2015 Embedded and Rapid Response Case Management

Transcription

1 2015 Embedded and Rapid Response Case Management Program Evaluation Our mission is to improve the health and quality of life of our members

2 2015 Complex Case Management Program Evaluation Table of Contents Introduction Page 1 Goals Page 1 Objectives Page 1-2 Evaluation Members by Diagnosis in Embedded and Rapid Response Case Management Pages /7 Nurse Advice Line Pages 4-5 Embedded and Rapid Response Case Management and Utilization Management, ER, Admission and Readmission Utilization Member Survey Results for Satisfaction with Embedded and Rapid Response Case Management Services Received Pages 6-8 Pages 9-11 Annual Review of Populations Pages Barriers/Opportunities Page Activities Pages 15-17

3 2015 Embedded and Rapid Response Case Management Program Evaluation Program Title: Embedded and Rapid Response Case Management (ECM/RROT) Program Evaluation Evaluation Period: January 1, 2015 December 31, 2015 Introduction: To improve the health status and quality of life of members with medical conditions while decreasing unnecessary hospitalizations and emergency room (ER) visits by improving member self-management skills, and by increasing adherence of both members and clinician with the National Clinical Practice Guidelines, which are based on current scientific data. To coordinate the closure of healthcare gaps; identify and address barriers to care; engage in face-to-face contact for education and advocacy, creating a positive overall experience for our members. Program Goals: Emergency Department Redirection Rate of 80% or greater. Emergency Department, Inpatient Admission, and 30 day Readmission Reduction of 20% or greater. To maintain a goal of 90% or above in member satisfaction with all areas of Case Management (CM) services. To maintain a goal of 75% or above in member's perception of improved overall health status and quality of life at the time of discharge from CM. Maintain or exceed the goal of 90% or above in member satisfaction with all areas of ECM services. Program Objectives: Provide for the collaborative process in assessing, planning, implementing, coordinating, monitoring and evaluating the options and services needed to meet the members health and human service needs. To increase the number of members who either improved or reached their optimal level of health at the time of discharge from CM. Decrease unnecessary hospitalizations and ER visits. Improve member self-management skills and self-advocacy. Provide coordination of care and services to members who have experienced a critical event or diagnosis needing the extensive use of resources and who need assistance navigating the health care system or those members with special health care needs. 2/1/16 Page 1

4 To annually evaluate the primary diagnosis of members who trigger and enroll in ECM/RROT services to assure Passport Health Plan (Passport) has the appropriate staff, materials, and resources to assist members in improving their health and quality of life. To annually assess the characteristics of Passport s populations and evaluate available resources to meet the needs of these members. ECM/RROT Case Managers interacted with 9,147 Members in Evaluation I. Members by Diagnoses in ECM/RROT Objective: To annually evaluate the primary diagnosis of members who trigger and enroll in ECM/RROT services to assure Passport has the appropriate staff, materials, and resources to assist members in improving their health and quality of life. 2/1/16 Page 2

5 Analysis of Findings: The graph above represents members by diagnosis/condition referred and enrolled into ECM/RROT. The top three diagnoses were: 1) Neurology Disorders 2) COPD, Including Asthma 3) Child Psychiatric Disorder The graph above notes 610 members with Neurological Disorders, 474 with COPD, Including Asthma, and 292 with Child Psychiatric Disorders. Sickle cell members when identified are contacted to participate in Complex CM. The case manager then works with the member to help coordinate their care for optimum health and quality of life. Members with Sickle Cell: The Embedded Case Manager working in the Hematology/Oncology specialty clinic has been an invaluable resource when attempting to outreach for correct phone numbers and coordination of the care when the Complex CM has lost the member to contact, or needed someone to intervene with the office staff or clinician. The Embedded Case Manager at the clinic has been able to interact with over 140 members during This is an increase of 81.8%. Members with HIV/AIDS: ECM has provided the 550 Clinic with an Embedded Case Manager to coordinate care for this special member group. If a member requires intensive CM Coordination she then will refer to Complex CM. The Embedded Case Manager at the 550 Clinic typically carries a case load of 102 members, and fluctuates based on member s needs. This year there are 213 members in ECM at the 550 Clinic. This is an outstanding increase of 108%. 2/1/16 Page 3

