Implementing Care Management for
Complex Patients in Primary Care –
Best Practices from Successful
Programs
Clemens Hong MD, MPH
Maine Community Care Teams Summit
November 14, 2013
Health Care Costs Concentrated in Sick Few
Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey.
Distribution of health expenditures for the U.S. population, by magnitude of expenditure, 2009 1% 5% 10% 50% 65% 22% 50% 97% $90,061 $40,682 $26,767 $7,978 Annual mean expenditure
Using complex care management teams to
improve patient care and reduce costs
Specially trained multidisciplinary, complex care management teams
3
One proposed solution to address healthcare cost problem
Goals
• Maintain/improve functional status
& self-efficacy – chronic disease & health system navigation
• Reduce costs by eliminating
unnecessary testing and reducing need for acute care services
Limited knowledge - effectiveness of CCM
o Evidence of effectiveness of primary care-integrated, CCM
remains limited
• Most demonstrate improvement in quality or reduction in
acute care utilization
• BUT effect on net cost reduction is less consistent
o Nonetheless, growing consensus that this approach can be
highly effective
o Universally adopted by Accountable Care Organizations
• There is a dearth of information to guide implementation of
these programs
Challenges for CCM Programs: Drops in Potential
Adapted from J Eisenberg JAMA. 2000
Engagement Finding opportunities for improvement Intervention Identification Potential opportunity Realized improvement • Poor performance at any point along this pathway reduces
Aim & Research Questions
• Aim
o To identify key operational attributes of successful primary
care-integrated, complex care management (CCM) programs
• Overarching research questions
o What are the core operational attributes and best practices
of successful primary care-integrated, CCM programs?
o How must successful primary care-integrated, CCM
Study Design & Methods
• Semi-structured, key informant interviews and review of
program materials
• Site selection: literature review, expert steering committee, &
snowball sampling
o Inclusion criteria:
• Primary care-integrated CCM program
• Existing data on performance/success
• Ongoing operation
Domains of Study
• Program Context & Control
• Team Structure
• Patient Selection
• Scope of Work & Key Tasks
• Patient Engagement
• Integration with Primary Care & Other Providers
• Integration of Information Technology
• Care Management Team Training
9
PC-CCMP Location Payer
Aetna 49 sites nationally Aetna Medicare
Atlanticare Special Care Center Atlantic City, NJ Atlanticare-self-insured
Camden Coalition Camden, NJ Medicaid
Care Management Plus Oregon Medicare
CareOregon Oregon Medicaid
Community Care of North Carolina North Carolina Medicaid
The Everett Clinic Everett, WA Medicare, Commercial Fletcher Allen–VT Blueprint CHTs Burlington Vermont All payer
Geisinger ProvenHealth Navigator NE/Central Pennsylvania Multipayer
Genesys HealthWorks Flint, Michigan Commerical & uninsured
GRACE Indiana Medicare, Dual eligible
Guided Care Baltimore Medicare
Health Quality Partners Eastern Pennsylvania Medicare, Commercial King County Care Partners Seattle, WA Medicaid
MGH CMS Demonstration Boston, MA Medicare
NY Health & Hospitals New York City Medicaid
SoonerCare Choice HMP Oklahoma Medicaid
10
!
