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P ti Patient Centered Medical Care: t C t d M di l C Vision to Reality Implementing Care Management for Complex Management for Complex Patients in Primary Care Clemens Hong MD, MPH Grantmakers in Health 2012 Fall Forum Health Care


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SLIDE 1

P ti t C t d M di l C Patient‐Centered Medical Care: Vision to Reality Implementing Care Management for Complex Management for Complex Patients in Primary Care

Clemens Hong MD, MPH

Grantmakers in Health 2012 Fall Forum Health Care Transformed: Better Delivery for Those Most in Need November 16, 2012

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November 16, 2012

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SLIDE 2

Outline Outline

  • Overview of complex care management (CCM) and

Overview of complex care management (CCM) and its relationship to primary care

  • Review core features of CCM programs
  • Recommendations to help spread CCM programs

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SLIDE 3

Health Care Costs Concentrated in Sick Few— Sickest 10 Percent Account for 65 Percent of Expenses i e e e A

  • u
  • e

e

  • E pe

e

Distribution of health expenditures for the U.S. population, by m agnitude of expenditure, 2 0 0 9

1% 5% 10% 22%

$90,061 Annual mean expenditure

50%

$40,682

65% 50%

$26,767

97%

$7,978

Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey.

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SLIDE 4

Building Blocks of Building Blocks of

10 10

Building Blocks of Building Blocks of High High‐Performing Performing

Template of the Future Template of the Future

Primary Care Primary Care

8 Prompt access to care 8 Prompt access to care 9 Coordination of Care 5 6 to care to care 7 Patient-Team Partnership Patient-Team Partnership Continuity of Care Continuity of Care Population Management

Willard & Bodenheimer The Building Blocks of

1 Engaged 1 Engaged 2 Data-driven 2 Data-driven 3 Empanelment 3 Empanelment 4 Team-based 4 Team-based

4 High-Performing Primary Care: Lessons from the Field, April 2012 (www.chcf.org)

Engaged Leadership Engaged Leadership Data-driven Improvement Data-driven Improvement Empanelment Empanelment Team-based Care Team-based Care

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SLIDE 5

Complex Care Management Complex Care Management Defined

Complex Care Management (CCM) is the organized p g ( ) g delivery of care to address the complex needs of high risk, community dwelling patients

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SLIDE 6

Research Questions Research Questions

  • What are the core, operational attributes of

successful CCM programs?

  • How do these programs customize for specific

populations or contexts? populations or contexts?

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SLIDE 7

Methods

  • Site selection: literature review, expert steering

, p g committee, & snowball sampling

  • Inclusion criteria:
  • Primary care-aligned CCM program
  • Existing data on performance
  • Ongoing operation
  • Data collection: 3+ Interviews/site
  • Data collection: 3+ Interviews/site
  • Analysis: 2 independent reviewers identified themes

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SLIDE 8

Domains of Study Domains of Study

  • 1. Team structure
  • 1. Team structure
  • 2. Patient selection

3 Patient engagement

  • 3. Patient engagement
  • 4. Integration with primary care & other providers

5 Scope of work & key tasks

  • 5. Scope of work & key tasks
  • 6. Integration of information technology

7 C (CM) t i i

  • 7. Care manager (CM) training
  • 8. Outcomes

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SLIDE 9

CCM Program Characteristics g

  • 18 programs from 14+ States

5 t f i t f ti i iti ti

  • 5 were part of a primary care transformation initiative
  • 12 urban, 3 rural, 3 mixed
  • Program payer mix
  • 8 multi-payer
  • 8 Medicaid/uninsured, 10 Medicare, 8 private
  • Program “ownership”
  • 7 payer, 8 delivery system, 2 payer/delivery System, 4

regional CM partnerships

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SLIDE 10
  • 1. Team Structure
  • Most lead Care Managers (CMs) are nurses (RNs)

“Ti ht l ” t t t

  • Tight vs loose team structure
  • Integrated multidisciplinary team  Independent CM
  • Multidisciplinary teams address different needs:
  • Administrative support staff
  • Pharmacists
  • Resource specialists/social workers
  • Behavioral health specialists

More

  • Behavioral health specialists
  • Health coaches
  • Community health workers (CHWs)

common in Medicaid

  • Community health workers (CHWs)

