Policy & Providers Lessons From The Health Care Arena for Managing Chronic Care Patients Producer: Bob Bua President - CareScout Panel: Peter Sosnow VP Corporate Development - Humana / SeniorBridge Mary Alexander Strategic Alliances Director - Home Instead, Inc. Kelly Funk Senior Associate Director - Alzheimer s Association 1
Functional and Activity Limitations Drive Healthcare Costs Functional limitations are the multipliers that drive healthcare costs in the chronically ill Relative risk of being among the top 5% most costly patients increases as patients with chronic conditions develop functional and activity limitations Chronic Conditions Congestive Heart Failure Chronic Obstructive Pulmonary Disease End Stage Renal Disease Diabetes Mellitus Hypertension Dementia or Mental Illness Looks like traditional healthcare Functional (Physical and Cognitive) Limitations Reaching Grasping Stooping Lifting Short-Term Memory Loss Instrumental Activities of Daily Living (IADL) Limitations Meal Preparation Shopping Housework Managing Money Telephoning Transportation Managing Medications Activities of Daily Living (ADL) Limitations Bathing Dressing Eating Transferring Walking Toileting Looks like an LTCi Claimant Source: Lewin Group analysis of 2006 Medical Expenditures Panel Survey, 2010 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 1.0 Everyone 2.7 2+ Chronic Conditions Only 4.3 Chronic Conditions and Functional Limitations 7.1 2+ Chronic Conditions and IADL/ADL Limitations 2
Increased Healthcare Costs Are Attributed to Seniors Who Are Getting Care in Our Hospitals Seniors account for Half of US Hospital Bill (and only 12% of population) Kaiser Family Foundation based on data from Congressional Budget Office 1 in 5 seniors are rehospitalized within 30 days Jencks, N England J Med, 2009 Majority of Medicare Dollar for Most Costly Seniors Spent in the Hospital Source: Lewin Group analysis of 2006 Medical Expenditures Panel Survey, 2010 Many Re-Hospitalizations are Likely Preventable People with multiple chronic medical illnesses report receiving conflicting advice from doctors Only 1/2 see a doctor or get self care instruction after discharge Jencks,N Engl J Med,2009; Flacker,J Hospital Medicine,2007 3
Sickest 20% of Medicare Members drives 75% of cost These 20% have: Chronic conditions Functional deficits Hospital admission in the prior 12 months Likely to have medical costs associated with the sickest 20% in the future Sickest 20% Percentage of Total Costs 5% 41% 15% 34% 30% 18% 30% 6% 20% 1% Percentage of Members 4
Stratifying Seniors by Health and Functional Status Ensures Appropriate Level of Care for Members Understanding the top 20% member needs Clinical model designed to meet needs of each patient segment M ore Number & Severity of Illnesses Few wer Functionally independent (25% Telephonic Care Coordination 1.2 hospital admits per year Low Severity (40%) Telephonic Health Coaching 0.6 hospital admit per year High Severity (10%) In-home Care Management In-Home Support 3 hospital admits per year Functionally limited (25% Telephonic or In-Home Care Management In-home Support 1.2 hospital admits per year Fewer Functional and Activity Limitations More 5
Thinking Differently About Hospital Readmissions 6
Care Management Overview Once member attributed... care manager assigned who engages...and utilizes complex chronic to program... multiple stakeholders, across settings... care components as needed Comprehensive care management Comprehensive care management and PCP coordination Coordination of community, Member attributed health & family resources to Complex Care Manager Member Manage acute episodes & Chronic Care Both telephonic and in-person transitions contact, as needed Advanced Illness Planning Home MD Clinical setting Close identified care gaps Scored based on Medication management claims data Behavioral health Other management Family Care giver PCP clinician s Home based personal care services Care manager functions as communications hub for care, working with member, family, physicians to identify full set of individualize needs. across spectrum of Health, Functional, Cognitive, Behavioral, Psychosocial, Environmental and Financial/Legal domains Member and caregiver education Remote biometric monitoring Disease diagnoses documentation by NPs/MDs 7
Continuum of In Home Services for the Top 20% These services improve the Health Status of Vulnerable Seniors while saving Medicare and health Plans Money. Care Management Telephonic care coordination, with targeted in person visits and remote monitoring. in Home - in-person care coordination (in home and MD office), supported by phone and remote monitoring. Post tacute Transitions - hospital and home visits it to prevent re-admissions i within 30 days. Caregiving - In home personal care services provided by home health aides and/or family care givers Advanced Illness provides non-directive counseling at end-of-life Documentation NP / MD Home Visit Program - initial and annual in home assessment improves accuracy of documentation Program for anyone in the 20% - so approximately 250,000 members would be expected to be enrolled in any one of these programs 8
