The CCNC Story. Presented by: Dan Gottovi, MD

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1 The CCNC Story How building medical homes for NC Medicaid patients and supporting them with case managers improved health status and saved money. Presented by: Dan Gottovi, MD

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3 Background NC is a rural state unsuited for traditional managed care NC is dominated by small practices and loosely organized medical systems The County Health System remains very strong Since the early 1990 s, NC has promoted Carolina Access, a Medical Home program for Medicaid recipients

4 Our Leaders and Mentors

5 Vision and Mantra If we use evidence based medicine and take really good care of the patients, I think we will save the Medicaid program money. - H. David Bruton, MD Secretary of NC HHS under Governor James B. Hunt

6 First Attempt Called Access I, which assigned Medicaid patients to a medical home without case management, did not result in any measurable savings. But, Carolina Access became the foundation for Community Care.

7 Waiver In 1998 the waiver that was in place for the Primary Care Case Management Program (Carolina Access) was amended to provide the practices and the networks an enhanced care management fee. The physicians continued to get reimbursed for the E & M codes via fee-for-service (currently, the Community Care program operates under a State Plan Amendment and the waiver is no longer needed).

8 Pilots

9 Having case managers assist medical home with the use of evidence based clinical guidelines for asthma as an example Saves Medicaid $$$...

10 Network ED Fever ED Otitis ED URI ED Asthma ED Diabetes AccessCare $ 224 $ 186 $ 171 $ 240 $ 413 $ 494 $ 382 ED CHF ED COPD AccessIICare of WNC $ 217 $ 180 $ 179 $ 249 $ 433 $ 255 $ 384 Access III of Lower Cape Fear $ 222 $ 187 $ 174 $ 233 $ 308 $ 390 $ 357 Southern Piedmont Community Care Plan $ 225 $ 170 $ 187 $ 232 $ 486 $ 315 $ 339 Carolina Collaborative Community Care $ 260 $ 178 $ 187 $ 275 $ 502 $ 474 $ 426 Carolina Community Health Network $ 270 $ 173 $ 194 $ 269 $ 354 $ 447 $ 412 Central Piedmont Access II $ 330 $ 205 $ 234 $ 361 $ 706 $ 975 $ 528 Community Care Partners of Greater Mecklenburg $ 297 $ 179 $ 187 $ 335 $ 423 $ 661 $ 555 Community Care of Eastern Carolina $ 239 $ 184 $ 182 $ 259 $ 331 $ 468 $ 364 Community Health Partners $ 244 $ 184 $ 185 $ 284 $ 396 $ 620 $ 452 Northern Piedmont Community Health Network $ 380 $ 224 $ 243 $ 403 $ 475 $ 548 $ 543 Partnership 4 Health Management $ 243 $ 175 $ 172 $ 266 $ 351 $ 455 $ 602 Sandhills Community Care Network $ 251 $ 176 $ 190 $ 233 $ 433 $ 440 $ 295 Wake & Johnston County Access II $ 415 $ 277 $ 303 $ 717 $ 598 $ 940 $ 973

11 Expansion Armed with this data and facing rising costs in the Medicaid budget, the new Secretary of NC HHS in 2000 challenged the ORH/CCNC leadership to expand the program to all of North Carolina s 100 counties

12 Today

13 Network Development CCNC and the Office of Rural Health staff provided a template and technical assistance to local leadership to assist with the local network development, which takes about a year.

14 Network Structure Three Networks are centered around major medical centers and the funds flow through those entities to hire the Network staff. The other eleven Networks were formed by establishing a local 501c3 Board.

15 Board Structure The CCNC/ORH template required getting the major stake holders on the local boards including: The Hospital Director or his/her representative The County Health Department Director or his/her representative A physician elected by or appointed by the County Medical Society The Department of Social Services

16 Board Additions Many Networks added: A representative from the local Area Agency on Aging A representative from the local Area Health Education Center A representative from the local management entities local mental health representative

17 Multi-County Networks Election of an Executive Committee with representatives of each county and each major stakeholder group is critical for success.

18 Access III of the Lower Cape Fear Onslow Bladen Pender Brunswick New Hanover Columbus

19 Initial Network Staff Each Network had a core staff of: A Network Coordinator who was often a nurse with an MPH or similar experience, interest and training. A Clinical Director who was a local physician who contracts with the Network for 20-70% of his/her time. Case Managers who were mostly RN s though respiratory therapists, social workers, and other individuals with lesser medical training have served as case managers.

20 Medical Management Committee Each Network has a Medical Management Committee made up of physician leaders who meet with the Clinical Director and staff to review Network and practice specific data.

21 Network Staff Evolution Over time, with the transition from specific disease management to chronic care management, all Networks have added a pharmacist, an IT coordinator, and most are adding quality improvement coordinators to assist with data analysis and presentations to physician practices.

22 How It Really Works 1 The average caseload for a case manager is 3500 recipients with between active cases on any given day. Activity levels vary from Heavy (4 or more contacts per month) with Light levels of activity as low as 1 contact per year. CMIS (Case Management Information System) provides case managers with information on their patients from Medicaid claims data including out patient visits, hospital visits and pharmacy utilization.

23 How It Really Works 1 (continued) CMIS provides templates that allow case managers to prioritize their case lists by level of severity. Almost all Networks have arranged for daily information from their hospitals on ED visits and hospitalizations of their patients. Practice specific audits of major initiatives are done annually and this data is also used by CMs, Clinical Directors, and MM Committees for their work with practices.

