2017 Catastrophic Care. Program Evaluation. Our mission is to improve the health and quality of life of our members
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1 2017 Catastrophic Care Program Evaluation Our mission is to improve the health and quality of life of our members
2 2017 Catastrophic Care Program Evaluation Table of Contents Program Purpose Page 1 Goals and Objectives Page 1-2 Member Interactions Page 2 Evaluation Top 15 Primary Diagnoses for Members in Catastrophic Care Pages 2-3 Number of Referrals by Source Page 4 Catastrophic Care Emergency, Admission and Readmission Utilization Pages 5 Member Discharge Status Page 6 Goals Met/ Not Met Page 7 Member Satisfaction Survey Results with Catastrophic Care Services Received Member Satisfaction Survey Results for Improvement of Health or Quality of Life Pages 8-9 Pages Annual Review of Passport Health Plan s Total Population Pages Barriers/Opportunities Page 14 Activities Pages 15-16
3 2017 Catastrophic Care Program Evaluation Program Title: Catastrophic Care (CC) Program Evaluation Evaluation Period: January 1, 2017 December 31, 2017 Program Purpose: The CC Program employs a member-centric approach that helps members and caregivers understand and engage in attaining or maintaining their optimal health. The objectives of the Program are to: Improve care coordination for members in collaboration with their primary care physician (PCP) and specialist treating clinicians. Support the clinician s treatment plan. Facilitate and coordinate transitioning the member to the least restrictive setting. Optimize chronic condition management by educating members about diagnoses and self-management. Implement personalized care plans. Improve medication adherence. Address member/caregiver needs regarding adequate support and resources at home. Improve adherence to the hospital discharge care plan for members discharged to home. Decrease avoidable utilization events (e.g., readmissions) and increase the number of members engaged with a Care Advisor. Program Goals and Objectives: Directly identify catastrophic and highly intensive cases through the utilization management (UM) process, member self-referral, clinician referral and predictive model. Facilitate safe care transitions. Honor the member s preferences for care. Partner with the member, caregiver and the primary and specialty care clinicians to develop a personalized plan of care in the least restrictive setting. Improve medication compliance. Address member/caregiver needs regarding adequate support and resources at home. Coordinate a comprehensive community based and home health care network of services. Identify and negotiate contracts with those services outside of the existing network. Facilitate appropriate communication across the entire care team. Support end of life and palliative care options with members and their clinicians. 3/15/18 DRAFT Page 1
4 Optimize chronic care management and close relevant gaps in evidence based care. Educate members about diagnoses and self-management. Lower total medical expense by avoidance of readmissions, emergency room (ER) visits, duplicative and unwarranted services, and specialist costs through coordinating care during acute, intensive care episodes. Member Interactions: CC interacted with 434 members in Evaluation I. Graph 1 Top 15 Primary Diagnoses for Members in CC Chronic obstructive pulmonary disease and bronchiectasis Spondylosis; intervertebral disc disorders; other back problems Chronic kidney disease Other lower respiratory disease Other aftercare Respiratory failure; insufficiency; arrest (adult) Other non-traumatic joint disorders Residual codes; unclassified Pneumonia (except that caused by tuberculosis or sexually Essential hypertension Other screening for suspected conditions (not mental Septicemia (except in labor) Cancer of brain and nervous system Complications of surgical procedures or medical care Other connective tissue disease Objective: To annually evaluate the primary diagnosis or Special Needs Category of members who trigger and enroll in CC services to ensure Passport Health Plan (Passport) has the appropriate staff, materials, and resources to assist members in improving their health and quality of life. 3/15/18 DRAFT Page 2
5 Analysis of Findings: Graph 1 represents members by diagnosis enrolled into CC. The top three diagnoses were: 1) Chronic obstructive pulmonary disease and bronchiectasis 2) Spondylosis; intervertebral disc disorders; other back problems 3) Chronic kidney disease Individuals with Special Health Care Needs: Passport evaluated the population for Individuals with Special Health Care Needs or ISHCN. Members defined as having special healthcare needs are members who have or are at risk for chronic physical, developmental, behavioral, neurological, or emotional conditions and who may require a broad range of primary, specialized medical, behavioral health (BH), and/or related services. ISHCN may have an increased need for healthcare or related services due to their respective conditions; therefore, Passport proactively identified, outreached, and enrolled these members into CC. In 2017, the Department of Health School Board Manager identified children with special