Care Management Enrollment for Complex Managed Medicaid Patients

Population Health Advisor EXCERPT Care Management Enrollment for Complex Managed Medicaid Patients Introduction.........................3 Key Lessons. 5 Case Profiles.... 7 2015 The Advisory Board Company

Population Health Advisor Project Director Tomi Ogundimu Contributing Consultants Eric Sun Meridith Weiss Executive Director Shay Pratt Program Directors Megan Clark Sara Sanchez LEGAL CAVEAT The Adv isory Board Company has made efforts to v erify the accuracy of the information it provides to members. This report relies on data obtained f rom many sources, however, and The Adv isory Board Company cannot guarantee the accuracy of the inf ormation provided or any analysis based thereon. In addition, The Adv isory Board Company is not in the business of giving legal, medical, accounting, or other prof essional advice, and its reports should not be construed as professional adv ice. In particular, members should not rely on any legal commentary in this report as a basis for action, or assume that any tactics described herein would be permitted by applicable law or appropriate f or a giv en member s situation. Members are adv ised to consult with appropriate prof essionals concerning legal, medical, tax, or accounting issues, before implementing any of these tactics. Neither The Adv isory Board Company nor its officers, directors, trustees, employ ees and agents shall be liable for any claims, liabilities, or expenses relating to (a) any errors or omissions in this report, whether caused by The Adv isory Board Company or any of its employ ees or agents, or sources or other third parties, (b) any recommendation or graded ranking by The Adv isory Board Company, or (c) failure of member and its employ ees and agents to abide by the terms set f orth herein. The Adv isory Board is a registered trademark of The Adv isory Board Company in the United States and other countries. Members are not permitted to use this trademark, or any other Advisory Board trademark, product name, service name, trade name, and logo, without the prior written consent of The Adv isory Board Company. All other trademarks, product names, service names, trade names, and logos used within these pages are the property of their respective holders. Use of other company trademarks, product names, service names, trade names and logos or images of the same does not necessarily constitute (a) an endorsement by such company of The Adv isory Board Company and its products and services, or (b) an endorsement of the company or its products or serv ices by The Advisory Board Company. The Adv isory Board Company is not affiliated with any such company. IMPORTANT: Please read the following. The Adv isory Board Company has prepared this report f or the exclusive use of its members. Each member acknowledges and agrees that this report and the inf ormation contained herein (collectively, the Report ) are conf idential and proprietary to The Adv isory Board Company. By accepting deliv ery of this Report, each member agrees to abide by the terms as stated herein, including the f ollowing: 1. The Adv isory Board Company owns all right, title and interest in and to this Report. Except as stated herein, no right, license, permission or interest of any kind in this Report is intended to be giv en, transferred to or acquired by a member. Each member is authorized to use this Report only to the extent expressly authorized herein. 2. Each member shall not sell, license, or republish this Report. Each member shall not disseminate or permit the use of, and shall take reasonable precautions to prevent such dissemination or use of, this Report by (a) any of its employees and agents (except as stated below), or (b) any third party. 3. Each member may make this Report available solely to those of its employees and agents who (a) are registered f or the workshop or membership program of which this Report is a part, (b) require access to this Report in order to learn f rom the inf ormation described herein, and (c) agree not to disclose this Report to other employ ees or agents or any third party. Each member shall use, and shall ensure that its employ ees and agents use, this Report for its internal use only. Each member may make a limited number of copies, solely as adequate for use by its employees and agents in accordance with the terms herein. 4. Each member shall not remov e from this Report any confidential markings, copyright notices, and other similar indicia herein. 5. Each member is responsible for any breach of its obligations as stated herein by any of its employ ees or agents. 6. If a member is unwilling to abide by any of the f oregoing obligations, then such member shall promptly return this Report and all copies thereof to The Adv isory Board Company. 2015 The Advisory Board Company 2

Overview of Project and Research Methodology Introduction and Purpose This brief provides case study profiles for conducing outreach to Medicaid managed care populations and other high-risk, complex patient populations, focusing on the following topics: Program marketing and branding Primary outreach methods Secondary outreach methods Coordination processes, including behavioral health coordination The case study profiles provide guidance for (1) framing care management programs for a Medicaid patient population, (2) engaging patients in initial outreach and enrollment efforts, (3) following up with patients to secure enrollment after initial contact with care management staff, and (4) coordinating and sharing information with primary care providers, behavioral health staff, and others. Research Methodology The Population Health Advisor team conducted a literature review to identify care management programs that have established processes for outreach and enrollment of complex patient populations with psychosocial needs. The team interviewed stakeholders from the identified organizations with models demonstrating positive outcomes. Profiled organizations were selected to represent a broad range of tactics that demonstrate innovative staffing, partnerships, and processes. 2015 The Advisory Board Company 3

