Identifying and Providing Care Management for Vulnerable Populations: A View From the Bronx, New York

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1 Identifying and Providing Care Management for Vulnerable Populations: A View From the Bronx, New York Presentation to the Third ACO Summit June 7, 2012 Stephen Rosenthal, MSc., MBA President, Chief Operating Officer CMO, The Care Management Company of Montefiore

2 Agenda Overview of the Bronx population Montefiore s integrated delivery system Montefiore s care coordination program Identifying and serving vulnerable and high risk populations The Montefiore Pioneer ACO 2

3 Overview of the Bronx Population and Montefiore s Integrated Delivery System

4 The Bronx, NY: 1.4 M People 31% poor (vs. 21% across all of NYC); 90% Hispanic and/or Black Heavy disease burden Higher prevalence of diabetes, obesity, asthma and other chronic conditions than NYC or NYS 20% higher per capita medical expense than US 8% of population accounts for 50% of medical expense 4

5 Government Payers in the Bronx: Population and Healthcare Spend 5

6 Montefiore s Integrated Delivery System Inpatient Care- Over 90,000 admissions Three general hospitals and one children s hospital 1,500 beds Ambulatory Care- 2.5 million visits/year 21 community primary care centers (>1 million visits) 16 school health centers (52,000 visits) 7 mobile healthcare units (11,000 visits) 4 emergency departments (301,000 emergency visits) 3 major specialty care centers (>1 million visits) Post-acute care Home care agency (500,000 visits) Rehabilitation University Hospital for Albert Einstein College of Medicine 6

7 Montefiore IPA and CMO Montefiore IPA Formed in 1995 MD/ Hospital Partnership Contracts with managed care organizations to accept and manage risk Over 2,300 physician members (1,740 employed) 430 PCPs 1,870 Specialists CMO Montefiore Care Management Established in 1996 Wholly-owned subsidiary of Montefiore Medical Center Performs care management delegated by health plans as well as other administrative functions, e.g. claims payment, credentialing Licensed UR agent and certified claims adjustors 7

8 Montefiore s Risk and/or Value- Based Population and Revenue Source 2012 Population 2012 Est. Revenue 2013 Population 2013 Est. Revenue Risk Contracts 140,000 $850 m 185,000 $1,085 m Shared Risk 78,000 $490 m 80,000 $685 m Medicaid health Home (Care Coordination) 10,000 $10 m 10,000 $18 m 228,000 $1,350 m 270,000 $1,788 m The organization is moving from a transaction-oriented business to performance/value-based system. 8

9 9 Montefiore s Care Coordination Program

10 Population Health Management Strategy POPULATION Self-ID Data Mining WELL & WORRIED WELL Sentinel Events, e.g. Post Discharge Provider Referral L O W I N T E R V E N T I O N I N T E N S I T Y WELL & WORRIED WELL MEMBERS ACCESS INFORMATION, AS NEEDED * My Montefiore * General Health Information * PHR FUNCTIONAL CHRONICALLY ILL MEMBERS ACCESS INFORMATION, AS NEEDED HEALTH EDUCATION & INTERVENTIONS ARE TARGETED TO MEMBERS * Self-management/empowerment tools * Customized assessments FRAIL ILL/HIGH UTILIZERS H I G H INTERVENTIONS ARE TARGETED TO MEMBERS HEALTH INFORMATION ACCESSED BY CAREGIVERS, AS NEEDED 10 FUNCTIONAL CHRONICALLY ILL FRAIL ILL/ HIGH UTILIZERS * Intensive/complex case management * Palliative care * Transitional care management

11 Vulnerable People: Need close monitoring Those with select chronic conditions currently in control Those being discharged from the hospital Those being discharged from home care services Duals Nursing home residents 11

12 High Risk People: Need Immediate Attention Those with high costs Those with select chronic conditions that are not in control (diabetes, heart failure, asthma, COPD and a combination of depression and one of the above chronic conditions) Those with multiple co-morbidities/ polypharmacy Homeless and those with unstable housing Frail elderly and cognitively impaired Those with serious psychosocial/economic problems 12

13 13 Care Guidance Program

14 Care Guidance Principles Comprehensive baseline assessment done on candidates for intensive case management Assessment covers medical, behavioral and social risk factors Care management system that links identified problems to possible interventions Individualized care plan produced Accountable Care Manager discusses care plan with patient and/or caregiver and modifies as needed Care plans shared with PCP 14

15 Care Guidance Principles Care management teams linked to specific PCMHs Use telemonitoring devices and telephone calls to monitor progress and reassess as needed Patients not identified as needing intensive case management can receive: Chronic care management (diabetes, CHF, asthma/copd, depression) Referral to House Calls, Palliative Care, Hospice Interventions during episodes of care: Post-discharge calls, ED Navigators, inpatient case managers Pharmacy reviews 15

16 Using PCMHs to better support high risk/ vulnerable populations Enhance staffing and systems to address patients mix of medical and psychosocial issues: Broaden use of team-based care by adding nurses and social workers to increase patient education opportunities Expand care coordination for patients seen by multiple providers (patient tracking, registries) Hub and Spoke Model (coordination with CMO) Increase patient-provider communication opportunities with secure messaging Increase responsiveness to patient feedback on their experience 16