healthcare needs and coordinated with health departments and schools throughout the state to ensure coordination of care and prevent duplication of care. Medically Complex Foster Children: Medically complex foster care children are identified by Department of Community Based Services (DCBS) worker, DCBS service plan, and/or via a medically complex foster care report provided monthly by the Department for Medicaid Services (DMS). All identified medically complex foster care children are enrolled in care management. Some also receive care management or case consultation from the BH Case Management Team. Care Advisors, Health Educators, Dietitians, Social Workers, and BH Case Managers collaborate during regular integrated meetings and via ongoing contact with one another to ensure the needs of these vulnerable members are being met. Care Advisors maintain regular communication with the Passport Foster Care and Guardianship Specialists and/or Manager of Specialty Populations to consult as well. The Care Advisor assigned to the member as well as the Foster Care Specialist participate in team conference calls led by the Children s Review Program (CRP) when the member s needs or presenting issues are impacting CRP s ability to locate appropriate placement for the child. 3/15/18 DRAFT Page 3
6 II. Graph Referral Sources Total Stratification Utilization Management 25 Rapid Response Outreach Team (RROT) Program: Transition Care Member/Caregiver Other Practitioner Program: Condition Care Program: Complex Care Program: Maternity Care Objective: Identify members proactively for CC through multiple resource avenues. Analysis of Findings: Graph 2 represents referrals by source. The top three sources were: 1) Stratification 2) Utilization Management 3) RROT, Transition Care and Member/Caregiver Multiple avenues are used to proactively identify members for CC. Education and information is distributed via the Member and Provider Handbooks, Member Newsletter, New Member Packets, and Member and Provider Program brochures. Provider Referral Forms are available as well on the Passport website. Education is provided through internal department meetings and the use of internal referral forms between CC and BH is encouraged. A daily report is obtained from the Health Information Line (24-Hour Nurse Line) of identified members. Health Risk Assessments (HRA) are utilized as a means of risk screening for the member. An attempt is made to obtain an HRA for all members. 3/15/18 DRAFT Page 4
7 III. CC Emergency, Admission and Readmission Utilization Goal: Emergency Department (ED), 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 CC. It analyzes rates during 2017 of utilization prior to enrollment in CC comparative to after. The goal of reducing ED, inpatient admission, and 30-day readmission rates by 20% or greater was exceeded for Inpatient utilization. The target was not met for ER utilization, Readmission Rates, or enrollment in CC. After CC involvement during 2017, the data demonstrates: An increase of 82% in ER utilization. A decrease of 92% in Inpatient utilization. A decrease of 18% in Readmissions Rates. Data demonstrates an increase of 9% in enrollment in CC compared to /15/18 DRAFT Page 5
8 IV. Graph Member Discharge Status Unable to Reach Declines Participation Problem Resolved/Goals Met 160 Insurance Terminated 140 Lost Contact 120 Deceased Not Appropriate for Program Externally Managed Patient in Hospice Patient in Long-Term Care Transferred to Complex Care Identified No Contact Info Transferred to Condition Care Objective: Identify barriers for CC from discharge status to reduce inability to sustain engagement with members. Analysis of Findings: Graph 3 represents reasons for member s discharge from CC during The top three reasons were: 1) Closed Unable to Reach 2) Declines Participation 3) Problem Resolved/Goals Met There were 188 (38%) members discharged due to Care Advisor being unable to reach the member; 71 (14%) members declined participation and 67 (14%) members were discharged/closed due to problem resolved/goals met. Discharge reasons remains consistent with /15/18 DRAFT Page 6
9 V. Graph 4 Goal: Meet or exceed a rate of 90% of goals partially or completely met for members enrolled in CC. Analysis of Findings: Graph 4 represents the status of goals for members enrolled in the CC Program. In 2017, 379 goals were completed/partially completed, an 84% increase compared to There was a total of one (1) goal that was not met, a 4% decrease compared to There was a goal completion rate of 99.99% for 2017; an increase of 44% from The goal to meet or exceed the target of 90% of goals partially or completely met for members enrolled in CC was exceeded. 3/15/18 DRAFT Page 7
10 VI. Member Satisfaction Survey Results with CC Services Received 100% 80% Member Satisfaction Survey Results for CC Services Received 100% 100% 100% 100% 100% 100% 100% 100% 75% 94% Goal 90% 60% 40% 20% 0% Understand Health Condition Professional and Courteous Manner Value of Written Materials Help with Making Decisions Total 1st Qtr 17 2nd Qtr 17 n = 1 n = 4 Member Satisfaction Survey Results for CC Services Received 100% 100% 100% 100% 100% 100% Goal 90% 80% 60% 40% 20% 0% 0% 0% 0% 0% 0% Happy with Services Received Support for Health Care Needs Create Plan of Care of Health Needs Help with Care and Supplies Needed at Home 3rd Qtr 17 4th Qtr 17 n = 0 n = 4 Total Goal: Achieve or exceed a score of 90% or above in all areas of member satisfaction for CC services. 3/15/18 DRAFT Page 8
