2016 Embedded and Rapid Response Care Management

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1 2016 Embedded and Rapid Response Care Management Program Evaluation Our mission is to improve the health and quality of life of our members

2 2016 Embedded and Rapid Response Care Management Program Evaluation Table of Contents Program Purpose Page 1 Goals Page 1 Objectives Page 1-2 Member Interactions Page 2 Evaluation Top 30 Primary Diagnoses in Embedded and Rapid Response Care Management Pages /7 Nurse Advice Line Pages 4-5 Embedded and Rapid Response Care Management Emergency, Admission, and Readmission Utilization Member Survey Results for Satisfaction with Embedded and Rapid Response Care Management Services Received Pages 5-6 Pages 7-10 Annual Review of Passport Health Plan s Total Populations Pages Barriers/Opportunities Page Activities Pages 15-17

3 2016 Embedded and Rapid Response Care Management Program Evaluation Program Title: Embedded and Rapid Response Care Management (ECM/RR) Program Evaluation Evaluation Period: January 1, 2016 December 31, 2016 Program Purpose: Utilize clinical staff in-house and onsite at clinician practices 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 clinicians with the evidence-based national clinical practice guidelines. 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/RR 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. Decrease unnecessary hospitalizations and ER visits. Improve member self-management skills and self-advocacy. 2/27/17 FINAL Page 1

4 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. To annually evaluate the primary diagnosis of members who trigger and enroll in ECM/RR 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. Member Interactions: ECM Care Managers interacted with 8,830 members in RR Care Managers interacted with 1,247 members in Evaluation I. Top 30 Primary Diagnoses for Members in ECM/RR Objective: To annually evaluate the primary diagnosis of members who trigger and enroll in ECM/RR services to assure Passport has the appropriate staff, materials, and resources to assist members in improving their health and quality of life. 2/27/17 FINAL Page 2

5 Analysis of Findings: The graph above represents members by diagnosis/condition referred and enrolled into ECM/RR. The top three diagnoses were: 1) Spondylosis; intervertebral disc disorders; other back problems 2) Nonspecific chest pain 3) Mood disorders The graph above notes 246 members with spondylosis; intervertebral disc disorders; other back problems, 200 with nonspecific chest pain, and 176 with mood disorders. The Embedded and RR Care Managers works with the member to help coordinate their care for optimum health and quality of life. Members with Sickle Cell: The Embedded Care 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 CCM has lost the member to contact, or needed someone to intervene with the office staff or clinician. The Embedded Care Manager at the clinic has been able to interact with 58 members from January through August In September 2016, it was decided to remove the Embedded Care Manager from this specialty clinic due to resource constraints. Members with HIV/AIDS: ECM has provided the 550 Clinic in Louisville with an Embedded Care Manager to coordinate care for this specialty care member group. If a member requires intensive CM coordination, the Embedded Care Manager will refer to Complex CM. In 2016 there were 91 members in ECM at the 550 Clinic. 2/27/17 FINAL Page 3

6 II. 24/7 Nurse Advice Line Goal: Emergency Department Redirection Rate of 80% or greater. Analysis of Findings: 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. Total number of calls received in 2015 and 2016 were 13,003 and 6,353 respectively. 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 evidence-based 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. 2/27/17 FINAL Page 4

7 In 2016, new members received information by mail about the nurse line on a monthly basis. The goal of achieving an Emergency Department Redirection Rate of 80% or greater was met as evidenced by the data shown above. The rate of redirection from the emergency department for 2015 was 88% and for 2016 was 87%. Member agreement with redirection advice also demonstrated a very high rate. The rates of member agreement post nurse discussion of recommended lower level of care was 95% in 2015 and 96% in The Passport Rapid Response Team makes follow-up calls to members as needed after initial calls to the 24/7 nurse line. Follow-up is done to ascertain that members are being seen by clinicians appropriately and that appointments are made with their Primary Care Provider (PCP) or other clinicians when appropriate. III. ECM and RR Emergency, Admission, and Readmission Utilization 2/27/17 FINAL Page 5

8 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 RR CM. This analysis reviews rates of utilization prior to enrollment in ECM and RR comparative to after. There was a slight increase of 9% in ER utilization after ECM involvement during 2016 compared to There was a 33% decrease in Inpatient Admission utilization after ECM involvement during 2016 compared to There was a decrease of 1% in Readmissions Rates after ECM involvement during 2016 compared to There was a decrease of 8% in ER utilization after RR involvement during 2016 compared to There was a 50% decrease in Inpatient Admissions utilization after RR involvement during 2016 compared to There was a decrease of 12% in Readmissions Rates after RR involvement during 2016 compared to There was an increase in total membership to Passport. This could explain the increase in inpatient admissions for the ECM and RR Programs. 2/27/17 FINAL Page 6

