Red Carpet Care: Intensive Case Management Program for Super-Utilizers

Transcription

1 Red Carpet Care: Intensive Case Management Program for Super-Utilizers Alice Stollenwerk Petrulis, MD Linda C. Stokes, PhD The MetroHealth System

2 Picture of MH

3 MetroHealth 750 bed facility includes Rehab, SNF Link to Case Western Reserve School of Medicine 500 employed physicians Level l Trauma, Burn Center, Spinal and Rehab, regional LifeFlight, 100k visit-ed 53% of county s uninsured/ Medicaid

4 Red Carpet Care Robert Woods Johnson funded Through Better Health Greater Cleveland - an Aligning Forces for Quality Center 2 year program Technical Assistance from Jeff Brenner and the Camden Coalition- Hotspotters Target Population - Super-Utilizers

5 HOW DID WE GET HERE? THE BEGINNING

6 Patient-Centered Medical Home Phased implementation 2009 to outpatient primary care sites across main campus and 9 satellite locations Transformational change Care teams Huddles Improved access Call center NCQA recognition Level 3

7 Care Coordinators RNs Uninsured program, added Waiver & ACO patients Navigation, Case management, Disease management Specific identification in EMR (EPIC) Registries Health outcomes: improvement in quality measures, decrease in utilization

8 GETTING CLOSER? ULTRA-UTILIZERS???

9 Patient Risk Distribution High Risk 10% patients 50% of Total charges Moderate Risk 30% patients 40% of Total charges Low Risk 60% patients 10% of Total charges

10 IMPROVE Statewide Medicaid effort to decrease avoidable ED visits NEO: Non-mental health ultra-utilizers Care plans devised by MH Medical Director in cooperation with PCP, Case Managers at payor Care Plans in EMR (EPIC) Ready identification by ED

11 IMPROVE Payor case managers Assisted in making appointments Appointment reminders Arranged transportation Educate about medications Accompanied patients on visits Offer free pre programmed phones Monthly review of plans

12 IMPROVE Outcomes Decrease in ED visits at MH by 44% in a year Increased communication with payor Effective education of patients Coordinated patient care Development of patient self-management and responsible behavior Program continues into 3rd year.

13 ARRIVAL ROLLING OUT THE RED CARPET

14 Red Carpet Care Started July 2012 Robert Wood Johnson funded Super-Utilizer project - Awarded to 6 Aligning Forces for Quality programs Technical assistance by Jeff Brenner and the Camden Coalition (Hot Spotters) Innovative financial model: PMPM, shared savings, payor funded APNs

15 Red Carpet Care One Medicaid and one Commercial payor 2 funded APNs - clinic within a clinic model Recruitment of high risk patients - DM, HTN, HF, multiple ED visits and IP, high cost 136 patients enrolled Meeting the patient where they are

16 Intervention Committee Team Payors Included BH team Community resources Weekly meetings initially Now monthly Case presentation

17 Tools for the APNS Registries Blackberries Journals Weekly- even daily- collaboration with payor CMs EPIC alerts/care plans

18 Tools for the Patients Phones Calendars Self-management tools Journals CAPHS survey- baseline and completion

19 Red Carpet Care Community Resources West Side Catholic Center University Settlement Home Visits Medication inventory Safety checks Insight

20 Graduation When do patients graduate? Evidence of show rate, medication adherence, self-management Graduation ceremony End of 2 yrs Testimonials Certificates Data Handoffs

21 WHERE DO WE GO FROM HERE?

22 Medicaid 1115 Waiver February 2013 to December 2013 Enrollment up to 30,000 patients Benefits included pharmacy, dental, and transportation not previously covered in charity care programs Care Coordinators imbedded in practice Collaboration with 2 FQHC practices Created closed network for care

23 Program Evaluation Utilization measures: Inpatient, Outpatient Primary, Specialty, ED, Ancillary, Urgent Cost measures: Total charges, PMPM Health outcomes: Conditions, Case Management, & improvement in quality measures

24 Key to Success The lynch pin for success in our programs by either name- is the Care Coordinator or Care Manager Going forward, new programs will further define successful interventions by these CMs

25 Transitional Coaches Transitional Coaches Fill the gap between inpatient and outpatient care Post-discharge phone calls Follow-up: For 30 days, or until Handoff to outpatient care coordinators Expect to prevent readmissions and ED visits

26 Accountable Care Organization Medicare ACO began January 2014 About 10,000 Medicare FFS Clinical side: Care coordinators Patient navigators new role Coordinator extender Home visits

27 Navigators Assists Providers and Care Coordinators with: Scheduling of appointments Communications with patients (calls & letters) Arranging transportation Assist with services from community resources Chronic disease self-management support Activities related to disease management

28 Lessons Learned Care Coordinators are the lynch pin Building relationship with patient is key to achieving desired outcomes Takes some time before expecting results Need to track data on activities in order to show results later

29 Lessons Learned Decrease in ED visits and hospitalizations is a loss of revenue in a FFS environment Incentives need to be aligned Winner: insurer Loser: hospital PMPM and Shared Savings level the playing field

30 Questions

31 Thank you Contact information: MetroHealth Systems Cleveland, OH Alice Stollenwerk Petrulis, MD Linda C Stokes, PhD lstokes@metrohealth.org