Key Lessons 2015 The Advisory Board Company 4

Summary of Lessons for Complex Care Patient Enrollment For Medicaid Populations, In-Person Introductions Are Key to Success Complex care management programs that successfully engage Medicaid managed care patients use warm handoffs to introduce patients to care managers whenever possible. Inpatient nurses or outpatient providers can set up an in-person introduction to care management staff and set the stage for relationship building between a patient and complex care manager. Another common strategy across successful enrollment efforts is to frame or brand the complex care management program as a supportive resource accessible to patients to improve acceptance among Medicaid patients. Additionally, standardizing protocols for follow up after the initial program introduction can help minimize ineffectual effort on the part of staff. Finally, staff responsible for outreach and enrollment are often the same staff responsible for coordinating with a patient s other providers to communicate a patient s involvement in complex care. Outreach Roadmap for Complex Managed Medicaid Patients 1 2 Tailor Program Marketing for Complex Medicaid Patients Create Standards for Enrollment and Ongoing Collaboration Find the Right Message Use Standardized Outreach Protocols Over-Communicate With Other Providers Frame care management differently for Medicaid patients than for other patient populations, such as employees Emphasize that the program is a resource available in connection with the primary care provider s office and that it is not a punishment for patients Warm handoffs with immediate inperson introduction by PCP or clinic staff are optimal for securing patient investment Follow-up outreach should use no more than three phone calls in several weeks and up to one letter Outreach staff should loop back with a patient s primary provider to inform them of the status of enrollment attempts Collaboration with carefully chosen partners can increase impact on patient management, such as home visits coordinated with home health Source: Population Health Advisor interviews and analysis. 2015 The Advisory Board Company 5

Summary of Leading Organizations Outreach Models Provider Organization Outreach Staffing Primary Method Secondary Method Number of Touches Behavioral Health Coordination Henry Ford Health System Embedded case managers in primary care clinics; Community health workers to join team in 2015 Warm handoffs from primary care providers; face-toface meetings during clinic appointments planned for 2015 Initial letter followed by phone calls 2-3 calls over several weeks, varying time of day Case managers maintain accountability for overall patient care plan Delegate behavioral health-specific care to behavioral health nurse practitioners Covenant Health Partners Patient navigators (Community Health Worker, BSW, LVN) IP bedside recruitment and telephonic outreach Phone calls by navigators, then letter 2 calls over 10 days Coordinate with local behavioral health clinic for patients with behavioral health needs Aceso Healthcare 1 Complex care managers embedded in primary care clinics Warm handoffs from primary care providers or clinic MAs; initial brief screening while patient is still in the clinic Phone calls followed by a letter 3 calls over 2 weeks, followed by a letter Notify referral source if unable to enroll patient in program Check clinic schedule so medical assistant can discuss with patient Social workers provide patients with behavioral health support information, assist with making appointments Iaso Health System 1 RN case manager embedded in certain clinics Provider sets up warm handoff for RN case manager to join the appointment and explain the program Phone calls by RN case managers or panel coordinators, then letter 2-3 calls, depending on patient reaction during 2 nd call; letter addressed from provider Community health workers engage patients in care management Social workers provide behavioral health support in 7 clinics Psychiatric NPs staff 3 clinics, can provide direct behavioral health treatment after warm handoffs 1) Pseudonym. Source: Population Health Advisor interviews and analysis. 2015 The Advisory Board Company 6

Case Study Profiles Henry Ford Health System Covenant Health Partners 2015 The Advisory Board Company 7

Case Study #1: Henry Ford Health System Embedded Case Managers Well-Positioned to Engage Patients Early Collaboration With Primary Care Providers Critical to Successful Outreach Case in Brief: Henry Ford Health System 1,679 bed, not-for-profit system with five hospitals in the Midwest Payer mix: Medicare and Medicare HMO patients comprise 43% of revenue, Blue Cross at 23%, Medicaid and Medicaid HMO at 15%, and other payers make up19% of revenue Henry Ford s largest system care management pilot includes 22 embedded case managers in primary care practices; The system is currently implementing a payer-neutral cross-continuum care management model that incorporates best practices learned from the ongoing Enhanced Care Program pilot Henry Ford owns the Health Alliance Partners (HAP) Medicaid plan, which includes case managers that help with disease management coaching and high-risk catastrophic coaching for health plan members Program Marketing Building off Existing Relationships to Increase Likelihood of Engagement HFHS markets the complex care management program primarily through patient outreach to case managers via their primary care physicians. Introducing the program through a patient s PCP builds off the existing rapport and trust because Medicaid patients are more likely to engage in complex care management if they feel the program is connected to a source they already trust for health information and guidance. Outreach letters are designed to emphasize certain characteristics of the program including: As part of the program the case manager is a nurse on the PCP s team who will be working as the patient s personal care manager The program is free of charge and increases access to the PCP The case manager s picture and biography Initial Outreach, Enrollment Initial Outreach Relies on Physician Phone Calls, Letters Outreach staff use care management IT to stratify patients by risk scores and prioritize which patients to outreach to for care management enrollment Case managers send program invitation letters to patients on behalf of their PCPs and through weekly notifications, let PCPs know which patients need an outreach phone call Case managers follow up with patients via phone to begin formal enrollment after physician introduction using standard operating procedures Patients agreeing to initial outreach come in for a super visit, which are face-to-face meetings with the physician and case manager to formally kickoff ongoing care management Plan to use community health workers (CHWs) to outreach to high-risk managed care and dual eligible patients in 2015 as part of Ambulatory Intensive Care model and connecting with patients in their communities Source: Population Health Advisor interviews and analysis. 2015 The Advisory Board Company 8