9 IV. 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. 2/27/17 FINAL Page 7

10 Analysis of Findings: The graphs above represents member satisfaction with ECM. The areas surveyed in the first graph include: 1) Manage needs better 2) Listen and explain clearly 3) Professional and courteous manner 4) Overall helpfulness The goal is 90% for each area. During 2016, a total of 206 were member surveys were returned. Results indicate 100% of members who responded to the survey reported satisfaction with managing needs better, 100% reported listened and explained information clearly, 100% reported professional and courteous manner, and 100% reported overall helpfulness. The goal was met in all areas. The areas surveyed in the second graph include: 1) Listen and explain clearly 2) Professional and courteous manner 3) Overall effectiveness 4) Value of information 5) Help understand health problems 6) Help in making decision about health The goal is 90% for each area. Results indicate 100% reported listened and explained information clearly, professional and courteous manner, and overall effectiveness. 91% of members who responded to the survey reported satisfaction with help in understanding their health problems and 98% of members who responded reported satisfaction with value of information. The goal was met in all areas. During 2016, there were no complaints received regarding the ECM Program or the ECM Case Managers. 2/27/17 FINAL Page 8

11 Member Survey Results for Satisfaction with RR Services Received Goal: Maintain or exceed the goal of 90% or above in member satisfaction with all areas of RR services. 2/27/17 FINAL Page 9

12 Analysis of Findings: The graphs above represents member satisfaction with RR. The areas surveyed in the first graph 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 2016, a total of 22 member surveys were returned. Results indicate 83% of members who responded to the survey reported satisfaction with frequency of contact, 100% of members reported ability of case manager to help coordinate their care, 94% of members reported usefulness of information, 83% of members reported overall helpfulness, and 100% of members reported professional and courteous manner. The goal was not met in all areas. However, results are not generalizable and cannot be deemed statistically valid due to the low number of returned surveys. The areas surveyed in the second graph include: 1) Overall effectiveness 2) Professional manner 3) Coordination of care 4) Value of information The goal is 90% for each area. There are no results for this second graph due to no returned surveys from membership. During 2016, there were no complaints received regarding the RROT Program or the RROT Case Managers. 2/27/17 FINAL Page 10

13 V. Annual Review of Passport s Total Population 2015 Top 5 Primary Diagnosis Codes for All Members 2015 Top 5 Secondary Diagnosis Codes for All Members Diagnosis Code Diagnosis Description ADD of Childhood with Hyperactivity Member Count Diagnosis Code 125,479 V5869 Diagnosis Description Encounter For Long-Term Use of Other Medications Member Count 60, Opioid Type Dependence Unspecified Abuse 90, Unspecified Essential Hypertension 51, Unspecified Episodic Mood Disorder Depression Disorder Not Elsewhere Classified 77, Anxiety State, Unspecified 38,070 64, Lumbago 36,478 V5869 Encounter For Long-Term Use of Other Medications 62, Nondependent Tobacco Use Disorder 33,876 2/27/17 FINAL Page 11

14 2016 Top 5 Primary Diagnosis Codes for All Members 2016 Top 5 Secondary Diagnosis Codes for All Members Diagnosis Code Z00129 Diagnosis Description Encounter for routine child health examination without abnormal findings Member Count Diagnosis Code Diagnosis Description Member Count 52,026 I10 Essential (primary) hypertension 34,068 J069 Acute upper respiratory infection, unspecified 36,327 J069 Acute upper respiratory infection, unspecified 21,682 I10 Essential (primary) hypertension 34,068 R05 Cough 21,278 J029 Acute pharyngitis, unspecified 31,127 J029 Acute pharyngitis, unspecified 21,133 Z00121 Encounter for routine child health examination with abnormal findings 29,529 M545 Low back pain 21,098 2/27/17 FINAL Page 12

15 Objective: To annually assess the characteristics of Passport s populations and evaluate available resources to meet the needs of these members. 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 2016, Passport engaged in enrolling several subpopulations as a group into CM services. Children were a majority of our plan enrolled population in years past; however, the adult population has increased over the past two years due to the expansion population. The adult population also 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 comorbidities of the CM population each have specific DM programs with the exception of End Stage Renal Disease (ESRD). 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. 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 clinicians. 2/27/17 FINAL Page 13