Care Management Reduces Hospital and Emergency Room Visits 9
Care Management Reduces Hospital Readmissions 10
Why Care Management Matters to LTCI Referral to care management agency could Delay and reduce cost of claims Improve client outcomes and satisfaction Prevent adverse events and future claims Hospital admissions Medical incompliance Disease complications and other acute events 11
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Overall ROI of 4:1 for the 252,000 Members Expected to Enroll in this Program High severity 13K (5%) Functionally Challenged 76K (30%) Health Challenged 63K (25%) At risk 101K (40%) Overall 252K Admit Reduction Number (%) 2.1 (58%) 0.7 (55%) 0.5 (46%) 0.2 (30%) 0.5 (48%) Care coordination and management Transition Care giving $PMPM benefit/cost $1,611/425 $426/64 $405/64 $167/37 $376/71 ROI 3.8 6.7 6.3 4.5 5.3 $PMPM benefit/cost $196/96 $91/44 $88/44 - $59/29 ROI 2.0 2.0 2.0-2.0 $PMPM benefit/cost $374/198 $116/78 - - $54/33 ROI 1.9 1.5 - - 1.6 Documentation $PMPM benefit/cost $312/29 $186/29 $175/29 $133/29 $168/29 (MRA 0.12) ROI 10.7 6.4 6.0 4.6 5.8 $PMPM benefit/cost Total $2,494/748 $819/215 $668/137 $300/66 $657/163 3.3 3.8 4.9 4.5 4.0 (~$1,745) (~$604) (~$530) (~$233) (~$494) Source: SeniorBridge and Humana Cares data, interviews; Medicare expenditure panel survey, 2009 13
HumanaCares/SeniorBridge Achieve ~50% Admit Reduction Focused on Highest Risk MA Members HumanaCares/SeniorBridge Achieve Significant Utilization Reductions Combined Impact: ~ 50% admit reduction IP admits/year Health Challenged Telephonic Care Members Mgmt Top 20% most costly MA members with admits 1+ 2.5 2.0 1.5 1.1 1.0 0.5 0.0 Pre IP admits/year 2.4 2.5 0.7 Post -26% IP admits/year 2.5 2.0 1.5-50% 1.3 1.0 0.65 0.5 In-Home Care Mgmt High severity Members Top 5% most costly MA members with admits 2+ 2.0 1.5 1.0 0.5 0.0 Pre 0.7 Post -71% 0.0 Pre Post Average admit reduction weighted by membership 14
Policy & Providers Lessons From The Health Care Arena for Managing Chronic Care Patients Mary Alexander Strategic Alliances Director - Home Instead, Inc. 15
Senior Care Continuum 16
Opportunity for a new type of active Care Management? Different companies may have various secret recipes. 17
Four Areas of Focus Nutrition Medication Doctor Management Appointments Warning Signs 18
Personal Side of Care Knowledge Compliance Meeting Basic Need 19
Pilot Study Partner with large for-profit hospital system 60 patient pilot study Primary diagnosis Heart Failure 30 Day plan of care GOAL: Reduce hospital readmissions by 1% 20
Model Readmission Risk Factors Nutrition Management Follow-Up Physician Visit Assistance Warning Signs Monitoring and Notification Medication Management Total hours based on patient need and additional care available (80-200 hours) 21
Outcomes 93% Success rate in pilot patients Hospital readmission rate overall dropped 9% $1500-$2500/client Able to fill gap in education and compliance 22
Pilot Study Test and Goals July 2012 to November 2012 with 2 non-profit hospitals Hospital #1 part of the tenth largest national healthcare system in the U.S. and is a 304 bed acute care community hospital Hospital #2 is a 220 bed medical/surgical hospital 30 Patient Study Pi Primary diagnosis i CHF (Heart Failure) and COPD 30 Day plan of care GOAL: Reduce unnecessary hospital readmissions within the first 30 days of discharge while improving patient self-reliance 23
Model Main focus on patient-centered goals with action plans A care consultation to be done in the hospital to determine patient specific needs Base 30 day plan Week 1: five visits Week 2: four visits Week 3: three visits Week 4: two visits 24
Outcomes 25
Policy & Providers Lessons From The Health Care Arena for Managing Chronic Care Patients Kelly Funk Senior Associate Director - Alzheimer s Association 26
Dementia - Programs Expense Elements The Situation Greater than 5 million individuals in the US are diagnosed with Alzheimer s Disease. This number is expected to soar to greater than 13 million by 2050. The Expense / Cost The cost for care in 2012 is $200 billion, increasing to $1.1 Trillion by 2050 Savings Opportunity A variety of savings opportunities can occur by impacting 1. Earlier diagnosis 3. Improving quality of life 2. Providing care location alternatives 4. Onset of the disease Take-aways The current system will not be able to handle the increasing number of individuals needing care, nor the cost. Finding ways to expand capacity, enhance outcomes and decrease cost are non-negotiable. Do Carriers feel obligated to provide for those that are in your book of business? Finding a way to more intelligently, effectively help, with a better ROI, can help your business succeed. 27
