P ti Patient Centered Medical Care: t C t d M di l C Vision to - PowerPoint PPT Presentation

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 Transformed: Better Delivery for Those Most in Need November 16, 2012 November 16, 2012 1

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 2

Health Care Costs Concentrated in Sick Few— Sickest 10 Percent Account for 65 Percent of Expenses i e e e A ou o e e o E pe e Distribution of health expenditures for the U.S. population, by m agnitude of expenditure, 2 0 0 9 Annual mean 1% expenditure 5% 22% $90,061 10% 50% $ 40,682 65% 50% $ 26,767 97% $ 7,978 Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey.

10 10 Building Blocks of Building Blocks of Building Blocks of Building Blocks of Template of the Template of the Future Future High ‐ Performing High Performing Primary Care Primary Care 9 8 8 Coordination of Prompt access Prompt access Care to care to care to care to care 5 6 7 Patient-Team Patient-Team Continuity of Continuity of Population Partnership Partnership Care Care Management 1 1 2 2 3 3 4 4 Willard & Bodenheimer The Building Blocks of Engaged Engaged Engaged Engaged Data-driven Data-driven Data-driven Data-driven Empanelment Empanelment Empanelment Empanelment Team-based Team-based Team-based Team-based High-Performing Leadership Leadership Improvement Improvement Care Care Primary Care: Lessons from the Field, April 2012 (www.chcf.org) 4

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 5

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?

Methods • Site selection: literature review, expert steering , p g committee, & snowball sampling o 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 7

Domains of Study Domains of Study 1. Team structure 1. Team structure 2. Patient selection 3 3. Patient engagement 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 7. Care manager (CM) training C (CM) t i i 8. Outcomes 8

CCM Program Characteristics g • 18 programs from 14+ States o 5 were part of a primary care transformation initiative 5 t f i t f ti i iti ti o 12 urban, 3 rural, 3 mixed • Program payer mix o 8 multi-payer o 8 Medicaid/uninsured, 10 Medicare, 8 private • Program “ownership” o 7 payer, 8 delivery system, 2 payer/delivery System, 4 regional CM partnerships 9

1. Team Structure • Most lead Care Managers (CMs) are nurses (RNs) “ Ti ht ” t • Tight vs loose team structure l t t o Integrated multidisciplinary team  Independent CM • Multidisciplinary teams address different needs: o Administrative support staff o Pharmacists o Resource specialists/social workers More o Behavioral health specialists o Behavioral health specialists common in o Health coaches Medicaid o Community health workers (CHWs) o Community health workers (CHWs) 10

2. Patient Selection: Three Common Approaches 1 Q 1. Quantitative tit ti o Claims-based risk prediction (harder for Medicaid) o Event-triggered: post-discharge, high-utilizer tracking 2. Qualitative – Referral 3. Combined The issue of mutability: y o Post-event o Motivation/readiness Key issue in Medicaid o Behavioral health 11

3. Patient Engagement g g • Connection to primary care • Face-to-face interaction • Longitudinal relationships • Traits of CM team members o Detective skills & creative problem solving o Ability to build trust Key o Cultural concordance – CHWs Strategies Strategies • Motivational interviewing M i i l i i i in o Sell it to patients & ensure early success Medicaid • Mobile workforce & technology M bil kf & t h l 12

4. Primary Care Integration y g • “ Tight vs loose ” integration o Embedded, high touch  off-site, low touch • Approaches to enhancing integration Approaches to enhancing integration o Co-location o Face-to-face interaction: accompaniment, meetings p g o Data/EMR Access o Early successes/Trust building o Education on CM role/benefits 13

5. Scope of Work & Key Tasks p y • Central task: to build relationships with patients, primary care teams & hospital/community partners i & h i l/ i • Touches • Twice weekly to monthly • Telephonic, office, in-home • Patient case load: 50-300 patients per CM o Depends on training, resources, & intensity of intervention o Depends on training, resources, & intensity of intervention o Use of teams, risk stratification & IT enable larger case loads 14

5. Scope of Work & Key Tasks p y • Comprehensive assessment & creation of care plans • Care coordination • Care coordination • With Hospitals/EDs, SNFs, Specialists, VNA, behavioral health & community-based resources behavioral health & community-based resources • Focus on Transitions of Care • Health coaching/self-management support H lth hi / lf t t • Address behavioral health needs Key S Strategies i • Address barriers to access/care in • Address social service needs Medicaid • Patient advocacy/activation 15

8 Outcomes 8. Outcomes QOL/ Mortality Quality of Mortality Q y Admit/ ED Total Cost Provider Patient of Care Experience Experience Functional Functional Care Readmit Utilization Status ����� ��         �� �� �� �� 16

What’s Needed? • Financial o Incentives that reduce unnecessary utilization and accelerate i t interoperable HIT bl HIT o Up-front investment in CCM infrastructure & programs o Reimbursement for uninsured post-ACA o Reimbursement for uninsured post-ACA • Organizational/Technical o Stronger primary care o Accelerated adoption of interoperable HIT o Multi-payer alignment to promote provider integration M lti li t t t id i t ti o Technical Assistance o Regional CM structures to help smaller/rural practices o Regional CM structures to help smaller/rural practices o Workforce development (professional & paraprofessional) 17

Acknowledgements Acknowledgements Acknowledgements Acknowledgements • Principal Investigator: i i l i o Tom Bodenheimer d h i Timothy Ferris o Randy Brown • RA: Allie Siegel RA: Allie Siegel o Nancy McCall o Nancy McCall • Funding: o Melanie Bella o Rushika o Rushika Fernandopulle o Steven Kravet • Program Officer: Melinda o Joanne Sciandra Abrams o Annette Watson • Steering Committee:

Questions? Questions? Questions? Questions? Contact: cshong@partners.org 19

6. Integration of IT g • Little advanced care management IT infrastructure • Limited: Li i d o Data availability o Support for care plans o Decision Support or task assignment ability o Decision Support or task assignment ability o Population management functionality o QI functionality QI f ti lit o Referral tracking 20

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 21