EmblemHealth Advocate for Quality
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- Charleen Lloyd
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1 EmblemHealth Advocate for Quality 2013
2 Average Health Care Spending per Capita, Adjusted for differences in cost of living 1 Dollars Source: OECD Health Data 2011 (June 2011). THE COMMONWEALTH FUND
3 Health Care Spending as a Percentage of GDP, Percent GDP refers to gross domestic product. Source: OECD Health Data 2011 (June 2011). THE COMMONWEALTH FUND
4 Mortality Amenable to Health Care 3 Deaths per 100,000 population* * Countries age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections. Analysis of World Health Organization mortality files and CDC mortality data for U.S. Source: Adapted from E. Nolte and M. McKee, Variations in Amenable Mortality Trends in 16 High-Income Nations, Health Policy, published online Sept. 12, THE COMMONWEALTH FUND
5 NEO-EHT MS1 Waste in the US Health System Failure of Care Delivery Failure of Care Coordination Overtreatment Administrative Complexity Pricing Failure Fraud and Abuse - Berwick and Hackbarth JAMA 2012
6 EmblemHealth Advocate for Quality NEO-EHT MS1 We are accountable for : Monitoring quality of care and service delivered to our members Conducting clinical quality improvement activities involving HEDIS, CAHPS, QARR, Stars and NCQA accreditation Impacting quality of care and cost of care through: clinical innovation effective utilization management programs targeted case and disease management programs health and wellness programs pharmacy management programs multispecialty group practice care coordination programs frequent communication through educational materials and reminders to patients, physicians, and hospitals regarding recommended preventive care
7 NEO-EHT MS1 We have implemented an EmblemHealth Clinical Model based on the IHI Triple Aim Better care for individuals through better quality, access, and customer service Better health for populations Lower per capita cost of care
8 NEO-EHT MS1 EmblemHealth Clinical Model Advocate for Quality We work to optimize health and well being and improve the affordability of care by helping members: Stay Healthy Get Well Quickly Live Better with Illness We do this by: Encouraging wellness and prevention Identifying and closing gaps in clinical care Emphasizing care coordination and accountable care as the means to deliver on the Triple Aim Educating members about high quality and high efficiency providers of care Our intent is to: Prevent unnecessary hospitalizations, avoidable readmissions, and unnecessary ER visits Enable rapid access to right care, right time, right provider, right place Make best use of hospital and SNF stays Promote member and physician engagement and satisfaction with programs and services 7
9 The Continuum of Care: Supporting the Individual From Wellness to End of Life NEO-EHT MS1 Stay Healthy Get Well Live Better Healthy to Healthy With Risk Factors Acute Illness: Minor to Major Living With Illness: Vulnerable to High Risk to End of Life Educational Mailings Nurseline Online Health Risk Assessments Online Personal Health Record Reminder System for Screening Exams Online Self Help Tools Integrative Wellness Discount Programs Prior Authorization for Medical Necessity Concurrent Review Discharge Planning Post Acute Transitional Case Mgt Home Health / DME Behavioral Health Management Point of Care Case Management Nurseline Discharge Reminders Nurseline Health Risk Assessment Disease Management Medication Management Focused Case Management Point of Care Case Management Behavioral Health Management Home Health / DME Palliative Care Hospice
10 EmblemHealth Clinical Innovations to Deliver on the Triple Aim NEO-EHT MS1 Focused Case Management Point of Care Case Management embedded in physician practices Telephonic case management for complex clinical cases and transitions of care from hospital to home Face to Face home visits for frail or otherwise vulnerable members Community based care centers for chronically ill Medicare and Medicaid populations to receive health screenings and education in the management of their conditions Integrated medical management program of internal and vendored clinical resources to optimize utilization support for those requiring substantial care NeighborhoodCare locations that coordinate with community based physicians and community based social service agencies to support optimal health Close relationships with large multispecialty practices like AdvantageCare Physicians and Montefiore to better assist members in getting the care they need.
11 Care Management Program Engagement Program Enrolled Members End of Life Program- Medicare members 3,445 Dignified Decisions- End of Life Program for commercial members 93 ComplexCare Solutions QOL- Cancer Program conducting home visits 603 Rare Disease Program 1,469 Complex Care Solutions EZC- Complex Case Management Program conducting home 3,179 visits Kidney Care-CKD/ESRD Program 579 Healthy Beginnings PATH- High Risk Pregnancy Program 1,100 EmblemHealth Complex Case Management- Internal CM Program 1,154 Medicare Diabetes Management- Medicare Diabetes Program with Community Centers 17,910 PATH-COPD- Disease Management Program 810 PATH-Diabetes-Disease Management Program 3,262 PATH-CAD- Disease Management Program 1,464 PATH-Asthma- Disease Management Program 878 PATH-HF Disease Management Program 1,200 Total 37,200
12 Face-to-Face Member Touches Diabetes Program: 27 Community Centers Program Visits 13, shoes -358 glucometers -87 in home scales Complex Case Management and Cancer Program: Clinician Home Visits 31,204 Home Assessments: Home Assessments for Medicaid and Medicare members 18,213 Total Face to Face member touches YTD 62,568
13 EmblemHealth Advocate for Quality 2012 Recognitions Quality Compass Top 12% of Commercial healthplans nationally QARR Number 1 Commercial healthplan in New York City and Long Island Number 1 Medicaid healthplan in New York State Number 1 Medicaid healthplan regionally in New York City, Long Island and Hudson Valley Medicare Stars 3.5 Star healthplan
14 EmblemHealth Advocate for Quality Examples of Behavioral Services Initiatives NEO-EHT MS1 Health Home HARP (Health and Recovery Plan) Targeting behavioral health comorbidities Improving depression screening in primary care with the NEBGH Preventing adverse outcomes from the inappropriate use of psychotropic medication by older adults Interventions to impact new HEDIS measures
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