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SLIDE 11
  • 2. Patient Selection:

Three Common Approaches

1 Q tit ti

  • 1. Quantitative
  • Claims-based risk prediction (harder for Medicaid)
  • Event-triggered: post-discharge, high-utilizer tracking
  • 2. Qualitative – Referral
  • 3. Combined

The issue of mutability: y

  • Post-event
  • Motivation/readiness

Key issue in

  • Behavioral health

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Medicaid

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SLIDE 12
  • 3. Patient Engagement

g g

  • 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

M i i l i i i

Key Strategies

  • Motivational interviewing
  • Sell it to patients & ensure early success

M bil kf & t h l

Strategies in Medicaid

  • Mobile workforce & technology

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SLIDE 13
  • 4. Primary Care Integration

y g

  • “Tight vs loose” integration
  • Embedded, high touch  off-site, low touch
  • Approaches to enhancing integration

Approaches to enhancing integration

  • Co-location
  • Face-to-face interaction: accompaniment, meetings

p g

  • Data/EMR Access
  • Early successes/Trust building
  • Education on CM role/benefits

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SLIDE 14
  • 5. Scope of Work & Key Tasks

p y

  • Central task: to build relationships with patients,

i & h i l/ i primary care teams & hospital/community partners

  • Touches
  • Twice weekly to monthly
  • Telephonic, office, in-home
  • Patient case load: 50-300 patients per CM
  • Depends on training, resources, & intensity of intervention
  • Depends on training, resources, & intensity of intervention
  • Use of teams, risk stratification & IT enable larger case loads

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SLIDE 15
  • 5. Scope of Work & Key Tasks
  • Comprehensive assessment & creation of care plans
  • Care coordination

p y

  • Care coordination
  • With Hospitals/EDs, SNFs, Specialists, VNA,

behavioral health & community-based resources behavioral health & community-based resources

  • Focus on Transitions of Care

H lth hi / lf t t

  • Health coaching/self-management support
  • Address behavioral health needs

Key S i

  • Address barriers to access/care
  • Address social service needs

Strategies in Medicaid

  • Patient advocacy/activation

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SLIDE 16

8 Outcomes

  • 8. Outcomes

Mortality Quality of Admit/ ED Total Cost Provider Patient QOL/ Functional Mortality Q y Care Readmit Utilization

  • f Care Experience Experience Functional

Status

      

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SLIDE 17

What’s Needed?

  • Financial
  • Incentives that reduce unnecessary utilization and accelerate

i t bl HIT interoperable HIT

  • Up-front investment in CCM infrastructure & programs
  • Reimbursement for uninsured post-ACA
  • Reimbursement for uninsured post-ACA
  • Organizational/Technical
  • Stronger primary care
  • Accelerated adoption of interoperable HIT

M lti li t t t id i t ti

  • Multi-payer alignment to promote provider integration
  • Technical Assistance
  • Regional CM structures to help smaller/rural practices
  • Regional CM structures to help smaller/rural practices
  • Workforce development (professional & paraprofessional)

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SLIDE 18

Acknowledgements Acknowledgements Acknowledgements Acknowledgements

i i l i d h i

  • Principal Investigator:

Timothy Ferris

  • RA: Allie Siegel
  • Tom Bodenheimer
  • Randy Brown
  • Nancy McCall

RA: Allie Siegel

  • Funding:
  • Nancy McCall
  • Melanie Bella
  • Rushika
  • Rushika

Fernandopulle

  • Steven Kravet
  • Program Officer: Melinda

Abrams

  • Joanne Sciandra
  • Annette Watson
  • Steering Committee:
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SLIDE 19

Questions? Questions? Questions? Questions?

Contact: cshong@partners.org

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SLIDE 20
  • 6. Integration of IT

g

  • Little advanced care management IT infrastructure

Li i d

  • Limited:
  • Data availability
  • Support for care plans
  • Decision Support or task assignment ability
  • Decision Support or task assignment ability
  • Population management functionality

QI f ti lit

  • QI functionality
  • Referral tracking

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7 CM Training

  • 7. CM Training
  • Most pair classroom didactics with on-the-job

Most pair classroom didactics with on the job training (shadowing/mentorship)

  • Motivational Interviewing – most important skill

g p

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