PROMISING MODELS OF CARE COORDINATION FOR BENEFICIARIES WITH CHRONIC ILLNESSES

Cheryl Schraeder, RN, PhD, FAAN

UIC College of Nursing

Patricia Volland, MSW, MBA

New York Academy of Medicine

Robyn Golden, MA, LCSW

Rush University Medical Center

Aging In America 2011

OVERVIEW Define care coordination

Identify proven care coordination/management interventions for beneficiaries with chronic illness Transitional Care

Comprehensive Care Coordination

Medicare/ Duals

Medicaid

Describe key distinguishing features

Describe internal and external evaluation

WHAT IS CARE COORDINATION? N3C defines care coordination as:

“A person-centered, assessment based, interdisciplinary approach to integrating health care and social support services in a cost-effective manner in which an individual’s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an evidence-based process which typically involves a designated lead care coordinator.”

WHAT IS THE PROBLEM? Most health care dollars are spent on a small

percentage of beneficiaries Those with complex chronic conditions

Causes of high utilization and costs: Deviations from evidence-based care Poor communication among primary providers,

specialists, health and community providers, patients, and families

Failure to catch problems early Failure to address psychosocial issues Lack of coordinated, longitudinal management Ineffective transitional management

WHAT IS EFFECTIVE CARE COORDINATION?

Intervention with rigorous evidence that:

Improves beneficiary outcomes

Reduces total health care expenditures for participating beneficiaries

Improved satisfaction or clinical indicators not sufficient

Net savings require reduced hospitalizations

PROMISING INTERVENTIONS Most evidence shows impacts are unreliable However, promising care coordination and care

management interventions are emerging Transitional care interventions

Care Transitions Intervention (Coleman) Transitional Care Model (Naylor) Enhanced Discharge Planning Program – RUSH (Perry)

Comprehensive Care Management - Medicare/ Duals Guided Care (Boult) GRACE (Counsell) Care Management Plus (Dorr) MCCD: Best Practice Sites (Brown)

Comprehensive Care Management – Medicaid/ Duals Integrated Care Management (Douglas) Community Based Chronic Care Management (Lessler) Hospital to Home (Raven) Health Care Management Program (Reconnu & Herndon)

TRANSITIONAL CARE: COMPONENTS

These programs: Engage patients with chronic illnesses while

hospitalized

Follow patients intensively post-discharge

Teach/coach patients about medications, self-care, and symptom recognition and management

Remind and encourage patients to keep follow-up physician appointments

Approaches to achieving these goals differ across programs

TRANSITIONAL CARE:THREE PROMISING MODELS Care Transitions Intervention (Coleman)

Patient-centered intervention designed to improve quality and contain costs for patients with complex care needs as they transition across care settings

Transitional Care Intervention (Naylor) Patient-centered intervention designed to improve

quality of life, patient satisfaction, and reduce hospital readmissions and cost for elderly patients hospitalized with CHF

Enhanced Discharge Planning Program (RUSH) Telephone-delivered social work-based transitional

care model (hospital to home) designed to promote patient safety and satisfaction, improve quality of life, and reduce preventable re-hospitalizations and ED visits.

TRANSITIONAL CARE:TARGET POPULATIONS Care Transitions Intervention (Coleman)

Included: Patients dc’d from hospital with certain diagnoses; 30-day Medicare readmissions for HF, MI, PNE; additional risk algorithm for readmission drawn from administrative data

Excluded: Dementia with no caregiver, primary psychiatric diagnosis, with psychotic elements, active drug or alcohol use

Transitional Care Intervention (Naylor) Included: 65+ CHF patient admitted to certain hospitals and

residing within 60 miles of designated hospital

Excluded: ESRD, non-English speaking

Enhanced Discharge Planning Program (RUSH) Included: 65+ returning home after discharge with 7+

prescriptions and 1 additional risk factor including living alone, past admission, no/unstable support system, other psychosocial issue

