Care Transitions A Community Partnership. Pamela Menard, NP, MBA V.P. Health Promotion & Care Management Washington, D.C.
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1 Care Transitions A Community Partnership Pamela Menard, NP, MBA V.P. Health Promotion & Care Management Washington, D.C. June 14, 2011
2 Independent Health A Snapshot Not-for-profit health plan established in 1980 Based in Buffalo, N.Y. Offers commercial group health plans; Medicare Advantage; Medicaid; Self-funded plan administration More than 365,000 members in WNY and across the nation IPA model Highest rated health plan in the nation for customer service: NCQA's Quality Compass 2009 and Subsidiaries include Pharmacy Benefit Dimensions (PBM administration) RelianceRx (specialty pharmacy) Nova Healthcare Administrators (Self-funded plans) YourNaturalOptions.com (vitamin/supplement company)
3 Goal Reduce readmissions by preparing members with knowledge and skills necessary to manage their conditions
4 Principles: Not a Health Plan program
5 Principles: Not a Health Plan program Engage physicians and providers in design and implementation
6 Principles: Not a Health Plan program Engage physicians and providers in design and implementation Align incentives
7 Principles: Not a Health Plan program Engage physicians and providers in design and implementation Align incentives Build collaboration through Operations team
8 Principles: Not a Health Plan program Engage physicians and providers in design and implementation Align incentives Build collaboration through Operations team Track and report results
9 Principles: Not a Health Plan program Engage physicians and providers in design and implementation Align incentives Build collaboration through Operations team Track and report results Evaluate and modify
10 Program Components: Enhanced discharge planning
11 Program Components: Enhanced discharge planning Home visit within 72 hours of discharge
12 Program Components: Enhanced discharge planning Home visit within 72 hours of discharge Self management guide
13 Program Components: Enhanced discharge planning Home visit within 72 hours of discharge Self management guide PCP visit within 7 days
14 Program Components: Enhanced discharge planning Home visit within 72 hours of discharge Self management guide PCP visit within 7 days Pharmacist review of all medications
15 Program Components: Enhanced discharge planning Home visit within 72 hours of discharge Self management guide PCP visit within 7 days Pharmacist review of all medications Ongoing telephonic health coaching for minimum of 30 days
16 Program Components: Enhanced discharge planning Home visit within 72 hours of discharge Self management guide PCP visit within 7 days Pharmacist review of all medications Ongoing telephonic health coaching for minimum of 30 days Referral to appropriate care support programs
17 Program Components: Enhanced discharge planning Home visit within 72 hours of discharge Self management guide PCP visit within 7 days Pharmacist review of all medications Ongoing telephonic health coaching for minimum of 30 days Referral to appropriate care support programs Facilitate communication with and between providers
18 Identifying Members At Risk The 7P s: Risk Assessment Principle Diagnosis CABG, CAD, Cardiac Valve, CHF, COPD, MI, Stent Problem medications Depression (Punk) Polypharmacy Patients on 5 or more medications Poor health literacy Patient support Prior hospitalization in the last 6 months
19 Partners Hospital Based Financial incentives not aligned Lack of buy in from medical staff Health Plan Program Other priorities Patient Centered Medical Home (P.C.M.H.) Financial alignment Practice based care coordinators Practice Patterns Lack of resources Physician / Healthcare System (Moderately Integrated) Financial alignment Strong PCP buy in and involvement Practice based care coordinators Integrated home care Desire to move to ACO model of care
20 Readmission Rates Overall Readmission Rate Hospital Based Readmission Rate 5.40% 5.20% 5.00% 6.80% 6.60% 6.40% PPR Rate 4.80% 4.60% 4.40% 4.20% 4.00% 5.27% 5.10% 4.96% PPR Rate 6.20% 6.00% 5.80% 5.60% 5.40% 5.20% 5.00% 6.65% 6.40% 6.36% Physician / Hospital Rate PCMH Rate 6.40% 5.00% 6.20% 4.50% PPR Rate 6.00% 5.80% 5.60% 5.40% 5.20% 6. 33% 5. 85% 5.60% PPR Rate 4.00% 3.50% 3.00% 2.50% 4.58% 4.05% 3.81% 5.00% %
21 Results 18% 17% 16% 14% 12% 12% % Improvement 10% 8% 6% 6% 4% 4% 2% 0% Overall Hospital Based Physician / Hospital PCMH
22 MTM Impact Analysis: Total costs (Medical and pharmacy) as average PMPY $23, $22, $21, $20, $19, costs (avg PMPY) 2009 costs (avg PMPY) Members participating Members eligible but not participating
23 Lessons: Agree to measurement Involve physicians upfront Engage patient / member Medication management key opportunities Timely communication difficult without integrated electronic support Focus on new healthcare delivery model vs. Program:
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