16 Member Engagement: Embedded Care Managers engaged 8,830 at risk members face-to-face in clinician offices to assist with community resources, access to care, preventive care arrangements and availability to work oneon-one in the office. This number has increased by 10% from Embedded Care 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 Care Managers outreached to 1,247 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 70% from 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. Attempt to obtain working phone numbers through clinicians, pharmacies, and Tracfone. Target and identify high risk members through the ECM services. Develop flyer 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. 2/27/17 FINAL Page 14

17 Collaborate with clinicians to encourage member participation. Barrier: Limited member response to the ECM/RR surveys. Opportunity: Encourage member response to survey at the time of discharge. Survey revised to reflect ease of answering questions and providing anonymous input. Activities for 2016: Member Education: Educated members/caregivers regarding benefits and services through face-to-face outreach, member newsletters, on-hold SoundCare messages, Passport s website, and member educational material. Embedded Care Manager at the Kentucky Refugee Mission (KRM) and Catholic Charities (CC) to assist our members with PCP problems associated with the language barrier. Embedded Care Manager at Jefferson Alcohol/Drug Abuse Center (JADAC) to meet with members to encourage health maintenance in conjunction with substance abuse issues. Updated Special Health Programs, Just for You! brochure for members on the different programs available for them to participate. Developed new Member Satisfaction Survey Postcard directing members to the Passport website to fill out their survey. There is a specific survey number based on the program the member was enrolled in. If the member would prefer to have a hard copy mailed to them, they can call into our Care Connector line and they will mail one to them to fill out and return. Screening Activities: Embedded Care Managers conducted depression screenings (PHQ-2) with 2,441 adult members, an increase of 49% from 2015, with 5% of the members with a positive screening. Further depression screening (PHQ-9) was conducted with those members. Embedded Case Managers referred 114 members to Behavioral Health (BH) services. Embedded Care Managers conducted the Pediatric Symptom Checklist- 17 (PSC-17), a depression screening for children ages 4-17; 28 members were screened and none had a positive screening. 2/27/17 FINAL Page 15

18 Rapid Response Care Managers conducted depression screenings (PHQ-2) with 27 adult members, with 85% of the members with a positive screening. Further depression screening (PHQ-9) was conducted with those members. Rapid Response Care Managers referred 23 members to BH services. Rapid Response Care Managers conducted the PSC-17, a depression screening for children ages 4-17; two (2) members were screened and none had a positive screening. Identification Activities: Embedded Care Managers are located in 42 large clinician offices, and one specialty clinic. Embedded Care Managers engaged face-to-face a total of 8,830 members and provided resource assistance and assessed for care coordination. This represents an increase of 10% from Rapid Response Care Managers outreached to 1,247 unique members for urgent needs and assessed for care coordination. This represents an increase of 70% from Distributed the Embedded Member Satisfaction Survey to members, 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) and monitored surveys for trends, none identified. Provided feedback to individual staff when appropriate and addressed any identified areas that needed improvement, none identified. 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 Utilization Management (UM), Member Services, and Provider Relations to identify members who could potentially benefit from CM services. Continued to improve integration and collaboration with BH to improve overall coordination of care for members with co-existing medical and BH diagnoses/conditions. 2/27/17 FINAL Page 16

19 Activities for 2017: Continued Interventions: Continue to monitor member care gaps and work with member and clinician to increase preventative health screenings. Continue utilizing other reports such as ER Utilization, Kosair ER, and Hospital admission reports to identify members who could potentially benefit from CM services. Educate members/caregivers through: o Face-to-face outreach o Telephonic outreach o Member newsletters o On-hold SoundCare messages o Passport s website o Member educational materials Evaluate alternate methods of communication with members for health messaging. Administer the PHQ-2, PHQ-9 (for adults) and PSC-17 (for children ages 4-17) to prescreen and screen for depression in members and referred members to the BH team as needed. 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. 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 placement of Embedded Care Managers into clinician practices with high volumes of members and ability to impact health outcomes. Continue to improve collaboration with BH to improve overall coordination of care for members with co-existing medical and BH diagnoses. To include behavioral health/substance abuse facilities. Work with pharmacies to provide medication reviews to aide clinicians and members in decreasing polypharmacy related problems. Overall the ECM/RR Programs noted improvements in Once again, Passport noted an increase to the number of members involved with the ECM/RR Programs. Based upon the 2016 evaluation, Passport developed new and innovative initiatives to strive towards the overall goal of improving the health and quality of life for our members. 2/27/17 FINAL Page 17

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