Excluded: Transplant

TRANSITIONAL CARE:STAFFING Care Transitions Intervention (Coleman)

APN, RN, social worker, or occupational therapist 1 care coordinator per 40 patients Duration: 30 days following hospitalization

Transitional Care Intervention (Naylor) Advanced Practice Nurses (3) 1 care coordinator per 39 patients Duration: 3 months following index hospitalization

Enhanced Discharge Planning Program (RUSH) Master’s prepared social worker with experience in

health and aging 1 care coordinator per 48 patients Duration: Up to 30 days, average 8 days

TRANSITIONAL CARE:INTERVENTION Care Transitions Intervention (Coleman)

Home visit post discharge, three follow-up calls

Based on 4 pillars: medication management, patient-centered record, primary care and specialist follow-up, knowledge of red flags

Transitional Care Intervention (Naylor) Hospital visit and home visits of varying frequency

Comprehensive assessment in hospital, defining priority needs and services

Ongoing advocacy, education, and communication to ensure plan of care

Enhanced Discharge Planning Program (RUSH) Pre-assessment through medical chart review to determine potential

needs

Telephonic biopsychosocial assessment and care coordination to stabilize situation, ensure medical and home health follow-up, and engage community-based service providers

TRANSITIONAL CARE:EVIDENCE Care Transitions Intervention (Coleman)

Intervention patients had Lower re-hospitalization rates at 90 days:

For any reason (17% vs. 23%) For initial condition (5% vs. 10%)

Lowered hospital costs 19% over 180 days ($2,058 vs. $2,546)

Transitional Care Intervention (Naylor) Intervention patients had:

54% fewer re-hospitalizations per patient after 12 months (1.18 vs. 1.79)

10.5% decrease in re-hospitalization rate (44.9% vs. 55.4%) 39% lower mean total costs ($7,636 vs. $12,481

Enhanced Discharge Planning Program (RUSH) Intervention patients had a lower 30 day post discharge

mortality rate compared to the usual care group (2.2% vs. 5.3%)

COMPREHENSIVE CARE COORDINATION: COMPONENTS These programs:

• Implement evidence-based guidelines for care management• Conduct a comprehensive assessment• Collaboratively develop and implement a plan of care• Teach/coach patients about proper self-care, medications,

how to communicate with providers• Monitor patients’ symptoms, well-being and adherence

between office visits• Advise patients on how to talk with and when to see their

physician• Apprise patients’ physician and other providers of important

symptoms or changes• Arrange for needed health-related support services• Coordinate communication among physicians,

health/community providers and patient/family Approaches to achieving these goals differ across

programs

COMPREHENSIVE CC - MEDICARE/ DUALS: FOUR PROMISING MODELS Guided Care: Boult

A model of comprehensive health care provided by nurse-physician teams for patients with several chronic conditions

GRACE: Counsell A model to improve the quality of care for low income

seniors by the longitudinal integration of geriatric and primary care services across the continuity of care

Care Management Plus (CMP): Dorr Patient-centered intervention designed to reduce

mortality and hospital admissions for elderly patients of primary care physicians

Medicare Coordinated Care: Brown Provide care coordination services to high risk

Medicare beneficiaries with multiple chronic conditions to improve quality and reduce total cost of care

COMPREHENSIVE CC - MEDICARE/ DUALS:TARGET POPULATION Guided Care (Boult)

Included: Older patients (65+) at high risk of using health services during the following year, as estimated by Hierarchical Condition Category (HCC) predictive model (scores of 1.2 or higher)

Excluded: Low HCC scores

GRACE (Counsell) Included: 65+, established patient of a site primary care clinician, income less than 200%

federal poverty

Excluded: Residence in nursing home, receiving dialysis, severe hearing loss, English language barrier, no access to telephone, severe cognitive impairment without an available caregiver

