Value Based Case Management: Lessons Learned from Boeing s Intensive Outpatient Care Program Theresa Helle Manager, Health Care Quality & Efficiency Initiatives, The Boeing Company Dr. Hussein Tahan, DNSc, RN Knowledge Editor, CMBOK and Executive Consultant, the Commission 1 Proprietary to CCMC
Agenda Patrice Sminkey, CEO, the Commission Welcome andintroductions Overview of Learning Objectives Theresa Helle, Manager, Health lthcare Quality & Efficiency i Initiatives, The Boeing Company Dr. HusseinTahan, Knowledge Editor, CMBOK and Executive Consultant, the Commission Questions and Answers Patient Centered Case Management: Effective Patient Education and Coaching 2
Audience Notes There is no call in number for today s events. Please use your computer speakers, or you may prefer to use headphones. Please use the chat feature on the lower left hand part of your screen to ask questions throughout the presentations. Questions will be addressed as time permits after both speakers have presented. A recording of today s session will be posted within one week to the Commission s website, http://www.ccmcertification.org Patient Centered Case Management: Effective Patient Education and Coaching 3
Learning Objectives Overview Discover how Boeing's Intensive Outpatient Care Program is working through dedicated case managers to help patients with chronic disease to intensely manage their care. Learn about the burden of unmanaged chronic illnesses to patients, families and employers, and the potential productivity outcomes of a targeted medical home program. Learn about the importance of focusing on behavioral health issues to help patients with chronic disease better manage their conditions. Explore workforce readiness issues in the case management field as new models of care, such as the medical home and value-based employer initiatives, move forward. Patient Centered Case Management: Effective Patient Education and Coaching 4
Theresa Helle Manager, Health Care Quality & Efficiency Initiatives, The Boeing Company Patient Centered Case Management: Effective Patient Education and Coaching 5
Managing Medically Complex Patients Intensive Outpatient Care Program Commission for Case Manager Certification December 7, 2011 Theresa Helle Manager Health Care Quality & Efficiency Initiatives Author,, Filename.ppt 6
The Boeing Company World's leading aerospace company and the largest manufacturer of commercial jetliners and military aircraft Total revenue in 2009: $68 billion More than 160,000 Boeing employees in 49 states and 70 countries Major operations in Washington, California and Missouri Health-related benefits spend $2 billion Challenging labor environment Author,, Filename.ppt 7
The Imperative for Purchasers to Act Boldly The current model of health care delivery leads to suboptimal quality, poor experience, and waste of valuable resources Small incremental change is wholly inadequate to make significant, sustainable improvements We need to go beyond tweaking benefits design, adding small bonuses, or putting band aids on the system We need to test completely different models of care Difficult for providers to lead redesign Unable to make the right changes given the current payment system Often don t recognize the need for change Feel that change may hurt them As in every other industry, it is the customer (the person who pays) who can best trigger change Author,, Filename.ppt 8
The Ambulatory Intensive Caring Unit (AICU) Model : A Focused High-Value Medical Home Design funded from a 2003 Grant from the California Health Care Foundation to develop a disruptive new model of delivering care as a strategy for reducing costs while maintaining or improving quality Effort led by Pranav Kothari, MD, Rushika Fernandopulle, MD (Renaissance Health) and Arnie Milstein, MD (Mercer and Pacific Business Group on Health) A core team of national & regional experts in primary care innovation, operations and process redesign reviewed existing literature & data, and examined the experience of prior similar il innovations A model was developed called the AICU focused on primary care-led, high intensity care management for the high risk population The initial designs and financial projections were subject to peer review panel of subject matter experts and leaders of traditional and more innovative practices Author,, Filename.ppt 9
