Transcript Promising Models of Care Coordination/Care Management for

Promising Models of Care Coordination for
Beneficiaries with Chronic Illnesses
Presented by:
Paul Shelton, EdD
Goals of Presentation
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Identify promising care
coordination/management interventions for
beneficiaries with chronic illnesses
 Transitional Care
 Comprehensive Care Coordination
Describe internal and external evaluation
Describe key distinguishing features of these
programs
Policy Implications
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Care Coordination
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A person-centered, assessment based,
interdisciplinary approach to integrating health
care and social support services cost-effectively
in which:
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an individual’s needs and preferences are assessed,
a comprehensive care plan is developed, and
services are managed and monitored by utilizing an
evidence-based process and an identified Care
Coordinator (New York Academy of Medicine, National
Coalition on Care Coordination).
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The Problem
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Most healthcare dollars are spent on a small
percentage of beneficiaries who have
complex chronic conditions
Causes of high utilization and costs:
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Deviations from evidence-based care
Poor communication among primary providers, specialists,
health and community providers, patients and families
Failure to catch problems early/patient compliance
Failure to address psychosocial issues
Lack of coordinated, longitudinal management
Ineffective transitional management (hospital - home, hospital nursing home, nursing home - hospital, nursing home - home)
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What is Effective Care Coordination?
Intervention with rigorous evidence
that:
 Improves patient outcomes
 Reduces total health care
expenditures for participating
patients
Improved satisfaction or clinical indicators
not sufficient
 Net savings require reduced hospitalizations
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Promising Interventions
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Promising care coordination
interventions:
1.
Transitional Care
Coordination (Coleman et al.
2006; Naylor et al. 2004; Perry
et al. 2011)
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Promising Interventions, cont.:
2.
Comprehensive Care Coordination
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Medicare/Duals - (Boult et al. 2008; Leff
et al. 2009; Dorr et al. 2008; Counsell et
al. 2007; Medicare Coordinated Care
Demonstration: Best Practice Sites, Brown
2009).
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Transitional Care
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These programs:
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Engage patients with chronic illnesses while
hospitalized
Follow patients intensively post-discharge
Teach/coach patients about medications, selfcare, and symptom recognition and
management
Remind/encourage patients to keep follow-up
physician appointments
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Transitional Care Intervention:
Coleman et al. (2006)
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Care Transitions: Coleman
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Patient-centered intervention designed to improve quality and
contain costs for patients with complex care needs as they
transition across care settings
Target Population
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Inclusion:
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A) Patients being discharged from the hospital with: stroke, congestive
heart failure, coronary artery disease, cardiac arrhythmias, COPD,
diabetes, spinal stenosis, hip fracture, peripheral vascular disease,
deep venous thrombosis, pulmonary embolism
B) 30 day Medicare readmission for HF, MI, PNE
C) Risk algorithm for readmission drawn from administration data
Exclusion:
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Dementia with no caregiver, primary psychiatric diagnosis, with
psychotic elements, active drug or alcohol use
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Transitional Care Intervention:
Coleman et al. (2006)
Staffing
 APN or RN or social worker or occupational therapist
Caseload: 1 care coordinator (CC) per 40 patients
Duration: 30 days following hospitalization
Focus
 Continuity of care by helping family maintain a personal
health record
 Help family understand how/when to obtain timely follow-up
care
 Coach patients to ask the right questions to the right health
care providers
 Help patients/families be more active in managing condition
and in developing/implementing self-care skills (i.e.
medication management, increased awareness of symptoms,
recognizing “red flags” and warning signs for care, along with
instructions on how to respond
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Transitional Care Intervention, cont.:
Mary Naylor et al. (2004)
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Care Transitions: Naylor
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Patient-centered intervention designed to improve quality of life,
patient satisfaction, and reduce hospital readmissions and cost for
elderly patients hospitalized with CHF
Target Population
Inclusion:
 A) Elderly patients (aged 65+)
admitted to 6 Philadelphia, PA,
hospitals with diagnosis of CHF
(DRG 127)
 B) Live in the community within a
60 mile radius service area
Exclusion:
 Could not have ESRD, non English
speaking
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Transitional Care Intervention, cont.:
Mary Naylor et al. (2004)
Staffing
 Advanced Practice Nurses (3)
Caseload: 1 care coordinator (CC) per 39 patients
Duration: 3 months following index hospitalization
Focus
 Continuity of care at hospital discharge to optimize
patient’s health status and arrange for needed home
care services
 After patients discharged home, prevention of
medication and other medical errors
 Help patients/caregivers with early symptom recognition,
management of chronic conditions, and
recommendations for future care.