CMP (Dorr) Included: Older chronically ill patients (65+) of primary care physicians served by

Intermountain Health Care, a large health care system in Utah, with multiple comorbidites and beneficiaries of Medicare Part B for at least 11 months prior to enrollment

Excluded: Patient declined to participate

MCCD Best Practice Sites (Brown) Included: Medicare beneficiaries with chronic obstructive pulmonary disease (COPD),

congestive heart failure (CHF) or coronary artery disease (CAD) and at least on hospitalization in the prior year and any of the 12 chronic conditions and two or more hospitalizations in the prior two years

Excluded: Enrolled in hospice, reside in nursing home or have end stage renal disease (ESRD)

COMPREHENSIVE CC - MEDICARE/ DUALS:STAFFING Guided Care (Boult)

Registered nurse based in primary care practice working with 3-5 physicians

1 care coordinator (CC) per 50-60 patients GRACE (Counsell)

An APN and social worker in collaboration with PCP and a geriatric interdisciplinary team led by a geriatrician

1 CC/social worker (SW) per 100-125 patients CMP (Dorr)

All care managers are RNs, generalists, located in primary care clinics

1 care coordinator per 350-500 patients MCCD Best Practice Sites (Brown)

Registered nurses trained in comprehensive care coordination Wash U: 1 CC per 85-95 patients HQP: 1 CC per 75-85 patients Mercy: 1 CC per 80 patients Hospice: 1 CC per 45 patients

COMPREHENSIVE CC - MEDICARE/ DUALS:INTERVENTION

Guided Care (Boult) Manages transitions between sites of care (rounds in hospital, design/execute discharge plan,

visits patient at home within 2 days of discharge, ensures patient return to PCP) Creates an evidence-based comprehensive “Care Guide” and “Action Plan”

GRACE (Counsell) Initial and annual in-home comprehensive geriatric assessment by a GRACE support team

consisting of an advanced practice nurse and social worker Activation each year of indicated GRACE protocols and corresponding team suggestions GRACE support team meeting with patient’s primary care physician to review, modify, and

prioritize initial and annual care plan protocols and team suggestions

CMP (Dorr) Reorganization of primary care through a team-based approach (RN/PCP) Intervention based on continuity of care and regular follow-up by CC Patient-centered assessment, comprehensive care planning, disease and self-management

education

MCCD Best Practice Sites (Brown) Clinical assessment; evidence-based guidelines and protocols Care planning: mutual, prioritized goals/action plans Care plan implementation (self-management strategies, service/provider coordination,

reporting changes in symptoms, medications, self-management activities)

COMPREHENSIVE CC - MEDICARE/ DUALS:EVIDENCE Guided Care (Boult)

8 month findings of 32 month trial: 24% fewer hospital days 29% fewer home healthcare episodes 37% fewer skilled nursing days 15% fewer ED visits 9% more specialists visits

GRACE (Counsell) Patients at high risk of hospitalization (PRA score >= .04) in year two had

significantly lower hospital rates/1000 (396 [n=106] vs. 705 [n=105]) and ED visits/1000 (848 [n=106] vs. 1314 [n=105]; P = .03)

CMP (Dorr) Reduced 2-year all-cause mortality rates by 24% For patients with diabetes, reduced 2-year all-cause mortality rates by 34% and

hospitalization rates by 22%

MCCD Best Practice Sites (Brown) Intervention patients in the 4 best practice sites had:

Lower re-hospitalization rates by 8% to 33% among high-risk enrollees Lower total Medicare expenditures combined 4 sites of $157 per member per month

(2010 dollars)

COMPREHENSIVE CC - MEDICAID/ DUALS: FOUR PROMISING MODELS Integrated Care Management (ICM)

Provides specialized care management services to: (1) complex, high risk patients; and (2) patients that require various levels of episodic supportive care management services