Momentum Around Similar Models Increasing payer and purchaser appetite and willingness to partner and innovate in AICU-like models. See it as a backbone for ACO and medical home - with early financial returns Makes intuitive sense; have been paying for disease management Near term increase in quality and lowering spend Members love it! So a rare win-win Models in: New Jersey - purchaser on-site Oregon - business coalition - 14 med group, 5 plans, 4 purchasers California - Pacific Business Group on Health Washington - Regence health plan, Boeing and other purchaser driven expansion Nevada - hospitalist centric model Geisinger - plan-embedded RNs into medical groups Hopkins - Medicare population Vermont - community based RNs Southeast - Academic center-led model IL, MO, MA, NC, FL - active planning Author,, Filename.ppt 10
Linking Payment Change with Clinical Redesign Each site created a new ambulatory intensivist practice for the predicted highest cost 5-20% of members Practices were staffed by specially identified MD, RN health coach, and other support Sites implemented shared care plans, increased access, proactively managed care No benefit changes, sites continued to bill fee-forservice for MD visits Copays for 1st intake visit was waived, rest continued as usual Sites were paid a case rate pmpm to cover nontraditional services Shared savings model for expanded model Author,, Filename.ppt 11
Intensive Outpatient Care Program Goals Health Costs Reduce net total health care spending for target population by 20% over 2 years Functional status Improve self reported functional scores (SF-12) and improve productivity in the workplace Quality Improve performance on chronic disease measures, both claims based and ones based on clinical data Staff Satisfaction Create an excellent work environment for physicians and staff Patient Experience Improve patient s experience of care across all dimensions in a standard survey Author,, Filename.ppt 12
Outcomes High Levels of Employee Satisfaction: Testimonials show exceptional reception on the part of patients, and surveys confirm improvements in virtually all measures of care and patient experience including access, communication, provider relationship, and care coordination Functional Status: Surveys document self-reported improvements in functional scores and productivity Clinical Quality: Lab data demonstrated objective improvements for key clinical measures Provider satisfaction: Physicians and nurses provided testimonials in support of the better care they were able to provide Cost savings 20% annual savings per enrollee as compared to a propensitymatched control group, net of supplemental fee to medical group primarily due to reduced ER visits, hospital admissions and inpatient days Author,, Filename.ppt 13
Clinical Outcomes Health Measures for IOCP Participants Better than Nat l Averages 90.00% 00% 89.70% 80.00% 70.00% 60.00% 66.10% 66.70% 59.70% 56.60% 50.00% 40.00% 30.00% 41.80% IOCP US Average 20.00% 00% 10.00% 0.00% Diabetes Hypertension Heart tdisease Hemoglobin < Blood Pressure < Cholesterol < 100 7 optimal 140 optimal optimal Author,, Filename.ppt 14
Improved Emotional, Mental and Physical Functioning 50.00 Survey Data N= 251 pre, 115 post 45.00 40.00 35.00 30.00 25.00 Previous Care IOCP 20.00 15.00 10.00 5.00 0.00 PHQ9` SF12 Mental SF12 Physical Previous Care 6.23 37.09 32.92 IOCP 4.86 43.08 37.79 PHQ9 - Patient Health Questionnaire - Depression screening scale. Low score is desired outcome SF12 - Short Form 12 question health survey. High score is desired outcome. Author,, Filename.ppt 15
Worksite Gains Increased Productivity at Work 25.0 20.0 15.0 10.0 Previous Care IOCP 5.0 0.0 How many days have you missed work in the 6 months for medical reasons How many days have you been less productive at work than you should for medical reasons? Previous Care 7.8 21.0 IOCP 3.4 6.7 Note: Results are self-reported Author,, Filename.ppt 16
IOCP Patient Testimonials I have been helped more in the last six months than years of seeing multiple doctors. Being a patient in the IOCP has been a life-changing event for me. I have learned to change the way I live and think. I finally stopped smoking. Somebody actually listens to me and is giving me the help I need. My BP is now normal after being high for many years. I am getting good advice about my prescriptions. I am able to take walks and hope to be swimming again soon. I am feeling positive now, I once felt doomed. I feel like a new person. Author,, Filename.ppt 17
Boeing IOCP, Geisinger, Hopkins show that focused care management interventions produce high quality, lower cost care Common themes in what works: Dedicated, intentional care management Keys to Targeted population Success Enfranchisement of the PCP Increased actionable data transparency Built within care processes Proactive, rules-based foundation High level of transition care coordination Leadership commitment, cultural readiness Defined effort, narrowed vision, partnership with patient Author,, Filename.ppt 18