6 II. 24/7 Nurse Advice Line 2014 and 2015 Member Emergency Department Redirection Rate by 24 hr Nurse Line 2014 and 2015 Member Agreement with Nurse Recommendation of Lower Level of Care by 24 hr Nurse Line 100% 80% 60% 82% 36% 37% 88% 100% 80% 60% 96% 95% 40% 20% 40% 20% 4% 5% 0% % Seek ER Care Directed to LLC Agrees Disagrees Goal: Emergency Department Redirection Rate of 80% or greater. Analysis of Findings: Total number of calls received in 2014 and 2015 were 9,511 and 13,003 respectively. This represents a 37% increase. The 24/7 nurse line is another method to assist membership to utilize appropriate health care services. Members contact the nurse line service for symptomatic calls in which a nurse assesses a medical complaint. Callers may also contact the nurse line service to obtain clinician referrals, general health information, or information about their health plan or its services. When a member contacts the nurse line service with a medical complaint, a specially trained registered nurse assesses the medical complaint using computerized algorithms and directs callers to the most appropriate level of medical care. Nurses have access to over 570 symptom-based computerized algorithms with more than 1,200 self-care instructions. The algorithms were developed from treatment protocols, from review of medical literature, and from an advisory panel of physicians. Medical literature is continuously reviewed to update and modify the algorithms. The algorithms use binary branch chain logic where each question elicits either a yes or no response from the caller to direct the next question and rule out serious conditions. In addition to the nurse line, mailings to members are conducted on a routine basis. Messaging centers around the following concepts: Call the Care for You Nurse Advice Line when you are sick, hurt or have a health related question. The Care for You Nurse Advice Line is a reliable and knowledgeable source for health care information. Passport beneficiaries have free, 24/7 access to health care information. 2/1/16 Page 4

7 In 2015, new members received information by mail about the nurse line on a monthly basis. The rate of redirection from the emergency department for 2014 and 2015 is 82%, 88% respectively. The member agreement post nurse discussion and education about illness was 96%, 95% respectively. Six of Passport's top 10 nurse advice line algorithms used were on adults, compared to four of the top 10 for the overall aggregate. Our Rapid Response Team makes outreach calls based on calls from the 24 hour nurse line. Follow up is done to ascertain that our members are being taken care of and that appointments are made with their Primary Care Provider (PCP) when appropriate. Also direction may be needed at that time. Passport Aggregate (All Axispoint Health Clients) 9/1/2014 through 8/31/2015 9/1/2014 through 8/31/2015 The two algorithms for Passport which are different from Axispoint Health s overall aggregate algorithms used are highlighted in the graph above. 2/1/16 Page 5

8 III. ECM and RROT ER, Admission and Readmission Utilization 2/1/16 Page 6

9 Goal: Emergency Department, Inpatient Admission, and 30 day Readmission Reduction of 20% or greater. Analysis of Findings: This is a comparison of utilization specifically related to members in ECM and RROT CM. In analyzes rates of utilization prior to enrollment in ECM/RROT comparative to after. There was a decrease (18.01%) and (22.62%) in ER Visits respectively when compared to utilization prior to ECM and RROT involvement. There was a decrease (44.72%) and (9.65%) in Inpatient Admissions respectively when compared to utilization prior to ECM and RROT involvement. There was a decrease (64.41%) and (49.06%) in Readmissions respectively as compared to utilization prior to ECM and RROT involvement. 2/1/16 Page 7