Community Based Chronic Care Management – King County Care Partners (KCCP) Provides patient-centered community-based, multidisciplinary

care management that empowers patients and enhances coordination, communication, and integration of services across safety-net providers to improve clinical outcomes and decrease unnecessary utilization

Hospital to Home Patient-centered intervention designed to address the complex

health and social needs of Medicaid patients to reduce health service utilization and costs to the state Medicaid program

Health Care Management Program (HMP) Focused on improving the quality of life for chronically ill

individuals living in Oklahoma, HMP is a disease management program providing nursing case management services to Medicaid recipients and practice facilitation services to primary care providers

COMPREHENSIVE CC - MEDICAID/ DUALS:TARGET POPULATION

Integrated Care Management (ICM) Intensive Care Management services are provided to complex, high-risk individuals (1% of

patients) with the highest cost, highest ED visits and hospital admissions, and highest prevalence of mental illness and substance abuse issues

Supportive Care Management services are provided to individuals who have a single care issue or several issues that will stabilize or resolve within a short period of time

Community Based Chronic Care Management – King County Care Partners (KCCP) Medicaid patients residing in King County, WA, who have received care from one of the

participating primary care clinics within the past 12 months, and have been identified from predictive modeling to be at particularly high risk of future healthcare utilization

Hospital to Home Predictive computer algorithm used to identify individuals as being high cost and high risk

for future hospital admission

Typical patients tend to be frequent users of the ED and hospitals, substance abusers, have serious health and mental health issues, and tend to be homeless

Health Care Management Program (HMP) Five percent of the total state Medicaid population (n = 5,000) with chronic illness(es),

determined to be at highest risk for future utilization via predictive modeling algorithms

Patient population is divided into 2 groups: Tier 1 = highest risk (n = 1,000), and Tier 2 = high risk (n = 4,000).

COMPREHENSIVE CC - MEDICAID/ DUALS:STAFFING Integrated Care Management (ICM)

Care Management is provided by clinical care managers (RN or social worker). Non-clinical staff work on care coordination activities.

Intensive care managers have a caseload of 30 to 70 patients

Community Based Chronic Care Management – King County Care Partners (KCCP) The intensive care management team is composed of 3 RNs, 2

Social Workers (MSW) with chemical dependency training, and a BA level individual experienced in chemical dependency counseling

Hospital to Home Care management teams are comprised of social workers, community-

based care managers, and a housing coordinator

Care manager case loads are capped at 25 patients

Health Care Management Program (HMP) RNs with special training in care management, quality

improvement methods, and organizational behavior and systems

COMPREHENSIVE CC - MEDICAID/ DUALS:INTERVENTION

Integrated Care Management (ICM) Assessment and Care Planning to identify the individual’s highest priority issues related to

their physical and behavioral health and psychosocial challenges and interventions to help them effectively manage their own health

Align the care team and all community providers involved in the patient’s care using a comprehensive electronic health information system that can be accessed by all providers

Community Based Chronic Care Management – King County Care Partners (KCCP)

In-person comprehensive assessment and collaborative goal setting Chronic disease self-management coaching Joint PCP visits of patients and their care managers Coordination of community services and care across the medical and mental health system

Hospital to Home Multi-disciplinary care management model incorporates motivational interviewing, harm

reduction, and access to housing using a ‘housing first’ approach Communication with patients via a consistent, care management team, including a first

person contact (care manager), to manage and coordinate care across multiple locations and providers

Emphasis on providing and coordinating needed medical care and mental health support either within health care or community systems and settings.

