Advanced Illness Care Coordination in a Medicare Advantage Setting

Richard Raskin, MD,FACPChief Medical Officer, East Division

Avon, CT

Danielle Butin, MPH,OTRDirector, Health Services, East Division

White Plains, NY

Angelina Yearick, JD, MSPHConsultant to Health Services

White Plains, NY

2

Setting the Stage

• Medicare Advantage

• Geography and Demographics

• Population Selection

* Health Risk Assessment

* HCC Scoring

* Claims Based/Predictive Modeling

* Diagnoses

3

Rationale for Development of Program Targeted at Medicare

Advantage Enrollees• Medicare enrollees have high incidence of chronic disease

and life-threatening illness• Clinical deterioration in these enrollees often occurs

suddenly • Patients facing end-of-life decisions often do not have the

requisite information to make informed choices about how they would like to spend their last days, and have not made these choices proactively.

• As a result, coordination of care for enrollees at end-of-life is inadequate, leading to suboptimal qualitative and financial outcomes.

4

Advanced Illness and Coordinated Care Program

The Advanced Illness Coordinated Care (AICC) Program, developed by Dr. Dan Tobin, is designed to:•Target enrollees with specific diagnoses for appropriate advanced care planning •Offer in home counseling to targeted enrollees.•Reduce the rate of patients dying in the hospital by providing patients the opportunity to spend the end-of-life in the setting of their choice;•Empower these enrollees to become more proactive in the delivery of their end-of-life healthcare services.

5

Program Description

The program consists of a 3-month intervention of up to 6 in-home counseling visits, focusing upon:

• Relief of death anxiety (counseling component). • Informed decision making about therapeutic

options and communication with surrogates, family members, caregivers and health care providers.

• Identification of opportunities for improved care coordination.

6

Staffing/Training • No health plan staff is allocated full-time to this

project.

• Contracted/Outsourced Models for Care Delivery: Model 1: Nurse Practitioners credentialed as Independent

Providers in AICC68 Trained providers in metro NY area to date

Model 2: Contracted Nurses and Social Workers through local Hospice Agency12 Trained Registered Nurses10 trained Social Workers

• All staff training is conducted by Dr Dan Tobin at a full day intensive seminar.

7

AICC Visits (Targeted in Borough of Queens, NY)

• Enrollee identified and mailed an introductory letter about the program.

• Follow-up call within 1 week to invite enrollee to participate

• Upon consent, AICC Provider assigned to conduct home visits

8

AICC Visits-What Happens at Home?

• Meeting 1 Introduce goals of AICCP How AICCP interacts with the primary care physician and the

acute care team, and What to expect.

• Meeting 2 Evaluate capacity of caregiver Discuss psychological, social, financial and practical concerns

• Meeting 3 Forging the partnership of member and caregiver in AICCP

care plan

9

AICC Visits – What happens at home?

• Meeting 4 Care management of functional impairment DNR orders

• Meeting 5 Obtaining feedback from providers on care plan Working with family members on care plan

• Meeting 6 Discuss accomplishments Address remaining concerns

10

AICC Providers-Need Back-Up• Coordination of services provided by Education &

Outreach Department• Additional service requests were made by practitioners

for: Home health care Nutrition consultations Prescription assistance Meals on wheels Transportation services DME Custodial care

11

AICC Visit Tracking

• CUP Profile (1-5) Curative, Uncertain,

Palliative

• Pain Assessment (1-5)• Coping with diagnosis (1)• Psychological Status (2)• Advance Directives (2)• Quality of Life (2)• Practical Issues (3)• Family Concerns (3)

• Palliative Care (4)• Spiritual/Religious Issues

(4)• Life-sustaining treatment

(5)• Psychological and other

concerns (5)• Bereavement needs (5)• Life closure (5)

Utilize 5 forms for data collection

12

Demographics of PopulationPlace of Residence

Home

(93%)

With Relative

(2%)

Caregiver Living Arrangements

Alone

(23%)

Spouse/Other CG

(69%)

Gender Male

(55%)

Female

(45%)

Ethnicity Caucasian

(67%)

African American

(20%)

Hispanic

(4%)

Asian

(2%)

13

Diagnoses of Population

• Main Diagnoses for Selection on hospitalization and predictive modeling: CHF COPD Metastatic Cancer

• Some additional diagnosis were added in predictive modeling: Alzheimer’s disease Stroke

14

Enrollment in Program By Number of Visits

45

15

23

8

38

0

5

10

15

20

25

30

35

40

45

1 visit 2 visits 3 visits 4 visits 5 visits

Number ofParticipantsCompleting Visits

15

Adherence with Advance Directives

• National prevalence of advance directives: 15-20%• Compliance with Advance Directives in Program

Advanced Directives

2 visits 3 visits 4 visits 5 visits

Yes 60% 61% 75% 84%

16

Selection of Health Care Proxy

Healthcare Proxy

Selected

3 visits 4 visits 5 visits

YES 71% 63% 78%

17

Financial Results of Program 6 months Post PMPM

No AICC

(N=128)

AICC Visits

(N=38)

Inpatient $2,186 $999

ER $34 $11

Outpatient $779 $365

SNF $110 $21

Homecare $132 $283

Total $3,942 $1,926

18

Current Status of AICC Participants

Receiving Services %

Homecare 50%

Hospice 3%

SNF 5%

No Services 42%

19

Mortality Data

• Nationally, about 80% die in hospital or facility

• 9.3 % of enrollees died within 18 months 41% died in the hospital 58% died at home, in a snf or with hospice

• Of those who died, the average lifespan was 6 months after start date

20

Interpretation of Data

• Impact of Number of Visits on Outcome

• Impact of AICC Provider-2 Models

• Utilization of Palliative Care/Hospice Services

• Medical Utilization Impact

21

Conclusions

• AICC can be an effective strategy to improve end of life care within a Medicare Advantage population.

• Program success requires careful enrollee selection. • Nurses and nurse practitioners are effective AICC

providers • AICC Providers with case management expertise are more

successful at sustaining member enrollment and achieving positive outcomes.

• Collaboration between hospice organizations and Medicare Advantage health plans has the potential for improving hospice utilization and clinical outcomes.