Keys to Success Patient perspective Successful recruitment requires a reinforcement of the relationship with the primary care physician Medical groups Need to be cognizant and respectful of the groups culture, and the groups other initiatives also need close collaboration, though, to insure the integrity of this model Nurse case manager has a critical role Other lessons learned Behavioral health issues are highly prevalent, making access to providers very important Timely notification of ER visits and hospitalizations is challenging Author,, Filename.ppt 19
Next Steps Expand Delivery Model Incorporate experience of other medical home pilots, fine-tune IOCP model Defined critical elements to optimize model and options for financial and operational structure Expansion underway in Seattle, St. Louis, So Cal in planning phase Author,, Filename.ppt 20
Closing Thoughts Innovate be willing to test new delivery models Be ready for a challenging, but extremely rewarding experience The outcomes and testimonials from patients, nurses and physicians are gratifying and prove that this type of partnership p and innovation can really make a difference Insanity is doing the same thing over and over and expecting different results -Albert Einstein Author,, Filename.ppt 21
Workforce Readiness Issues Knowledge Editor, CMBOK and Executive Consultant, the Commission Corporate Director of Nursing Education & Research NewYork Presbyterian Hospital Dr. Hussein Tahan, DNSc, RN Assistant Professor, Clinical Nursing Columbia University School of Nursing Patient Centered Case Management: Effective Patient Education and Coaching
Case Managers Exist in all settings across the continuum of health and human services Are the linchpin between clients/support systems and members of the health care team (both internal and external to the practicesetting) Are effective in their roles highlydependent on how well they are prepared: knowledge, skills and competencies 23
Workforce Issues of Special Note Talent Pool Supply and demand Ai Aging workforce Changing practice environment Qualifications Background: professional discipline Skills, knowledge and abilities Ongoing education and competence 24
Major Challenge Volume Credible research about the number of case managers in the workforce is lacking Anecdotally speaking, over 100,000 in the U.S. No data about those in leadership compared to direct care No data about workforce by discipline, setting or professional background CCMC reports certifying about 30,000 Not knowing who these case managers are presents a great challenge to estimating supply and demand 25
Major Challenge Training Educational preparation of case managers: Lacks standardization Is primarily employer based Is done through h on the job training i Limited school based academic programs today compared to mid 1990s Lack of academic and organized approach to education of case managers resulted in shortage of experienced candidates 26
Professional Discipline Specialization f % Nursing 6,057 88.5 Social Work 109 1.7 Vocational Rehabilitation 107 1.6 Other 567 8.2 27 CCMC s Role and Function Study, 2009
Age Distribution Range f % Range f % 30 57 0.8 51-55 1,863 27.2 31-35 188 2.7 56-60 1,472 21.5 36-40 463 3.7 61 65 648 9.5 41-45 738 10.7 66 70 122 18 1.8 46-50 1,290 18.88 >70 18 03 0.3 28 CCMC s Role and Function Study, 2009 (numbers are rounded)
Gender Gender f % Female 6,625 96.4 Male 251 3.6 29 CCMC s Role and Function Study, 2009
Educational Background f % Associate 1,426 20.7 Diploma (Nursing) 856 12.4 Bachelor's 3,067 44.4 Master's 1,393 20.2 Doctorate 49 0.7 Other 36 0.5 30 CCMC s Role and Function Study, 2009
Patient Protection & Affordable Care Act Improving Quality & Efficiency of Care Reduction of Hospital Readmissions Provisions for Medical Home Provisions for Medication Therapy Management Access to Care Provisions for Care Coordination Community Based Care Transition Programs Chronic Care Disease Management Transitional Care Provisions Wellness Programs Shared Decision Making Impetus for New Models of Care 31
Traditional Models No Longer Work Fragmented Expensive and inefficient Duplication of functions Potential for over use or under use of resources Risk for quality concerns Not patient centered enough