17 Significant Improvement in Severe Diabetic Medicare Patients Groups with baseline A1c 9. CMO patients have a significantly higher rate of achieving target A1c <=8 Cumulative Percent HgbA1c <8 P <.01 Note: Sample Size includes 386 Medicare patients managed by CMO vs. 1,052 Not CMO Medicare Patients with a median age of 71 for CMO Patients vs. 67 for Non-CMO Patients 17

18 Decline of 30% for Diabetic Patient Admissions Source: CMO Paid Claims; Author: H. Shao 18

19 Effective Management of Diabetes has resulted in a 12% Drop in Total Costs 19 Note: Rx costs not available Note: Projected Costs Estimated using healthcare inflation trend of 16% Source: CMO Medical Expense Report; Author: H. Shao

20 20 Identifying and Serving High Risk/ Vulnerable Populations

21 Identifying high-risk/ vulnerable patients Data mine in clinical, billing and claims systems Use predictive tool to identify those at risk of readmission (at point of admission) Collect data related to sentinel events Post-discharge calls ED patient navigators and inpatient case managers Referrals from medical, behavioral care, social service, and housing providers Patient/ caregiver self-referrals 21

22 Care Coordination for High Risk/ Vulnerable Populations Individual Level Assessment tools focus on medical and psychosocial issues Expand capability to work with participants face-to-face Incorporate tools to support individual behavior change Provider Level Improve access and availability Expand PCMH infrastructure Incorporate behavioral health expertise into care management teams System Level Support organizational behaviors that reduce preventable utilization Partner with other providers/agencies to identify vulnerable patients and create integrated comprehensive care plans Develop IT infrastructure to support cross-organizational communication and data exchange 22

23 High risk example: Housing-at-Risk Real Time flagging of individuals who present in the ED or are admitted to the hospital who have Address that says homeless, undomiciled or shelter Home address that is one of our hospital or clinic sites or a shelter address PCP who specializes in care for this population Been identified by housing/social service provider as at-risk When a Housing-at-Risk person presents ED Social worker is beeped and alert is sent to ED Patient Navigator or Inpatient Social Work Manager (as appropriate) alert includes list of previous ED visits and reason for visit (e.g. visit to get prescriptions refilled) 23

24 High risk example: Housing-at-Risk Social worker meets with patient and ED providers to assist in discharge plan, assure care is accessed and unnecessary admission avoided Housing organization may come to pick up patient and drive to another care setting if necessary Some housing providers support patients in following treatment plans Regular case rounds on most challenging patients Have secured 2 respite beds to facilitate hospital discharge of the homeless and allow extended recovery time outside the acute care setting 24

25 High risk example: Programs for Frail Elderly Identified through provider referrals and case manager recommendations Provide primary care, at home, for those unable to access care on an ambulatory basis using teams of physicians, nurse practitioners and social workers Patients use telemonitoring devices to respond to standard set of questions on daily basis and care managers call patients to follow up depending on responses 25

26 Vulnerable population example: Synergy Program An evidence-based model for treatment of depression and/or alcohol abuse with chronic medical conditions Use clinical/claims information to identify patients in need Administration of PHQ 9 and AUDIT-C by PCP Interventions conducted in PCMH and telephonically Collaborative Care for Depression SBIRT protocol (screening, brief intervention, referral to treatment for at- risk alcohol use) Psychiatry Consultation and Short Term Therapy Intensive Case Management for Complex Patients Telephonic Psychotherapy for Depression and At-Risk Alcohol Use 26

27 27 Montefiore Pioneer ACO

28 Montefiore Pioneer ACO Population Initially attributed 23,250 fee-for-service Medicare beneficiaries 9,076 (39%) Duals 1,153 (4.9%) opted out of data sharing 21,292 beneficiaries with claims data 503 deaths to date 12,887 (55%) managed by community physicians not employed by Montefiore 780 live in nursing homes 28

29 Major Categories of ACO Expense $334.6 million 29

30 Pioneer ACO Charlson Conditions Charlson Comorbidities Non ICM % Total ICM % ICM Total Beneficiaries (deaths excluded) 20, % 1, % Diabetes without complications 3,590 17% % Chronic Pulmonary Disease 2,311 11% % Cancer 1,824 9% % Congestive Heart Failure 1,362 7% % Renal Disease 1,331 6% % Diabetes with complications (total) 1,239 6% % * Known deaths excluded * Conditions with 10% or more in either cohort 30

31 Pioneer ACO Candidates for Intensive Case Management 1,906 individuals (2+ admissions or expense >$50k in last 12 months) 9% of the population = 55% of the medical cost ($184m) 96 have already died 49% are Duals At least 113 reside in SNFs 55% have some psychiatric diagnosis Almost 70% are with non-employed PCPs 31

32 Ongoing efforts for ACO population New targeted interventions for select groups (e.g. Duals, ESRD) Additional interventions for SNF residents Expand linkage with non-employed ACO providers Expand strategies for beneficiary engagement Focus on patient satisfaction (7 of 33 ACO quality measures) Expand current programs 32

33 Expected Results of Accountable Care Bronx is a healthier community Bronx residents are more satisfied with their health care services Medicare achieves short term savings and decreased spending in long term The Bronx accountable care model is Sustainable Patient-Centric Transferable Efficient use of financial resources 33

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