10 , UM ER and Inpt Admits 1, , Medical Admits/1000 BH Admits/1000 Medical Days/1000 BH Days/1000 Medical ALOS BH ALOS 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter 2014 Q1 Q2 Q3 Q4 Average Days Medical Admits/1, BH Admits/1, Medical Days/1, BH Days/1, , Medical ALOS BH ALOS UM ER and Inpt Admits Medical Admits/1000 BH Admits/1000 Medical Days/1000 BH Days/1000 Medical ALOS BH ALOS 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter 2015 Q1 Q2 Q3 Q4 Average Days Medical Admits/ BH Admits/ Medical Days/ BH Days/ Medical ALOS BH ALOS Analysis of Findings: This is a comparison of 2014 and 2015 utilization specifically related to UM. Compared to 2014, there was an increase of 4% in Medical Admissions, a 58% decrease in BH Admissions, an 15% decrease in Medical Days, a 93% decrease in BH Days, an 17% decrease in Medical ALOS, and a 67% decrease in BH ALOS. 2/1/16 Page 8

11 IV. Member Survey Results for Satisfaction with CM Services Received* *Rapid Response CM utilized the In House CM Satisfaction Survey in 2015 Goal: Maintain or exceed the goal of 90% or above in member satisfaction with all areas of CM services. Analysis of Findings: The graph above represents member satisfaction with CM. Areas surveyed include: 1) Frequency of contact 2) Professional manner 3) Coordination of care 4) Value of information 5) Overall effectiveness The goal is 90% for each area. During 2015, 78 member surveys were distributed, of which 17 were returned yielding a 22% return rate. Results indicate 100% of members who responded to the survey reported satisfaction with frequency of contact, 93% reported professional and courteous manner, 75% reported ability of case manager to help coordinate their care, 97% reported usefulness of information, and 100% reported overall helpfulness. The goal was met in three of the four areas. During 3 rd Quarter 2015, out of the forty-four (44) member surveys that were mailed, only one (1) was returned yielding a 2% return rate. In an attempt to increase the return of surveys, we are revamping the design of the survey to be more user-friendly to promote members to return the surveys mailed to them. 2/1/16 Page 9

12 V. Member Satisfaction Results for Improvement of Health or Quality of Life Goal: Maintain or exceed the goal of 75% or above in member's perception of improved overall health status and quality of life. Analysis of Findings: The graph above represents the members satisfaction regarding improvement in health or quality of life. Areas surveyed include: 1) Goals set by Case Manager and Member 2) Quality of Life 3) Overall Health 4) Control of Pain The goal is 75% for all areas. Results indicate 51% of members who responded to the survey reported improvement in quality of life, 35% reported improvement in overall health, and 20% reported better pain control. The goal was not met in all areas. There were four (4) unfavorable results in overall health. There were seven (7) unfavorable in control of pain. This may be attributed to the inception of House Bill 1 and a decrease in PCPs prescribing practices for pain control and the increased use of clinicians in Pain Management. It was noted that there were no member complaints in /1/16 Page 10

13 VI. Member Survey Results for Satisfaction with ECM Services Received Goal: Maintain or exceed the goal of 90% or above in member satisfaction with all areas of ECM services. The graph above represents member satisfaction with CM. Areas surveyed include: 1) Manage needs better 2) Listen and explain clearly 3) Professional manner 4) Overall helpfulness The goal is 90% for each area. During 2015, 3,682 member surveys were distributed, of which 223 were returned yielding a 6% return rate. Results indicate 100% of members who responded to the survey reported satisfaction with managing needs better, 100% reported listened and explained information clearly, 99% reported professional and courteous manner, and 100% reported overall helpfulness. The goal was met in all areas. 2/1/16 Page 11

14 VII. Annual Review of Population 2014 Top 5 Primary Diagnosis Codes for All Members 2014 Top 5 Secondary Diagnosis Codes for Members Diagnosis Code Diagnosis Description Member Count Diagnosis Code Diagnosis Description Member Count ADD of Childhood with Hyperactivity 135, Unspecified Essential Hypertension 66, Unspecified Episodic Mood Disorder 99, Lumbago 38, Unspecified Essential Hypertension 71, Nondependent Tobacco Use Disorder 35, Unspecified Chest Pain 70, Diab W/O Comp Type II/Uns Not Stated Uncntrl 34, Diab W/O Comp Type II/Uns Not Stated Uncntrl 70,157 V5869 Encounter For Long-Term Use of Other Medications 29,652 2/1/16 Page 12