11 Analysis of Findings: The areas surveyed in the first graph include: 1) Understand Health Condition 2) Professional and Courteous Manner 3) Value of Written Materials 4) Help with Making Decisions The goal is to achieve 90% satisfaction for each area. During 2017, sixty (60) member surveys were distributed, of which five (5) were returned (8% response rate). Of the members who responded to the survey, 100%, 75%, respectively for 1st and 2nd Quarter 2017, reported they could understand health condition better, and 100%, 100% respectively for 1st and 2nd Quarter 2017, reported the Care Advisor had a professional and courteous manner, the written materials they received had value, and they received help with making decisions regarding their health. The areas surveyed in the second graph include: 1) Happy with Services Received 2) Support for Health Care Needs 3) Create Plan of Care of Health Needs 4) Help with Care and Supplies Needed at Home The goal is to achieve 90% satisfaction for each area. During 2017, eighteen (18) telephonic member surveys were conducted, of which four (4) members responded (22% return rate). Of the members who responded to the survey, 0%, 100%, respectively for 3rd and 4th Quarter 2017, reported satisfaction in the following areas: happy with the services they received, support given regarding their health care needs, creating a plan of care, and help with care and supplies needed at home. Only one topic (Understand Health Condition) fell below satisfaction rate target. Target was met or exceeded in all other areas. The total number of returned surveys (9) is too small to draw conclusions about the generalizability of the results. 3/15/18 DRAFT Page 9
12 VII. Member Satisfaction Survey Results for Improvement of Health or Quality of Life Member Satisfaction Survey Results for Improvement of Health and Quality of Life 100% 100% 100% 100% 100% 100% 80% Goal 75% 67% 60% 50% 50% 40% 20% 0% Deal with Health Condition Quality of Life Overall Health Total 1st Qtr 17 2nd Qtr 17 n = 1 n = 4 Member Satisfaction Survey Results for Improvement of Health and Quality of Life 100% 100% 100% 93% 80% 80% Goal 75% 60% 40% 20% 0% 0% 0% 0% 0% Set Goals Plan for Assistance Overall Quality of Life Total 3rd Qtr 17 4th Qtr 17 n = 0 n = 4 Goal: Achieve or exceed a score of 75% or above in member's perception of improved overall health status and quality of life. 3/15/18 DRAFT Page 10
13 Analysis of Findings: The graphs above represent the members satisfaction regarding improvement in health or quality of life. The areas surveyed in the first graph include: 1) Deal with Health Condition 2) Quality of Life 3) Overall Health The goal is to achieve 75% satisfaction/agreement for each topic. Of the members who responded to the survey, 100%, 100%, respectively for 1st and 2nd Quarter 2017, reported they could understand their health condition better, and 100%, 50% respectively for 1st and 2nd Quarter 2017, reported improvement in quality of life, and improvement in overall health. The survey areas represented in the second graph include: 1) Goals set by Care Advisor and Member 2) Plan for Assistance 3) Overall Quality of Life The goal is to achieve 75% satisfaction/agreement for all topics. Of the members who responded to the survey, 0%, 100%, respectively for 3rd and 4th Quarter 2017, reported they could set and follow goals better and could plan for assistance when needed, and 0%, 80% respectively for 3rd and 4th Quarter 2017, reported improvement in overall quality of life. In 1st Quarter 2017, the target was not met in the areas of Quality of Life and Overall Health. Targets were met or exceeded in all other areas. The total number of returned surveys (9) is too small to draw conclusions about the generalizability of the results. During 2017, there were no complaints received regarding the CC Program or Care Advisors. 3/15/18 DRAFT Page 11
14 VIII. Annual Review of Passport s Total Population 3/15/18 DRAFT Page 12
15 5,471 5, , , , , , , , , , , , , , , & 2017 Member Demographics 400, , , , , , ,000 50,000 - Male Female Age 0-17 Age Age 65+ Urban Rural Total Members Gender Age Group Location 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 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 2017, Passport focused on several subpopulations for enrollment in CC services. Children have been a majority of our plan enrolled population in years past; however, the adult population has increased over the past two years due to Medicaid expansion. Adults were the majority of enrollees in the CC Program in In years past, Passport had more female members than male, which remains consistent in Members with an End Stage Renal Disease (ESRD) diagnosis are enrolled in the CC Program (versus other available care management programs) due to needing dialysis and a higher level of care coordination. Therefore, Passport has made a conscious decision to keep those members in CC. No barriers are identified thus no changes are needed at this point. The presence of substance abuse has increased with CC enrollees. This corresponds to the opioid epidemic that has been declared in the state. Member Engagement: Care Advisors engaged 136 members in This represents a 9% increase from Members appropriate for this program have multiple and complex co-morbidities and psychosocial barriers. Care Advisors work with the members to decrease readmissions and ER utilization and to increase utilization of outpatient services and compliance with treatment and care plans. 3/15/18 DRAFT Page 13