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Comprehensive Care
Coordination Programs
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Implement evidence-based guidelines for care management
Conduct a comprehensive assessment
Collaboratively develop and implement a plan of care
Teach/coach patients about proper self-care, medications, how to
communicate with providers
Monitor patients’ symptoms, well-being and adherence between office
visits
Advise patients on how to talk with and when to see their physician
Apprise patients’ physician and other providers of important symptoms
or changes
Arrange for needed health-related support services
Coordinate communication among physicians, health/community
providers and patient/family
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Comprehensive Care Coordination:
Medicare/Duals
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Guided Care
Care Management Plus (CMP)
Medicare Coordinated Care
Geriatrics Resources for Assessment and
Care of Elders (GRACE)
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Comprehensive Care Coordination:
Guided Care
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Guided Care: Boult
 A model of comprehensive
health care provided by
nurse-physician teams for
patients with several
chronic conditions
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Comprehensive Care Coordination:
Guided Care
Target Population
 Inclusion Criteria
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Older patients (65+) at high risk of using health
services during the following year, as estimated by
Hierarchical Condition Category (HCC) predictive
model
High risk was equated with HCC scores of 1.2 or
higher
Exclusion Criteria
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Low HCC scores
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Comprehensive Care Coordination:
Guided Care
Staffing
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Registered nurse based in primary care practice working with 3-5 physicians
Caseload: 1 care coordinator (CC) per 50-60 patients
Duration: Ongoing
Focus
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Enhance primary care by infusing the operative principles of all seven chronic
care innovations
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Comprehensive patient evaluation
Individual care planning
Promote adherence with evidence-based guidelines
Empower patient
Promote healthy lifestyle
Coordinate care of multiple conditions
Coordinate care across provider settings
Caregiver support and education
Access to community resources
Make evidence-based, state-of-the-art, chronic care available continuously from
teams of professionals that patients trust
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Care Management Plus (CMP)
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CMP: Dorr
 Patient-centered intervention designed to
reduce mortality and hospital admissions for
elderly patients of primary care physicians.
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Care Management Plus (CMP)
Target Population
 Inclusion:
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A) Elderly (65+), chronically patients of primary care
physicians served by Intermountain Health Care, a
large health care system in Utah
Medicare Part B for at least 11 months prior to
enrollment
Multiple comorbidities, diabetes, frailty, dementia,
depression, other mental health needs
Physician referral
Exclusion:
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Patient declined to participate
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Care Management Plus (CMP)
Staffing
 All care managers are RNs, generalists, located
in primary care clinics
Caseload: 1 care coordinator (CC)/350-500
patients
Duration: 24 months
Focus
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Continuity of care through specialized information
technology system
Education for specific diseases and problem-solving skills
Emphasis on evidence-based treatment plans and
protocols
Flexibility of care planning and treatment plans
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Comprehensive Care Coordination:
MCCD Best Practice Sites
MCCD
 Provide care coordination services to high risk Medicare
beneficiaries with multiple chronic conditions to improve
quality and reduce total cost of care
Evidence
 Intervention patients in the 4 best practice sites had:
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Lower re-hospitalization rates by 8% to 33% among high-risk
enrollees
Lower total Medicare expenditures combined 4 sites of $157 per
member per month (2010 dollars)
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Comprehensive Care Coordination:
MCCD Best Practice Sites
Target Population (portion of study in each
promising practice program)
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Inclusion Criteria
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Medicare beneficiaries with chronic obstructive pulmonary disease
(COPD), congestive heart failure (CHF) or coronary artery disease
(CAD) and at least on hospitalization in the prior year and any of
the 12 chronic conditions and two or more hospitalizations in the
prior two years
Exclusion Criteria
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Enrolled in hospice, reside in nursing home or have end stage
renal disease (ESRD)
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Comprehensive Care Coordination:
MCCD Best Practice Sites
Staffing