Program/Population Utilization/Cost Admit / Quality Readmit
ED Use Cost Quality Provider Experience
QOL/ Patient Experience
GENERAL TREND ↓ ↓ ↓ ↑ ↑ ↑
Aetna's Medicare Advantage Provider Collaboration Program ↓ ↓ ↓ ↑ ↑ ---
AtlantiCare Special Care Center ↓ ↓ ↓ ↑ ↑ ↑
Camden Coalition ↓ ↓ ↓ ↑ --- ---
Care Management Plus ↓ ↑ ↓ ↑ --- ---
CareOregon Health Resilience Program (for Health Share of Oregon) ↓ ↓ --- --- ↑ ↑
Community Care of North Carolina - Community Care of the Sandhills ↓ ↓ ↓ ↑ --- ---
The Everett Clinic ↓ --- ↓ ↑ --- ↑
Fletcher Allen - Vermont Blueprint Community Health Teams ↓ ↓ ↓ ↑ --- ↑
Geisinger ProvenHealth Navigator ↓ ↓ ↓ ↑ ↑ ↑
Genesys HealthWorks Health Navigator ↓ ↓ --- ↑ --- ↑
Geriatric Resources for Assessment and Care of Elders (GRACE) ↓ ↓ ↓ ↑ ↑ ↑
Guided Care ↓ ↑ --- ↑ ↑ ↑
Health Quality Partners ↓ ↓ ↓ ↑ ↑ ↑
King County Care Partners ↓ --- ↓ ↑ --- ↑
Massachusetts General Hospital Care Management Program ↓ ↓ ↓ ↑ ↑ ↑
New York City Health & Hospitals Chronic Illness Demonstration
Project ↓ --- --- ↑ --- =
Oklahoma SoonerCare Choice Health Management Program ↓ ↓ ↓ ↑ ↑ ↑
Program' Mortality' Admit/' Outcomes! Readmit' ED' Utilization' Cost'of' Care' Provider' Experience' Patient' Experience' Quality'of' Care' QOL/' Functional' Status' General'Trend' !' ! ! !' "' "' "' "' ! ! ! Aetna’s Medicare PCP ""! !! !! !! "! ""! "! ""! Atlanticare SCC ""! !! !! !! "! "! "! ""! Camden Coalition ""! !! !! !! ""! ""! ""! "! Care Management Plus !! !! "! !! "! "! "! ""! Care Oregon ""! !! !! !! ""! "! "! "! Community Care of NC ""! !! !! !! ""! ""! "! ""! The Everett Clinic ""! !! !! !! "! "! "! "! Fletcher Allen–VT Blueprint CHTs ""! !! !! !! ""! "! "! "! Geisinger ProvenHealth Navigator =! !! !! !! "! "! "! "! Genesys HealthWorks ""! !! !! ""! ""! "! "! ""! GRACE !! !! ! !! "! ""! "! "! Guided Care =! !! "! !! "! "! "! ""! Health Quality Partners !! !! !! !! ""! ""! "! ""! King County Care Partners !! !! !! !! ""! "! "! ""! MGH CMS Demonstration ! ! ""! ! "! "! " ""! NY Health & Hospitals "" ! ""! "" ""! "! " ""! SoonerCare Choice HMP "" ! !! ! "! "! " ""! Sutter Care Coordination Program ""! ! !! ! ""! ""! " ""!
Funding & Operational Control
• Funding o Grants o Health Systems o Payers • Operational Control o 8 Delivery System o 7 Payero 2 Joint Payer/Delivery system
CCM Team Structure
•
Most lead Care Managers (CMs) are nurses (RNs)
•
“Tight vs loose” team structure
o Integrated multidisciplinary team à Independent CM
•
Multidisciplinary teams address
different needs:
o Administrative support staff
o Pharmacists
o Resource specialists/social workers
o Behavioral health specialists
o Health coaches
14 PCP Care Manager Pharmacist Financial Service Specialist Mental Health Team Substance Abuse Specialist Community Resource Specialist Pallia=ve Care and Hospice Community Agencies Hospice VNAs Non Acute Care Agencies Elder Service Network Transport Providers Civic Organiza=ons
Complex Care Team Healthcare & Community Services Specialist
CCM Team Structure
Patient Selection
1. Quantitative
o Applying risk prediction software to claims datat
o Acute care utilization focused
o High risk condition focused
2. Qualitative
o Referral – Physician/Staff or Patient
- 16 -
Effective Targeting of Care Management
Population Volume ß Healthy ß Chronic Illnesses ß Medically Complex/ High Utilizers
Scope of Work & Key Tasks
• Central task
o to build relationships with patients, primary care teams &
hospital/community partners
• Touches
• Twice weekly to monthly
• Telephonic, office, in-home
• Patient case load: 25-500 patients per CM
o Depends on training, resources, & intensity of intervention
Scope of Work & Key Tasks
• Comprehensive assessment & creation of care plans
• Care coordination
• With Hospitals/EDs, SNFs, Specialists, VNA, behavioral health &
community-based resources
• Focus on Transitions of Care
• Health coaching/self-management support
• Address behavioral health needs
• Address social service needs
• Address barriers to access/care
• Advanced care planning
• Patient advocacy/activation Emergency Department & Acute Inpatient Care Outpatient Specialist Care CARE MANAGEMENT & PRIMARY CARE SNF & Rehab Care
Patient engagement
§ Connection to primary care § Face-to-face interaction § Longitudinal relationships § Traits of CM team members