Health Care Management Program (HMP) All patients receive comprehensive health status, health literacy, behavioral health, and

pharmacy assessments Strong emphasis is placed on self-management education and coordination of and access to

community services Nurse case management is provided face-to-face for highest risk patients and telephonically

for high risk patients

COMPREHENSIVE CC - MEDICAID/ DUALS:EVIDENCE

Integrated Care Management (ICM) Under evaluation

Community Based Chronic Care Management – King County Care Partners (KCCP) Preliminary results indicate: increased patient satisfaction with care, increased

patient self-management and self-efficacy skills, increased primary care physician satisfaction with services provided

Health service utilization and cost outcomes are being evaluated in an ongoing RCT

Hospital to Home Evidence from a pilot study suggests reduced hospitalizations by 38% and costs

to Medicaid of $5,000/person A formal program evaluation is currently being conducted by the New York State

Department of Health

Health Care Management Program (HMP) A comprehensive evaluation of HMP is underway Initial findings suggest significant savings to the Oklahoma State Medicaid

program

EVALUATION: INTERNAL Achieving model fidelity

Comprehensive and ongoing care coordinator training

Evidence-based practice guides established and updated Feedback provided to care coordinators on

implementation of these guidelines

Tracking of and feedback to care managers on established contacts

Tracking and reporting amount of time care coordinator spends on tasks

Need web-based method to measure fidelity and generate feedback

EVALUATION: EXTERNAL

Effect on hospital admissions and readmissions

Effect on medical costs By service

Total

Return on investment Did savings exceed intervention costs?

Effects on quality of care indicators Screenings, preventive care, ER visits, infections,

falls, mortality, etc.

Effects on patients’ quality of life

NYAM/ SWLI LITERATURE REVIEW:

Purpose Update of Best Practices in Care Coordination for older

adults with one or more chronic conditions

Methodology Conducted a search in Pubmed, Cinahl,* Ageline, Cochrane,

Psychinfo, and/or Soc/Index/Soc collection articles published between 2000 and 2010 in English

The Inclusion criteria Intervention 3 months or longer Explicit link between medical and community and long

term care services Quantitative or qualitative health, social, or economic

outcomes

* Cumulative Index to Nursing and Allied Health Literature

WHAT DISTINGUISHES SUCCESSFUL MODELS? COMPARING EFFORTS:

MODEL SYNTHESIS LITERATURE REVIEW

Targeting •Patients with select chronic conditions including co-occurring serious mental health diagnoses and substance abuse

•Those who were hospitalized in previous year or at time of enrollment

•Program targeting to identify the population who can most benefit from a given intervention

Intervention •Conduct comprehensive in-home initial assessment

•Develop a mutually agreed upon “action plan” with goal

•Frequent face-to-face contact (home, office) with patients (~1/month)

•Baseline and ongoing assessment of health and social needs

•Interdisciplinary approach to allow providers to address a spectrum of health and social service needs

•Flexible provision of services and service intensity

Primary care provider

•Strong rapport with primary care provider/specialist/hospital•Face-to-face contact through co-location, regular hospital rounds, accompanying patients on physician visits•Assign all of a physician’s patients to the same care coordinator when possible

•Enhanced communication among providers, frequently including the primary care physician

WHAT DISTINGUISHES SUCCESSFUL MODELS? COMPARING EFFORTS:

MODEL SYNTHESIS LITERATURE REVIEW

Patient Education

•Providing a strong, evidence based patient education/coaching intervention for managing health, symptoms, medications

•Evidence-based protocols to assess health and social condition and develop care plan

Training •Initial comprehensive training of CC•Performance feedback to CCs

•At least 15 percent of articles included for review report specialized training for service providers as intervention component

Community link

•Coordinate communication among physicians, health/community providers and patient/family

•Connection to existing community health and supportive services

BEST PRACTICES FOR CARE COORDINATION/MANAGEMENT MODELS Follow evidence based practices/guidelines for care

management Address psychosocial issues

Staff with experts in social supports and community resources for patients with those needs

Being a communications facilitator Care coordinators actively facilitating communications

among providers and between the patient and the providers

Implement self management, coaching and support with patient/family

Implement effective medication management plan Manage care setting transitions

Having a timely, comprehensive response to care setting transitions (esp. from hospitals and skilled nursing facilities)

THANK YOU!

Questions?