a demonstration/pilot project Payment for being a PCMH Incentives allowed practices to hire dedicated population health staff: Medical home assistant Care coordinator Phone nurse

Lessons from Level 3 Medical Homes: Formal Approach to Quality Improvement Level 3 practices tended to use the following strategies: Piloting changes before implementing them practice-wide Performance feedback to physicians

Future Holds Promise: Medical Homes Showing Positive Results Outcomes Improving quality of care Systematic reviews (AHRQ 2012) Moderately strong evidence of improvement PCPCC2012 Most state-based PCMH initiatives show improvement in quality Improvingpatient experience Moderately strong evidence of improvement Improved patient experience Reducingcost and utilization Inconclusive, absenceof data Most state-based PCMH initiatives show reduction of cost, ED visits and hospital use

Future Holds Promise: NCQA s 2014 standards will continue to drive capabilities further The Practice Team (PCMH 1G) Defining staff leading change effort Regular team meetings to discuss individual patients Using a regular method to evaluate teamness within practices Care Management (PCMH 3) Decoupling 3 important conditions from review of files for care management activities (3C) Practices will define criteria and identify patients most appropriate for these service Referral Tracking and Follow-Up (PCMH 5B) Establishing formal agreements with specialists (including behavioral health) Triaging referrals Sharing care plans

Future Holds Promise: Emphasis on Care/Case Management Increasing Affordable Care Act (ACA) initiatives aimed at care coordination include provisions for: Requiring CMS to reduce payment to hospitals with high readmissions Requiring health plan reporting on structures such as case management that improve health outcomes (Section 2717) Supporting the development of ACOs and PCMHs to emphasize the need for care coordination Payment models moving towards value assume or reward care/case management: ACO and MSSP quality measures and shared savings model imply population health infrastructure Commercial payment models that subsidize care/case management ($ and/or staff)

Implications for Combining Care Management and Case Management Approaches for Population Health Think about work flows related to care/case management Define roles needed to carry out functions Use each team member to the top of their license Have the right tools in place to support care management functions (e.g. EHRs/registries) Make sure those tools can help you to: Proactively identify patients Track referrals Think about how you can use technology to capture patient experience and communicate provider performance Participate in collaborative/payer initiatives to get support for implementation (e.g. dedicated nurse care manager) 31

Framework for Automating Care/Case Management 32

Sample Care Team Roles in 2 MD Practice 5000 PATIENTS 2 Primary Care MDs, 2 Medical Assistants No Disease (60%) With Disease (40%) Risk Level Well At-Risk High Risk Low Risk Mod Risk High Risk Segment 30% 25% 5% 27% 10% 3% # Patients 1500 1250 250 1350 500 150 Care Team Role 0 0 Health Coach 250case load 2000 cases/yr LPN 1000 case load 5000 cases/yr RN 500 case load 5000 cases/yr Case Manager 150case load 1000 cases/yr FTE 0 0 1 1 33

Optimize Care Team Roles with Automation Patient Service Representative or Medical Assistant Schedule visits and tests indicated in Phytel Outreach interface and Pre-Visit reports Send out pre-visit communications and conduct follow up using Phytel Campaigns Care Manager Stratify patients by risk using Coordinate reports and filters Use Campaign functions to reach out to subgroups of patients with care gaps Reinforce importance of proper diabetes management through personal and automated patient education Physician Review Phytel Registry reports for attributed patients Assign high risk patients to Care Manager using Phytel reports and filters Address all diabetes care opportunities at every encounter, even for non-diabetes visits, using Phytel Patient Care Summary CMO/Quality Committee Review performance on each clinical goal overall and by location and provider Meet with MDs and Care Teams at least monthly to review progress 34

Track Performance to Target Improvement Monitor Quality Performance Presents an integrated quality dashboard using EMR and clinical data Enables oversight of chronic and preventive care conditions Allows you to gauge practice effectiveness and help resolve care gaps Accurately measure practice performance Monitor individual care providers performance Compare effectiveness of quality programs Compare your organization against national averages Enables your care team to track several different programs with a set of conditions and metrics related to that quality initiatives Helps your practice qualify for medical home and P4P programs 35

Engage Patients with HIT Assists 1) All >9 A1c and no office visit are sent a text message to call care manager 2) All >9 and BMI >35 are sent an automated invitation to a group visit with a diabetes dietician 3) All between A1c 7 and 9 are sent an automated message to encourage visit website to take diabetes selfmanagement course 4) All diabetics <7.0 are sent an email message emphasizing the importance of nutrition and exercise to maintain low A1c levels with a link to a mobile app to track their progress 36

Questions 37

References 1 Phillips, C., et al., 2004. Comprehensive Discharge Planning With Post-discharge Support for Older Patients With Congestive Heart Failure: A Meta-analysis. JAMA. 291(11), 1358-67. 2 Kainzinger, Florian, et al., 2009. Optimization of hospital stay through length-of-stay-oriented case management: an empirical study. J Public Health.17:395 400 3 Reid, R., P. Fishman, O. Yu, T. Ross, J.T. Tufano. 2009. Patient-Centered Medical Home Demonstration: A prospective, quasi-experimental, before and after evaluation. American Journal of Managed Care. 15(9), e71-e87. 4 Flottemesch, T., S.H. Scholle, P.J. O Connor, L. Solberg, S. Asche, L.G. Pawlson. 2010. Are Characteristics of the Medical Home Associated with Diabetes Care Costs? Under review. 5 Grumbach, K., P. Grundy. Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the United States. November 16, 2010. http://www.pcpcc.net/files/evidence_outcomes_in_pcmh.pdf (January 12, 2011) 6 Emily Chuanmei You, Emily C. et al., 2012. Effects of case management in community aged care on client and carer outcomes: a systematic review of randomized trials and comparative observational studies. BMC Health Services Research. 12:395. http://www.biomedcentral.com/1472-6963/12/395 7 Scholle, Sarah Hudson "Support and Strategies for Change Among Small Patient-Centered Medical Home Practices." Annals Of Family Medicine 11(Supplement 1). 38