California Medi-Cal Readmission Reduction Initiative Population Health

Transcription

1 California Medi-Cal Readmission Reduction Initiative Population Health Lydia Mata RN, MBA, MSN-HC, CCM Director, Case Anthem BlueCross

2 Agenda Introduction Target Population Program Goal Interventions and Quality Care Readmission Reduction Initiative Cycle Readmission Reduction Initiative Outcomes 2

3 Introduction In 2015, we discovered that 275 SPD members accounted for 80% of our Fresno county IP readmissions at Community Regional Medical Center (CRMC). In response, we developed the case management Readmissions Reduction Initiative (RRI) program. The RRI program was first piloted in Fresno County to address readmissions for Seniors and Persons with Disabilities. In collaboration with CRMC, Anthem BlueCross (ABC) delivered intensive Care Coordination services to stabilize high risk patients. ABC partnered with CRMC, patients/caregivers, providers and community services to ensure patients had the support and education they needed to safely navigate from the hospital to home, or other care setting, and to prevent avoidable IP and ER readmissions. 3

4 Target Population Readmission Score (RAS) Likelihood of Readmission in the next 30 days Targets scores 25 and above Daily Census Chronic Illness Indicator (CI3) In comparison to average member Predictive risk score (1-4) Represents 12 months of diagnosis and paid claims information Likelihood of Inpatient Admission (LIPA) Prioritizes top 2% highest acuity members Predicts an admission in the next 60 days Modeled internally using our population for CI3 groups 2-4 4

5 Program Goals Helping patients understand their plan of care and to remove barriers to accessing care Coordination of care across the network (Specialists, pharmacies, hospitals, long term care supports, community services) Developing and maintaining value based care structures Implementing data and technology, providing a comprehensive view of a patient s health 5% Complex Cases- Requiring Face to Face coordination and support 20% Care - single serious condition or multiple chronic conditions 25% Care Coordination and Disease - single mild chronic conditions 50% Population - Preventative Care 5

6 Interventions Quality Care Within 72 hours of discharge Member Assessment/Engagement Access to discharge medications, Durable Medical Equipment (DME), authorizations, transportation Education on Red Flags Medication Reconciliation with member Assessment and data collection of SDOH (Food, Housing Assistance, Employment, Stress, Material Security) Within 10 business days Face-to Face Post-discharge visit with CM Primary Care Physician (PCP)/Specialist appointment assistance Action Plan complete Member Health Record Medication Reconciliation with PCP Within days Evaluation and application for caregiver support (In-Home Supportive Services, In Home Operations, Community Based Adult Services) Activation of support services: Behavioral Health Service linkage Member disease and health education Permanent Housing/ Connections to community resources 6

7 Readmission Reduction Initiative Overview (Fresno, Tulare, Sacramento, Butte, Alameda, and LA Counties) Utilization Member Identification (> 18 y/o, SPD, > 2 Readmissions in 12 months, daily census/emr, various referral sources) Aid Category Hospital Stabilization/Activation of long term supports (Housing, SUD/BH, CBAS, IHSS, Complex Case ) RN/SW Assessment (Review utilization claims/tar, Pharmacy, Medical Records, Member Surveys, SDOH, family/caregiver support) Diagnosis County Health Action Plan (Medication Reconciliation, Health/Red Flag Education, transportation, Community resources, follow up care) 7 Member / Provider Engagement (RN/SW/CHW, face to face in hospital, post discharge appointment, home)

8 Readmission Reduction Initiative Outcomes County Start Date- Dec 2017 # Members enrolled Readmission Reduction % Alameda 5/ % Butte 1/ % Fresno 12/ % Los Angeles 1/ % Sacramento 11/ % Tulare 10/ % Quality Measures Average % Member Enrollment/Engagement > 85% Post Discharge appointment compliance > 77% * Cost savings is calculated by comparing utilization 12 months prior to enrolling in the RRI program and adjusted for regression to the mean. 8

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