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Registered nurses trained in comprehensive care coordination
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Washington University and Health Quality Partners had staff primarily located in
community offices (not hospital, clinic, home health); Mercy Medical Center staff located
in hospital and primary care clinics and Hospice of Valley staff located in Hospice
Agency
Caseload
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Wash U: 1 CC per 85-95 patients
HQP: 1 CC per 75-85 patients
Mercy: 1 CC per 80 patients
Hospice: 1 CC per 45 patients
Duration: Ongoing
Focus
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Improved self-care
Improved symptom recognition and management
Improved medication management
Implementation of evidence-based practices
Improved transitional care
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Internal Evaluation
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How to achieve fidelity to model:
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Comprehensive and ongoing training of care coordinators
Established and updated evidence based guides for practice
Regular feedback to care coordinators on whether patients are
receiving care consistent with guidelines
Tracking of and feedback to care managers on established
contacts (monthly visits, visits within 24 hours of hospital
discharge, etc.)
Feedback on implementing self-management and evidencebased guidelines with patients
Tracking and reporting amount of time care coordinator spends
on tasks (assessing, planning, monitoring, educating, coaching,
documenting, supporting, and coordinating)
Need web-based care management system to measure
fidelity and generate feedback
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External Evaluation: What we Need
to Evaluate to Judge Success
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Effect on hospital admissions and readmissions
Effect on medical costs (by service type, total)
Whether savings exceed intervention costs
Effects on quality of care indicators (e.g.,
screening tests, preventive care, ED visits,
infections, falls, mortality, etc.)
Effects on patients’ quality of life
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What Distinguishes Successful Comprehensive
Care Coordination/Care Management?
Targeting
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Patients with select chronic conditions including co-occurring
serious mental health diagnoses and substance abuse.
Those who were hospitalized in previous year or at time of
enrollment
Caseload
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Small enough caseload size (e.g. 40-80)
Training and Feedback CC
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Initial comprehensive training of care coordinators
Deliver effective patient education and coaching
 Providing a strong, evidence based patient education/coaching
intervention for managing health, symptoms, medications
Performance feedback to care coordinators
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What Distinguishes Successful Comprehensive
Care Coordination/Care Management?
Primary Care Provider
 Strong rapport with primary care provider/specialist/hospital
 Face-to-face contact through co-location, regular hospital
rounds, accompanying patients on physician visits
 Assign all of a physician’s patients to the same care coordinator
when possible
Contacts
 Frequent face-to-face contact (home, office) with patients
(~1/month)
Intervention
 Conduct comprehensive in-home initial assessment
 Develop a mutually agreed to “action plan” with goals
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What Distinguishes Successful Comprehensive
Care Coordination/Care Management?
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Interventions follow evidence-based practices/guidelines for care
management
Address psychosocial issues: Staff with experts in social supports and
community resources for patients with those needs
Being a communications facilitator: Care coordinators actively
facilitating communications among health and community providers
and between the patient and the providers
Implement self management, coaching and support with patient/family
Implement effective medication management plan
Manage care setting transitions: Having a timely, comprehensive
response to care setting transitions (esp. from hospitals and skilled
nursing facilities)
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Policy Implications
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Best short run opportunity for reducing costs is improving
transition from hospital to home
Need payment reform to incentivize hospitals and primary
care practices to implement these programs
 Medicare and Medicaid incentives to reduce readmissions
 Tying physicians’ compensation to quality and efficiency scores
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Medicare and Medicaid should consider separate
reimbursement for care managers implementing proven
interventions with target groups
Special training programs for care coordinators and
managers are needed
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Contacts – Questions or Additional
Information
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Paul Shelton, EdD
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Email: [email protected]
Phone: 1-205-748-0050
Cheryl Schraeder, RN, PhD, FAAN
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Email: [email protected]
Phone: 1-217-586-6039
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