16 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. Attempt to obtain working phone numbers through unable to reach, providers, pharmacies, Spokeo, and TracFone. Barrier: Member unwilling to comply with treatment plan and its completion. Opportunity: Member education regarding the benefits of CC through individualized contact with the member. Collaborate with providers to encourage member participation. Barrier: Limited member response to the CC survey. Opportunity: Encourage member response to survey at the time of discharge. Developed new telephonic Member Satisfaction Survey. Questions include happy with services received, provided support to take care of health needs, care team worked well to create a plan to take care of health needs, help to get care and supplies needed at home, set goals that helped improve day-to-day needs, helped make plans so member can get help when needed, and if their overall quality of life had improved since working with the Care Advisor. 3/15/18 DRAFT Page 14
17 Activities for 2017: Provider Education: Encouraged provider involvement with CC. Member Education: Educated members/caregivers regarding CC benefits and services through telephonic outreach, Passport s website, and member educational material. CC identified and enrolled medically complex foster care members, and members identified as individuals with special health care needs. Developed new telephonic Member Satisfaction Survey. Questions include happy with services received, provided support to take care of health needs, care team worked well to create a plan to take care of health needs, help to get care and supplies needed at home, set goals that helped improve day-to-day needs, helped make plans so member can get help when needed, and if their overall quality of life had improved since working with the Care Advisor. Screening Activities: Administered the Patient Health Questionnaire (PHQ) 2 and the Pediatric Symptom Checklist-17 (PSC-17) a BH screening used with member s ages 4 to 17. There were 48 adult members screened and 2% of those members had a positive result, leading to the PHQ-9 being administered. Of those members, eight (8) were referred for BH services. There were no pediatric members screened using the PSC- 17 screening tool during Administered the Member Satisfaction Survey telephonically to members enrolled in the CC Program, 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. Identification Activities: CC interacted with 434 members in Care Advisors exhausted all measures to establish and maintain contact with members including calling clinician offices, utilizing the Medical Management System to locate current address and phone numbers, and mailing unable to contact letters with business cards attached. Collaborated with other departments such as UM, Member Services, and Provider Relations to identify members who could potentially benefit from CC services. 3/15/18 DRAFT Page 15
18 Activities for 2017 (Continued): Activities for 2018: Continued to improve integration and collaboration with BH to improve overall coordination of care for members with co-existing medical and BH diagnoses/conditions. Continued Interventions: Encourage provider involvement with CC. Identify and enroll medically complex foster care members, and members identified as individuals with special health care needs into CC. Increase provider/practice engagement, targeting select practices to implement care conferences where CC needs of patient roster will be discussed. Educate members/caregivers through: o Telephonic outreach o Member newsletters o On-hold SoundCare messages o Passport s website o Member educational materials Continue to monitor member care gaps and work with member and clinician to increase preventative health screenings. Evaluate alternate methods of communication with members for health messaging. Build the PSC-17 into the care management platform. 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 conduct 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 CC services. 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. Revise member and clinician correspondence (i.e., letters, materials, etc.) to improve member and clinician education regarding CC services. Overall the CC Program noted improvements in Once again, Passport noted an increase in the number of members participating in the CC Program. Based upon the 2017 evaluation, Passport continued to adapt and evolve in working toward the overall goal of improving the health and quality of life for our members with catastrophic conditions. 3/15/18 DRAFT Page 16
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