15 5,163 4, , , , , , ,861 73,691 95, , , , , , ,604 Diagnosis Code V Top 5 Primary Diagnosis Codes for All Members 2015 Top 5 Secondary Diagnosis Codes for Members Diagnosis Description Member Count Diagnosis Code Diagnosis Description Member Count ADD of Childhood with Encounter For Long-Term Use Hyperactivity 125,479 V5869 of Other Medications 60,714 Opioid Type Dependence Unspecified Essential Unspecified Abuse 90, Hypertension 51,033 Unspecified Episodic Mood Disorder 77, Anxiety State, Unspecified 38,070 Depression Disorder Not Elsewhere Classified 64, Lumbago 36,478 Encounter For Long-Term Use of Other Medications 62, Nondependent Tobacco Use Disorder 33, & 2015 Member Demographics 350, , , , , ,000 50,000 - Gender Age Group Location Objective: To annually assess the characteristics of Passport s populations and evaluate available resources to meet the needs of these members. 2/1/16 Page 13

16 Analysis of Findings: Population Analysis: At least annually, Passport assesses, analyzes, and evaluates the characteristics and needs of its member population in order to identify relevant subpopulations, revise and update its processes to meet member needs, and to assure Passport has all the needed resources to address member s needs. During 2015, Passport engaged in enrolling several subpopulations as a group into CM services. As in years past, children remain a majority of our plan enrolled population at approximately 83%, increased from 80% in However, the adult population tends to be the age group enrolled in CM services. Also, as in years past, the female population is higher than the male population. Noted co-morbidities of the CM population each have specific DM programs with the exception of End Stage Renal Disease. Members with an ESRD diagnosis tend to utilize CM services versus DM due to needing dialysis and a higher level of care coordination than typical DM programs. Therefore, Passport has made a conscious decision to keep those members in CM. At this time, no barriers are identified thus no changes are needed at this time. Another notable population analysis is the increase in member population with discernable Behavioral Health (BH) Issues. We have placed Embedded Case Manager s at JADAC, Phoenix and working towards St. John s and the VOA. Substance use as well has been noted with an increase in referrals as well. This most certainly can be contributed to House Bill I and the declination in prescribing opioids by our Clinicians. Member Engagement: Embedded Case Managers engaged 8,280 at risk members face-to-face in clinician offices to assist with community resources, access to care, preventive care arrangements and availability to work one-on-one in the office. This number has increased by 91% from 4,345 in 2014 Embedded Case Managers work with the lower risk members to identify them for preventive care screenings and to identify members for more intensive care coordination as needed. Rapid Response Case Managers outreached to 867 unique members to assist with urgent needs and to identify conditions for Complex CM that require more intensive assistance to avoid complications. This number has increased by 18.9% in 2015, as 777 unique members were outreached in Barriers and Opportunities Barrier: Inability to locate member for initial assessment or ongoing contact. Opportunity: Collaborate with clinicians to encourage member participation and locate additional demographics. Member education regarding the benefits of CM through the Member Newsletter. 2/1/16 Page 14