Patient Protection & Affordable Care Act The changing dynamics of the health care environment prompt all of us, especially those in case Improving Quality & Efficiency of Care h gq l h Reduction of Hospital Readmissions Provisions for Medical Home Provisions management, for Medication Therapy to always Management be Access prepared to Care and ready to adapt Provisions for and Care to Coordination possess specific Community Based knowledge, Care skills Transition and programs abilities ChronicCare Care Disease Management Transitional Care Provisions Wellness Programs Shared Decision Making 33
New Models of Care Approach to Medical Care Health IT Care Delivery Systems Quality and Safety Reimbursement 34
Approach to Medical Care Provision Renewed focus on primary care Expansion of role of hospitalist, t intensivist i i tto practice settings other than hospitals Primary care provider assumes responsibility for managing care across the entire continuum of health and human services patient s lifetime Health care professionals to optimize their roles and practices to the extent of their licensure Use of non physician resources 35
Care Delivery Systems Patient centered care patient t expanded dto patient/family/social t/f il / i l network Multidisciplinary care teams beyond the walls of the practice setting collaboration, cooperation, communication Effectiveness through evidence based practice interventions, treatments and outcome targets care guidelines based on less is more and better Focus on wellness and prevention Primary, secondary and tertiary Health & human services Managing transitions of care across various settings 36
Health IT Platform for providers exchange of and access to information across: disparate health care systems and settings EMRs and PHRs Use of robust decision support systems at the point of care care provider and patient oriented Use of remote monitoring technology for better patient/social network engagement and management of disease 37
Quality & Safety Electronic and real time surveillance of performance Proactive approach Safety alerts/triggers Meeting regulatory and accreditation standards Risk assessment, stratification and predictive modeling beyond dhealth plans or disease management programs socioeconomic factors play primary role Social media technology for proactive, targeted and just in time counseling and support to patients/social networks 38
Reimbursement Value based purchasing Outcomes based Workforce based (skills and competencies) Global, capitated, and bundled reimbursement structures Risk placed primarily on the new care delivery model Time of coverage spans beyond episode of care Technology based Remote monitoring Social media technology for proactive, targeted and just in time counseling/support 39
Recruitment of Talent Look in Advertisein in specific media non traditional g y places Engage partners with special knowledge in your search for talent Select based on values and potential Create the type of professional you desire Train on the job Designate a mentor system Invest in education Partner with schools 40
Educational Preparation ACADEMIC School based Degree or certificate programs Academic credit non ACADEMIC On the job training Informal Local, regional, national conferences Learning institutes 41
Possible Education Curriculum Functions Case Management Process & Services Resource Utilization & Management Psychosocial & Economic Support Rehabilitation hbili i Ethical & Legal Practices Outcomes Knowledge Case Management Concepts Health Care Management & Delivery Principles of Practice Health Care Reimbursement Psychosocial Aspects Rehabilitation ti 42 CCMC s Role and Function Study, 2009
Strategies for Effective Education Partnership between practice and academe Build evidence based academic programs Commission s s role and functions study can be the foundation Inter professional educational programs Allow flexibility for curriculum review and revision as indicated by changes in the industry Maximize use of online educational programs (virtual university) Ongoing training and education to ensure current, necessary competencies 43
Ultimately Case managers must possess the education, skills, knowledge, competencies, and experiences needed TO effectively render appropriate, safe, and quality services to patients and their support systems / social networks 44
As leaders, we are obligated to maintain case managers who are Knowledgeable Skilled (Current) (Standardized) Competent Effective Experienced (Guided) Educated (Appropriate) 45 CCMC, 2010
Thank you! Question and Answer Commission for Case Manager Certification 15000 Commerce Parkway, Suite C Mount Laurel, NJ 08054 Corporate: 1 856 380 6836 6836 Email: ccmchq@ccmcertification.org www.ccmcertification.org 46 Proprietary to CCMC