24 How It Really Works 2 Decisions about clinical initiatives were initially made by the network Clinical Directors with input from NC HHS and ORH staff based on Medicaid budget needs. New initiatives now emanate from the State leadership team and from the Networks. They are presented and discussed at the Statewide Clinical Directors meetings. After discussion at the Network level they are voted upon at the next Clinical Directors meeting.

25 How It Really Works 2 (continued) Local Networks can initiate projects as long as they do not interfere with work on the statewide initiatives.

26 Current State-wide Disease & Care Management Asthma Diabetes Initiatives Pharmacy Management (PAL, Nursing Home Polypharmacy) Dental Screening and Fluoride Varnish Emergency Department Utilization Management Case Management of High Cost-High Risk Congestive Heart Failure Chronic Care Program including Aged, Blind and Disabled

27 Current Local Network Quality Improvement Initiatives Assuring Better Child Development ABCD Attention Deficit and Hyperactivity Disorder ADD/ADHD HealthNet/Coordinated care for the uninsured Childhood Obesity Stroke Prevention Diabetes Disparities Medical Home/ED Communications

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29 Information Silos Patient Demographics Information Patient Clinical Information Patient Case Management Information Patient Medicaid Claims Data User Communication and Information Sharing

30 Patient Demographics Personal Information (Address, SSN etc.) Contacts Information (Emergency, Guardian, Foster Care etc.) Insurance Information (Primary Insurance, Deductible etc.) Employment Information (HealthNet uninsured program only) Income Information (HealthNet Individual, Household etc.) Assets Information (HealthNet uninsured program only.)

31 Patient Case Management Information Demographics

32 Patient Case Management Information Demographics (cont.)

33 Patient Clinical Information Pharmacy Claims

34 Patient Clinical Information All Claims Combined

35 Patient Case Management Information Care Plan

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39 Asthma Recent Results 40% decrease in hospital admission rate 16% reduction in Emergency Department visit rate 93% received appropriate maintenance medications Diabetes 15% increase in quality measures Source: 2007 Asthma Disease Management Program Summary

40 CCNC Fiscal Year 03 (July 2002 June 2003) Annual Cost - $8.1 Million (Cost of Community Care Operations) Annual Savings - $60 million compared to CCNC FY02 Annual Savings - $203 million compared to estimated cost of Fee For Service (FFS) reimbursement Source: Mercer Cost Effectiveness Analysis AFDC only for Inpatient, Outpatient, ED, Physician Services, Pharmacy, Administrative Costs, Other

41 CCNC Fiscal Year 04 Annual Cost - $10.2 Million (Cost of Community Care Operations) Annual Savings - $124 million compared to CCNC FY03 Annual Savings - $225 million compared to FFS Source: Mercer Cost Effectiveness Analysis

42 Recent CCNC Fiscal Years 06 & Annual Savings - $231 million compared to FFS 07 Annual Savings - $135 million compared to FFS NC Medicaid Administrative Costs are only 6%

43 Keys to Success Talented leadership at the State and Network level who are committed to making health care better for the least of these my children. Pilots to try out new initiatives Work groups The 3 Cs Communicate Communicate Communicate!!!!

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45 Work Groups: CMIS User Work Groups work on system requirements and testing. Chronic Care Strategic Planning higher level decision makers working to implement policies and procedures to meet legislative requirements Setting Expectations integrates Chronic Care strategies into CCNC Network and care managers daily activities by setting standards and implementing policies. Mental Health, Pediatrics, Special Initiatives and others as required to meet pr gram requirements.

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47 Next Steps Enhance the medical home ability to manage chronic illness Enhance support for patient self-management Improve care planning & coordination across provider settings Integrate specialist expertise into the care improvement process Strengthen clinician communication and performance feedback Invest in an improved Clinical Information System Implement 646 Better integration with IPIP Better integration with mental health efforts Support for quality of life initiatives

48 Intervention Exempt 646 Counties Martin Tyrrell Hertford Dare Brunswick New Hanover Pender Cumberland Warren Northampton Halifax Nash Wayne Duplin Edgecombe Pitt Greene Bertie Jones Gates Carteret Pamlico Washington Hyde Robeson Columbus Bladen Sampson Person Hoke Harnett Granville Wake Johnston Vance Franklin Caswell Alamance Chatham Orange Davie Stanly Stokes Rockingham Guilford Randolph Union Anson Richmond Gaston Mecklenburg Cabarrus Forsyth Davidson Montgomery Alleghany Wilkes Surry Ashe Catawba Yadkin Iredell Clay Polk Caldwell Watauga Mitchell Cherokee Macon Graham Swain Jackson Haywood Madison Rutherford McDowell Yancey Avery Burke Alexander Transylvania Henderson Buncombe Cleveland Lincoln Rowan Moore Scotland Lee Durham Wilson Lenoir Beaufort Craven Onslow Holdouts Updated: October 1, 2009

49 14 Practices 7 just starting 11 practices 6 just starting 16 practices 7 just starting 18 practices 4 just starting 9 practices 5 just starting 18 practices 12 just starting 134 Practices identified 93 practices fully engaged, 41 just starting 9 regions 24FM, 9 GIM, 19Peds, 23 other (multi, HD, FQHC, RH) ~ 50%EHR 20 practices 22 practices

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51 Want to know more

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