17 Attempt to obtain working phone numbers through unable to contact, clinicians, pharmacies, and Tracfone. Target and Identify high risk members through the ECM services. Flyer developed to encourage members to keep current addresses and phone numbers up-to-date with the State. Barrier: Member unwilling to comply with treatment plan and its completion. Opportunity: Member education regarding the benefits of CM through the Member Newsletter. Member education regarding the benefits of CM through individualized contact with the member. Collaborate with clinicians to encourage member participation. Barrier: Limited member response to the CM survey. Opportunity: Encourage member response to survey at the time of discharge. Survey revised to reflect ease of answering questions and providing anonymous input. Consider a follow-up phone call to complete survey if not returned timely. Activities for 2015: Embedded Case Managers are located in 43 large clinician offices, which is an increase of six new large clinician offices from 2014 and one specialty clinic. A total of 8,280 members were engaged face-toface for resource assistance and assessed for care coordination. Rapid Response Case Managers outreached to 867 unique members for urgent needs and assessed for care coordination. This represents an increase of 18.8% from Embedded Case Managers conducted depression screenings (PHQ-2) with 1,196 adult members with 10% of the members with a positive screening. Further depression screening (PHQ-9) was conducted with those members. Embedded Case Managers referred 120 members to BH services. Embedded Case Mangers conducted depression screenings (PHQ-2) with 98 pediatric members with 12% of the members with a positive screening. Further depression screening (PSC-17) was conducted with those members. Embedded Case Managers referred 12 members to BH services. 2/1/16 Page 15

18 Reviewed the results of quarterly reporting to identify opportunities to improve the CM process. Reviewed surveys as received and conducted outreach to those members who indicate fair or poor responses on their survey (if the member completes contact information section of the survey tool). Monitored for trends, provide feedback both positive and negative to individual staff and address any identified areas that need improvement. Encouraged clinician involvement with CM. Educated members/caregivers regarding CM benefits and services through telephonic outreach, member newsletters, on-hold SoundCare messages, Passport s website, and member educational material. Continued utilizing other reports such as ER Utilization, Kosair ER, and Hospital admission reports to identify members who could potentially benefit from CM services. Collaborated with other departments such as UM, Member Services, and Provider Relations to identify members who could potentially benefit from CM services. Updated Care Coordination: Your Connection to DM and CM Programs pamphlet for clinicians on the different programs available to their membership. Updated Special Health Programs, Just for You! brochure for members on the different programs available for them to participate. Placed an Embedded Case Manager at the Kentucky Refugee Mission (KRM) and Catholic Charities (CC) to assist our members with PCP problems associated with the language barrier. Paced an Embedded Case Manager at JADAC. CM on site to meet with members to encourage health maintenance in conjunction with substance abuse issues. Activities for 2016: Continue to monitor member care gaps and work with member and clinician to increase preventative health screenings. Evaluate alternate methods of communication with members for health messaging. Review the results of quarterly reporting to identify opportunities to improve the CM process. Evaluate new satisfaction survey questions content for ease of understanding and return of survey to evaluate effectiveness of change. 2/1/16 Page 16

19 Consider a follow-up phone call to complete satisfaction survey if not returned timely. Review surveys as received and conducted outreach to those members who indicate fair or poor responses on their survey (if the member completes contact information section of the survey tool). Monitor for trends, provide feedback both positive and negative to individual staff and address any identified areas that need improvement. Encourage clinician involvement with CM. Educate members/caregivers regarding CM benefits and services through telephonic outreach, member newsletters, on-hold SoundCare messages, Passport s website, and member educational material. Continue utilizing other reports such as ER Utilization, Kosair ER, and Hospital admission reports to identify members who could potentially benefit from CM services. Collaborate with other departments such as UM, Member Services, and Provider Relations to identify members who could potentially benefit from CM services. Continue to evaluate placing Embedded Case Managers for placement into clinician practices with high volumes of members and ability to impact health outcomes. Preparing to add three new Norton Offices at least this year, to start. Embedded Case Manager to be placed at the Global Health Clinic. Increased enrollment noted in Kenton County. Will continue to monitor for ECM opportunities. Continue to improve collaboration with BH to improve overall coordination of care for members with co-existing medical and BH diagnoses. To include BH/substance abuse facilities. Revise member and clinician correspondence (i.e., letters, materials, etc.) to improve member and clinician education regarding CM services. Work with pharmacies to provide medication reviews to aide clinicians and members in decreasing polypharmacy related problems. Update satisfaction survey to obtain a better sampling for analysis. Create educational material and resources for our members with substance abuse issues with the assistance of Dr. Kristen Andrews here at Passport. 2/1/16 Page 17