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1DSHS | Research and Data Analysis Division ● January 2014 (MANCUSO)
Integrating Data to Support Care Management Transformation
The Washington State Experience
David Mancuso, PhDDirector, Research and Data Analysis Division
Washington State Department of Social and Health Services
January 14, 2014
Getty Images, iStock
2DSHS | Research and Data Analysis Division ● January 2014 (MANCUSO)
Our Challenge
A small proportion of the Medicaid population accounts for a disproportionate share of Medicaid costs
High-cost clients are far more likely to be served in multiple Medicaid delivery systems
Behavioral health conditions are key drivers of disability-related Medicaid caseload growth and expenditures
Getty Images, Hemera
3DSHS | Research and Data Analysis Division ● January 2014 (MANCUSO)
$3,183
$5,721
$3,439
$3,036
$1,999
Complex Clients Drive Medicaid Costs
ALLHigh Medical
Risk
Clients with Significant Functional
Impairments
Clients with Serious Mental
Illness Clients with Substance Use
Disorders
High medical risk clients
without these 3 conditions
High medical risk disabled adult Medicaid enrolleesTOTAL PER MEMBER PER MONTH COST, ALL MEDICAID DELIVERY SYSTEMS WASHINGTON STATE SFY 2010
TOTAL = 29,008 n = 7,327 n = 16,843 n = 11,962 n = 6,921
NOTE: There is some duplication across client categories.
4DSHS | Research and Data Analysis Division ● January 2014 (MANCUSO)
Dental Services
Medical Eligibility Medicaid, State Only
Hospital Inpatient/ Outpatient
Managed Care Services
Physician Services
Prescription Drugs
Homelessness
Housing Assistance
Arrests Charges
Convictions
Incarcerations
Community Supervision
Hours
Wages
Births
Deaths
WASHINGTON STATE
Department of Social and Health Services
INTEGRATED CLIENT DATABASE
Nursing Facilities
In-home Services
Community Residential
Functional Assessments
Case Management
Community Residential Services
Personal Care Support
Residential Habilitation Centers and Nursing Facilities
Medical and Psychological Services
Training, Education, Supplies
Case Management
Vocational Assessments Job Skills
Child Protective Services
Child Welfare Services
Adoption
Adoption Support
Child Care
Out of Home Placement
Voluntary Services
Family Reconciliation Services
External
Internal
Institutions
Dispositional Alternative
Community Placement
Parole
Food Stamps
TANF and State Family Assistance
General Assistance
Child Support Services
Working Connections Child Care
DSHS Juvenile
Rehabilitation
DSHS Economic Services
DSHS Aging and Long-
Term Support
DSHS Developmental
Disabilities
DSHS Vocational
Rehabilitation
DSHS Children’s Services
Administrative Office of the Courts
Employment Security
Department
Department of Health
Department of Corrections
Washington State Patrol
Department of Commerce
Health Care Authority
Child Study Treatment Center
Children’s Long-term Inpatient Program
Community Inpatient Evaluation/ Treatment
Community Services
State Hospitals State Institutions
Assessments
Detoxification
Opiate Substitution Treatment
Outpatient Treatment
Residential Treatment
DSHS Behavioral Health and Service
IntegrationMental Health and Substance Abuse Services
Integrated Data Capacity in Washington State
5DSHS | Research and Data Analysis Division ● January 2014 (MANCUSO)
Extreme ER/ED utilization
Expected future medical costs
Prospective inpatient risk
Care gaps and quality indicators
High-risk targeting approaches
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6DSHS | Research and Data Analysis Division ● January 2014 (MANCUSO)
Prospective Inpatient Admission Risk Model
27.7%
21.4%
18.7%
15.6%
12.9%
11.2%
9.4%
8.8%
8.0%
8.0%
7.1%
6.1%
6.0%
5.3%
5.3%
5.2%
5.1%
5.0%
5.0%
4.9%
Sickle-cell disease
Dialysis catheter infection
Pneumonia
Hemophilia/von Willebrands
Lung transplant
Secondary malignant neoplasm
Congestive heart failure
Age 85 or above
Chronic skin ulcer
Liver transplant
Chronic renal failure
Ulcerative colitis
Diabetes, type 1 with complications
Septicemia
Chronic obstructive asthma
Chronic nephritis
Decubitis ulcer
Heart transplant
Rx for Liver Disease
Alcohol dependence
Example condition within risk group
Get
ty Im
ages
, iSt
ock
7DSHS | Research and Data Analysis Division ● January 2014 (MANCUSO)
9.8%
5.8%
4.2%
2.1%
1.7%
0.9%
0.3%
0.2%
Additional impact per hospital admission in prior 30 days
Additional impact per hospital admission in prior 31-90 days
Additional impact per hospital admission in prior 91-182 days
Additional impact per hospital admission in prior 183-365 days
Additional impact per OP ER visit in prior 30 days
Additional impact per OP ER visit in prior 31-90 days
Additional impact per OP ER visit in prior 91-182 days
Additional impact per OP ER visit in prior 183-365 days
Prospective Inpatient Admission Risk Model continued
Patient Example
Jane has been diagnosed with congestive heart failure (9.4%), poorly controlled type 1 diabetes (6.0%), and chronic obstructive asthma (5.3%).
• She was hospitalized once in the prior 31-90 days (5.8%), and twice in the prior 183-365 days (2 x 2.1% = 4.2%).
• She has been to the ED twice in the past month without being admitted to the hospital (2 x 1.7% = 3.4%).
• Her risk of an inpatient admission in the next 6 months is 28.3%.
Hospital Admission Impact . . .
Outpatient Emergency Room Utilization Impact . . .
Get
ty Im
ages
, iSt
ock
8DSHS | Research and Data Analysis Division ● January 2014 (MANCUSO) 8DSHS | Research and Data Analysis Division ● AUGUST 8, 2013
9DSHS | Research and Data Analysis Division ● January 2014 (MANCUSO) 9
10DSHS | Research and Data Analysis Division ● January 2014 (MANCUSO) 10
11DSHS | Research and Data Analysis Division ● January 2014 (MANCUSO) 11DSHS | Research and Data Analysis Division ● AUGUST 8, 2013
12DSHS | Research and Data Analysis Division ● January 2014 (MANCUSO)
CLOSE-UP
Drug
Adherence
12DSHS | Research and Data Analysis Division ● January 14, 2014
13DSHS | Research and Data Analysis Division ● January 2014 (MANCUSO)
Provider Reporting Ability
CLOSE-UP
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14DSHS | Research and Data Analysis Division ● January 2014 (MANCUSO)
Intervention strategy: health home interventions focused on management of high-risk patients
Nurse care manager to client ratio 1:50
– Primarily face-to-face
– Telephone support as needed
Evidence-based protocols including:
– Diabetes management
– Pain management
– Fall assessment and prevention planning
– Medication management
– Health Action Planning
– Coaching for Activation™
Comprehensive Assessment including Patient Activation Measure (PAM™)
Client-centered Health Action Plan and Goal Setting Worksheet
– Set goals with client according to activation level
– Education towards self-management of chronic illness
Getty Images, iStock
15DSHS | Research and Data Analysis Division ● January 2014 (MANCUSO)
Early returns show promise
Chronic Care Management evaluation
– Modest net savings
– Driven by reduced Hospital IP and SNF costs
– Reduced mortality
– Increased patient satisfaction
$27
$253
+ $46
+ $180
Medical Costs
Long-term Care Costs
Intervention Costs
OVERALLSavings
Cost DetailEstimated per member per month impact
http://publications.rda.dshs.wa.gov/1396/