Dementia - Programs Impact Earlier Diagnosis The Situation As of 2012 Medicaid Annual Wellness Visit now includes Health Risk Assessment Prior to or during an Annual Wellness Visit appointment, a Medicare beneficiary (or caregiver) will be asked by the doctor or a health care professional to complete a Health Risk Assessment (HRA). The HRA includes some questions about the beneficiary's health, which may provide important information to discuss with the health professional during the Annual Wellness Visit. The Annual Wellness Visit also includes questions to help the doctor determine if there has been a change in cognitive abilities and whether the person needs to be evaluated for Alzheimer's disease. The Expense / Cost Savings Opportunity Take-aways Why the Panel cares? Why a long term care insurance carrier might care? 28
Dementia - Programs Care Location Alternatives The Program: Maximizing Independence at Home, an 18 month study by Johns Hopkins Why? To help people age in place without sacrificing their quality of life. Efficiency is key, as in the efficient use of resources (i.e., dollars). How it worked: 303 people 70 years plus. One third received home visit and care coordination intervention (including needs assessment and identification of community resources). The program also provided education and informal counseling to caregivers and patients, as well as informal counseling and problem solving. Coordinators contacted the families at least once monthly and more frequently if necessary. Outcome: Patients who met regularly were significantly less likely to leave their homes or die than those in the control group (30 percent vs. 45.6 percent) and were able to remain in their homes significantly longer. The study group had more of their needs met relative to the control group, most significantly in areas of safety and legal issues. Take-aways A more comprehensive, proactive approach to improve quality of life and potentially decrease cost Holistic approach addresses more needs 29
Dementia - Programs Impact Quality of Life The Program: An early intervention study to examine the effectiveness of a new treatment method that integrates two existing interventions. Why? ID ways to keep people functioning independently, longer, decrease caregiver burden (and potentially cost). How it worked: 40 patient caregiver "teams," participate in twice-weekly sessions for 10 weeks. The intervention consists of 10 weeks in multi-family groups of five to seven dyads, focusing on cognitive and memory skill improvement, as well as socialization. Expected Outcome: Hoping to see fewer everyday memory lapses, as well as less reported distress and enhanced quality of life for both members of the dyad. Take-aways Why panel cares? Improved memory and socialization could lead to longer period of independence (lower costs to insurers)? Less stress could lead to enhanced quality of life 30
Dementia - Programs Delay Onset of the Disease The Situation: The Lipitor example If a treatment became available in 2015 that delayed the onset of Alzheimer s disease for five years (a treatment similar to the effect of anti-cholesterol drugs) on preventing heart disease) Savings Opportunity Take-aways The cost reduction is significant Carriers this is a valid reason to help front load the research 31
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Dementia - Programs Proposed: Pre or Post Claim Program The Program: Providing education, support and planning via an online tool and portal for the loved ones of a person with dementia. Why? Evaluate if early, pro-active engagement increases support and decreases cost and stress. How it will work? The study will look at a cohort of long term care claimants, half of whom will be included in the intervention, with the others serving as the control group. Expected Outcome: Validate if early intervention/support to the family impacts the: a. location of care (in home, facility, etc.) b. length of care before progressing from home care to facility care c. level of loved one engagement/communication d. levels of caregiver/loved ones stress e. cost 33
Dementia Programs Kelly Funk, CLTC 34
Policy & Providers Lessons From The Health Care Arena for Managing Chronic Care Patients Producer: Bob Bua President - CareScout Panel: Peter Sasnow VP Corporate Development - SeniorBridge / Humana Mary Alexander Kelly Funk Strategic Alliances Director - Home Instead, Inc. Senior Associate Director - Alzheimer s Association 35