Case Managers Retain Ownership Over Patient Management Additional Clinical Care Needs Delegated to Other Providers Follow-Up Enrollment Outreach Standards Who performs follow-up? Method of contact? How often? When to stop following up? How to close feedback loop? After Initial Phone Call by Physician Embedded case managers Letter, phone calls; occasionally attend other appointments to meet patient (e.g., cardiology) 2-3 calls over several weeks, varying times of day If no response after 3 calls; Patient does not respond to written communication Communication with physician patient s EMR Coordination Primary Case Managers Retain Ownership, Accountability for Patients HFHS often case managers collaborate with behavioral health nurse practitioners embedded in some of the clinics, who focus on depression care and treatment Case managers remain primary point of contact for patient but delegate depression-specific care to NPs Other psychosocial needs remain in the purview of the case managers Patient information shared and communicated through EMR Source: Population Health Advisor interviews and analysis. 2015 The Advisory Board Company 9

Case Study #2: Covenant Health Partners Patient Experience Workshop Improves Patient Outreach Workshop Role Play Highlights Key Words, Gestures to Build Patient Trust Case in Brief: Covenant Health Partners Integrated health system based in Lubbock, TX with four hospitals and 977 combined beds Payer Mix: 33K lives under risk-based contracts (includes self-funded, MSSP, Medicare Advantage, state retired employees); also participate in Delivery System Reform Incentive Payment Program (DSRIP) with mostly Medicaid and unfunded/uninsured patients Staffing: Three centralized teams work with distinct payer populations: commercial contracts, adult DSRIP, and pediatric DSRIP, with each team staffed with an RN care coordinator and a mix of navigators (Community Health Worker, SW, or LVN); clinic navigators work within two largest primary care offices with patients in the clinic setting Deployment: Navigators perform home visits for patients within a 60-mile radius, but will scale back visits to fit patient needs; phone-based navigation used to offset the decreased frequency of home visits Program Marketing Emphasize Partnership with PCP, Free Service to Attract Patients Program explanation focuses on four main points: Provide information to help patient become better educated on health care needs Ensure continuity of care by partnering with primary care physician Support post-discharge to secure community resources Free service and neither the patient nor their insurance is billed Asked system patient experience leader to present on how to introduce the care management program to patients and run a workshop where staff practiced role playing the enrollment process; workshop emphasized words and gestures that impact patient perception of the program and trust in staff members Primary Outreach Methods Bedside Visits a Key Opportunity for Patient Engagement Patients identified for care management by inpatient case manager, physician or other health care provider and then reviewed by intake coordinator for appropriateness for program For inpatient referrals, the program care management liaison (Community Health Worker, LVN or BSW) presents the program to patients at the bedside, with time per week varying between 1-4 hours depending on number of patients seen When a physician identifies a patient for care management, staff notify the PCP that the patient has enrolled in the program. In some cases, the PCP can then discuss the program in person with a warm handoff to the care manager Method of outreach (primary): Bedside visit and phone outreach Source: Advisory Board research and analysis 2015 The Advisory Board Company 10

Track Effectiveness of Outreach Tactics to Streamline Efforts Constant Focus on Outreach Improvement Yields Results Follow-Up Outreach Outreach Methods Who does follow-up? Method of contact? How many times, over what period? When to stop following up? How to close feedback loop? After Initial Introduction by Provider Patient navigator Phone calls, letter 2 calls over 10 day period 1 After 10 days Make note in EMR; if declined, send notification of patient refusal to referring provider 2 Coordination Local Behavioral Health Partnership Boosts Team Capacity Work closely with one OP behavioral health clinic that was looking to increase referrals to their facility Over time have built a strong partnership where both teams co-manage patients medical and behavioral needs For severe behavioral health patients, the OP behavioral health clinic takes over management of the patient Program Impact 50% Increase in consent rate in pediatric program after adding inpatient bedside enrollment, locating staff to the children s campus and providing a consultation room 1) Program cut number of calls from 3 to 2 after looking at the data and seeing little difference between 2 nd and 3 rd calls on patient consent rate 2) Notification prompts referring provider to reach out to patient to encourage participation; in one instance a PCP told a patient that he would fire the patient from his practice if she did not participate Source: Advisory Board research and analysis. 2015 The Advisory Board Company 11

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