§ Detective skills & creative
problem solving
§ Ability to build trust
§ Cultural concordance – CHWs
§ Motivational interviewing
§ Sell it to patients & ensure early
success
§ Mobile workforce & technology
19
Tailored approach at Camden Coalition 1. Reach out to patients during
hospitalization or ED
2. Provide a personalized introduction,
use open-ended questions
3. Once armed with specific needs of
patient, can tailor presentation of services
Making the right pitch to patients is important
Primary care integration
§ Poor interactions with primary care were major barriers to effective
CCM
§ Recommended approaches
§ “Tight vs loose” integration
§ Embedded, high touch à off-site, low touch
§ Enhancing integration
§ Co-location
§ Face-to-face interaction: accompaniment, meetings § Data/EMR Access
§ Early successes/Trust building § Education on CM role/benefits
Engaging Other Critical Resources
• Ties to inpatient facilities/EDs
o Communication with inpatient CMs
o Communication with skilled nursing facilities
o CM Team members embedded at hospital sites – ED/Hospital CM
• Ties to community-based agencies
o Home health agencies
o Elder Resource Centers
o Community Centers
o Social Service Agencies
PCP# Pa%ent# CM# OUTPATIENT# PHARMACY# FINANCIAL## SERVICES# MENTAL## HEALTH# SUBSTANCE## ABUSE# COMMUNITY# RESOURCE# SPECIALIST# PALLIATIVE# CARE#and# HOSPICE# VNAs Elder Service Network Transport Providers Community Care Agencies Hospice Civic Organizations Non-Acute
Health information technology (HIT)
§ Little advanced care management HIT infrastructure
§ Some risk prediction, but with limited data availability § Limited population management functionality
§ Some task assignment/”tickling” ability
§ CM tasks rarely tracked – little QI functionality § Limited referral tracking
• HIT needs for CM activities
§ Data integration with access to real-time data from multiple data sources § Real-time notification of high-risk events
§ Advanced population management IT platforms that have:
§ Population management functionality – registry function, decision
support, task assignment/”tickling” ability
§ Supports secure communication and documentation § Quality/Performance monitoring
Training
• Most pair classroom didactics with on-the-job training
(shadowing/mentorship)
• Motivational Interviewing cited as most important skill
included in training – often ongoing
• Other training elements include:
• Program goals • Geriatric or disease specific issues
• Care manager role • Cultural competence
• Care management protocols • Palliative care
• Approaches to primary care
engagement
• Leadership/change management/
teamwork
Important concepts for ensuring efficient care
management intervention
• Build strong relationships with patients, primary care teams,
and other community care partners
• Continuously assess motivation & readiness for change
• “A good CM doesn’t do everything”
o Allocate the CM resource to high-yield activities, complement
existing services, & focus on mutable issues
o Use HIT infrastructure to enhance CM efficiency
Conclusion
• Primary Care-Integrated CCM Programs are a critical piece of
national healthcare delivery transformation to improve health & reduce costs
• We need to address financial, operational and technical
barriers to ensure widespread adoption of these programs
• AND ensure that we learn from past efforts at care
coordination while appropriately tailoring interventions for different context & population needs
Acknowledgements
• Principal Investigator:
Timothy Ferris
• RAs: Allie Siegel, Powell
Perng, Paola Miralles
• Funding:
• Program Officer: Melinda
Abrams • Steering Committee: o Tom Bodenheimer o Randy Brown o Nancy McCall o Melanie Bella o Rushika Fernandopulle o Steven Kravet o Joanne Sciandra o Annette Watson
Questions
?
What’s Needed?
• Financial
o Incentives to reduce unnecessary utilization and accelerate
interoperable HIT development
o Up-front investment in CCM infrastructure & programs
• Organizational/Technical
o Stronger primary care
o Accelerated adoption of interoperable HIT
o Multi-payer alignment to promote provider integration
o Technical Assistance to address implementation challenges
o Regional CM structures to help smaller/rural practices
o Workforce development (professional & paraprofessional –
