Lessons Learned in Care Management Meghan Sheridan, RD, CDE Ohio Association of Community Health Centers 2017 Annual Conference 1
Objectives: Rationale for team-based care model Lessons learned in implementing a successful team-based care model in the primary care practice Current trends in care management
Why Practice in a Team Model?
The future is here already, it just not evenly distributed. W. Gibson # of Practices Innovation Adoption Curve Late Majority Early Majority Most Many Not Many Early Adopters Innovators Very Few Activity Driven Revenue Adapted from E.M. Rogers, Diffusion of Innovations, 4 th edition (New York: The Free Press, 1995) Value-Based Contracts 4
Shift from Volume-to-Value Yesterday Today Tomorrow Day after Tomorrow Quality / HEDIS based bonuses Quality reporting and expanded measure set Quality reporting and expanded measure set Fee-for-Service Productivity / Work unit-based pay Capability-based revenue Fee-for-Service Productivity / work unit-based pay Quality / HEDIS based bonuses Capability-based pay Productivity-based pay with performance bonuses Total cost management for populations Base pay plus an increasing income from populationbased performance Revenue based on quantity of services Revenue based on quantity of services with performance bonuses Performance-based payment through risk sharing contracts/ networks Revenue from base pay plus population performance 5
Burden of Work Expanding reporting, billing, patient outreach, and documentation requirements Hours in the work day remain the same 6
Sharing the Work Burden = Revenue & Better Quality of Life Providers typically handle everything themselves Teams of people can handle the workload 7
What is Team-Based Care? Current Model Team-Based Care Model https://www.ucsf.edu/news/2014/08/116856/team-based-approach-primary-care 8
Bridge to Value-Based Care Reimbursement Multi-Payer Advanced Primary Care Practice Demonstration (MAPCP) Participation from eight states Embedded care managers to coordinate care, improve access and patient education, and link to community resources Positive outcomes (first two years) Reduced growth in Medicare expenditures by $83 PMPM compared to Patient-Centered Medical Home (PCMH) controls Medicare ROI of 8.64 Significant improvement in communication, coordination, medication review, self-management, and attention to mental health 9
MAPCP Michigan Findings: Average Change in Medicare Expenditures Outcome Total Medicare Acute Care Post-Acute Care ER Outpatient Specialty Physician Primary Care Provider Home Health Other Non-Facility Laboratory Imaging Cost Compared to PCMH Control -$83.43* pmpm -$38.70* pmpm -$18.66* pmpm -$1.17 pmpm -$2.87 pmpm -$12.18* pmpm -$5.40* pmpm -$1.58 pmpm -$1.43 pmpm -$1.24 pmpm -$0.68 pmpm Other Facility -$1.29 pmpm *Statistically Significant 10
Why Practice in a Team Model? Mitigates increased work burden Provides better care for patients at reduced cost Positions you to be successful in reimbursement reform 11
The Big Eight
Hindsight is 20/20 1) Clarify the role 2) Hire the right licensure 3) Hire the right person 4) Optimize technology 5) Treat the care manager like a provider 6) Learn how to bill 7) Plan to change things even if you feel like they are going well 8) Leverage in value-based contracts The right experience to turn 20/20 hindsight into 20/20 foresight 13
1) Clarify the Care Manager s Role Augment the provider s assessment Teach and counsel Manage barriers Link to community resources Coordinate care Drive behavior change 14
2) The Right Licensure Define your Specialty Gap What type of help does your patient population need? Education Linkages with community resources Financial help What type of support would you, as a provider, most like to delegate to somebody else? 15
Multidisciplinary Team Roles Social Worker Pharmacist Dietitian Family support/dynamics Medication reconciliation Nutrition/supplement education Transportation Medication adherence Nutrition assessment DME/home care Medication administration Medical nutrition therapy for specified health condition Community resources Polypharmacy Diet compliance Behavioral health Medication cost issues Barrier management Financial resources Advance directives End of life issues Neglect/abuse Adverse drug interactions Medication disposal Medication education Enhance physician s abilities in complicated cases Nutrition related symptom management 16
Multidisciplinary Team Roles Nurse Mid-Level Psychologist Education on disease Clinical goal support Increase access to clinical decision maker after hours Increased access to primary care services and billable services such as Annual Well Visits Mental and behavioral health services Individual, group, and family interventions effective for depression, anxiety, pain, and adjustment issues surrounding chronic illness Plan of care understanding / adherence Group visits Formal assessment and diagnostic services Gaps in care Coordination of care Education Home environment Transition of care Coordination of care Condition changes Education Coordination between mental and physical care 17
3) The Right Fit Knowledgeable of community resources and clinical diseases Independent Self-motivated Detail oriented Process driven Tech savvy Up-to-date clinical knowledge Connection with providers Connection with staff Connection with patients 18
4) Optimize Technology Systems Easy access to information Consistency in documentation Simplify workflow Automatic assignment of patients Gaps in care Outreach 19
5) Treat the Care Manager Like a Provider Discuss patient cases Space to work Dedicated schedule Scheduling support Billing support 20
6) Leave No Dollar on the Table Learn how to bill immediately! Work through rejections and denials Use health plan resources It s a sustainability issue, and an important success metric 21
7) Fixing What Does Not Feel Broken Practices may feel the burden of Fee-for-Service (FFS), but still function as a business The transformation of changing up the practice to provide team-based care requires fundamental change 22
8) Leverage in Value-Based Contracts Most value-based contracts are centered on: Practice transformation/capability implementation Cost efficiency Quality measure performance Leverage the work of your care manager to perform in these areas and maximize revenue from non-ffs sources 23
Current Trends in Care Management
On the Horizon Ambulatory pharmacy Integration of behavioral health New ancillary roles 25
Ambulatory Pharmacy Address the shortage of primary care providers by freeing up the provider s time to see more patients Increasing recognition for role in medication reconciliation and transitions of care Cost reduction estimated to be $363.45 to $398.98 per member with chronic conditions, such as diabetes mellitus and heart failure 1 26
Integration of Behavioral Health Most patients are dependent on primary care for behavior health treatment, yet few are appropriately identified and treated in this setting 29% of adults with medical conditions also have a mental health condition Across the top 9 chronic conditions, depression and anxiety go undiagnosed 85% of the time 2 Addressing behavior health disorders substantially improves outcomes when compared to treating a chronic medical condition alone 3 27
New Ancillary Roles Advanced care teams are starting to use new roles to meet the needs of their patients and ensure top of license work Community Health Workers Social Service Technicians 28
Summary Benefits of team-based care: Pure FFS payment is a non-sustainable practice model Financial sustainability depends on maximizing performancebased revenue Interventions to maximize HEDIS, Stars, and risk-adjustment incentives can close a practice s FFS gap For practices at financial risk for per member per month (pmpm) cost, care management is a key intervention to achieve financial goals Meeting our eight biggest lessons learned head on will improve your chance of successfully implementing team-based care 29
References 1. Viswanathan, Meera, Leila C. Kahwati, Carol E. Golin, Susan J. Blalock, Emmanuel Coker-Schwimmer, Rachael Posey, and Kathleen N. Lohr. "Medication Therapy Management Interventions in Outpatient Settings."JAMA Internal Medicine JAMA Intern Med 175.1 (2015): 76. 2. Epstein, Becker, Green Advisors. The Challenges and Rewards of Integrating Behavior health into Primary Care. 13 Oct. 2015, Webinar. 3. Sptizer, JAMA 1999; Kessler, Arch Gen Pysch 2005 30
Meghan Sheridan, RD, CDE Population Health Manager msheridan@medadvgrp.com