Promising Models of Care Coordination for Beneficiaries with Chronic Illnesses

Presented by:

Paul Shelton, EdD

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Identify promising care coordination/management interventions for beneficiaries with chronic illnesses Transitional Care Comprehensive Care Coordination

Describe internal and external evaluation Describe key distinguishing features of

these programs Policy Implications

Goals of Presentation

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Care Coordination

A person-centered, assessment based, interdisciplinary approach to integrating health care and social support services cost-effectively in which: an individual’s needs and preferences are

assessed, a comprehensive care plan is developed, and services are managed and monitored by

utilizing an evidence-based process and an identified Care Coordinator (New York Academy of Medicine, National Coalition on Care Coordination).

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The Problem Most healthcare dollars are spent on a

small percentage of beneficiaries who have 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/patient compliance Failure to address psychosocial issues Lack of coordinated, longitudinal management Ineffective transitional management (hospital - home,

hospital - nursing home, nursing home - hospital, nursing home - home)

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Intervention with rigorous evidence that:

Improves patient outcomes Reduces total health care

expenditures for participating patients

Improved satisfaction or clinical indicators not sufficient

Net savings require reduced hospitalizations

What is Effective Care Coordination?

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Promising care coordination interventions:

1. Transitional Care Coordination (Coleman et al. 2006; Naylor et al. 2004; Perry et al. 2011)

Promising Interventions

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Promising Interventions, cont.:

2. Comprehensive Care Coordination

Medicare/Duals - (Boult et al. 2008; Leff et al. 2009; Dorr et al. 2008; Counsell et al. 2007; Medicare Coordinated Care Demonstration: Best Practice Sites, Brown 2009).

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Transitional Care

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/encourage patients to keep follow-up physician appointments

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Transitional Care Intervention: Coleman et al. (2006)

Care Transitions: Coleman Patient-centered intervention designed to improve quality

and contain costs for patients with complex care needs as they transition across care settings

Target Population Inclusion:

A) Patients being discharged from the hospital with: stroke, congestive heart failure, coronary artery disease, cardiac arrhythmias, COPD, diabetes, spinal stenosis, hip fracture, peripheral vascular disease, deep venous thrombosis, pulmonary embolism

B) 30 day Medicare readmission for HF, MI, PNE C) Risk algorithm for readmission drawn from administration

data Exclusion:

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

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Transitional Care Intervention: Coleman et al.

(2006)Staffing APN or RN or social worker or occupational therapistCaseload: 1 care coordinator (CC) per 40 patients Duration: 30 days following hospitalizationFocus Continuity of care by helping family maintain a

personal health record Help family understand how/when to obtain timely

follow-up care Coach patients to ask the right questions to the right

health care providers Help patients/families be more active in managing

condition and in developing/implementing self-care skills (i.e. medication management, increased awareness of symptoms, recognizing “red flags” and warning signs for care, along with instructions on how to respond

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Transitional Care Intervention, cont.:

Mary Naylor et al. (2004) Care Transitions: Naylor

Patient-centered intervention designed to improve quality of life, patient satisfaction, and reduce hospital readmissions and cost for elderly patients hospitalized with CHF

Target Population Inclusion:

A) Elderly patients (aged 65+) admitted to 6 Philadelphia, PA, hospitals with diagnosis of CHF (DRG 127)

B) Live in the community within a 60 mile radius service area

Exclusion: Could not have ESRD, non

English speaking

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Transitional Care Intervention, cont.:

Mary Naylor et al. (2004)Staffing Advanced Practice Nurses (3)Caseload: 1 care coordinator (CC) per 39 patientsDuration: 3 months following index hospitalizationFocus Continuity of care at hospital discharge to

optimize patient’s health status and arrange for needed home care services

After patients discharged home, prevention of medication and other medical errors

Help patients/caregivers with early symptom recognition, management of chronic conditions, and recommendations for future care.

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Comprehensive Care Coordination 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

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Comprehensive Care Coordination: Medicare/Duals

Guided Care Care Management Plus (CMP) Medicare Coordinated Care Geriatrics Resources for Assessment

and Care of Elders (GRACE)

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Comprehensive Care Coordination: Guided Care

Guided Care: Boult A model of

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

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Comprehensive Care Coordination: Guided Care

Target Population Inclusion Criteria

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

High risk was equated with HCC scores of 1.2 or higher

Exclusion Criteria Low HCC scores

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Comprehensive Care Coordination: Guided Care

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

physiciansCaseload: 1 care coordinator (CC) per 50-60 patientsDuration: OngoingFocus Enhance primary care by infusing the operative principles of all seven

chronic care innovations Comprehensive patient evaluation Individual care planning Promote adherence with evidence-based guidelines Empower patient Promote healthy lifestyle Coordinate care of multiple conditions Coordinate care across provider settings

Caregiver support and education Access to community resources Make evidence-based, state-of-the-art, chronic care available

continuously from teams of professionals that patients trust

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Care Management Plus (CMP)

CMP: Dorr Patient-centered intervention designed to

reduce mortality and hospital admissions for elderly patients of primary care physicians.

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Care Management Plus (CMP)

Target Population Inclusion:

A) Elderly (65+), chronically patients of primary care physicians served by Intermountain Health Care, a large health care system in Utah

Medicare Part B for at least 11 months prior to enrollment

Multiple comorbidities, diabetes, frailty, dementia, depression, other mental health needs

Physician referral Exclusion:

Patient declined to participate

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Care Management Plus (CMP)

Staffing All care managers are RNs, generalists,

located in primary care clinicsCaseload: 1 care coordinator (CC)/350-500

patientsDuration: 24 monthsFocus

Continuity of care through specialized information technology system

Education for specific diseases and problem-solving skills

Emphasis on evidence-based treatment plans and protocols

Flexibility of care planning and treatment plans

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Comprehensive Care Coordination:

MCCD Best Practice SitesMCCD Provide care coordination services to high risk

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

Evidence 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)

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Comprehensive Care Coordination: MCCD Best Practice Sites

Target Population (portion of study in each promising practice program)

Inclusion Criteria 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

Exclusion Criteria Enrolled in hospice, reside in nursing home or have end

stage renal disease (ESRD)

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Comprehensive Care Coordination: MCCD Best Practice Sites

Staffing Registered nurses trained in comprehensive care coordination Washington University and Health Quality Partners had staff primarily located

in community offices (not hospital, clinic, home health); Mercy Medical Center staff located in hospital and primary care clinics and Hospice of Valley staff located in Hospice Agency

Caseload 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 patientsDuration: OngoingFocus Improved self-care Improved symptom recognition and management Improved medication management Implementation of evidence-based practices Improved transitional care

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Internal Evaluation How to achieve fidelity to model:

Comprehensive and ongoing training of care coordinators

Established and updated evidence based guides for practice

Regular feedback to care coordinators on whether patients are receiving care consistent with guidelines

Tracking of and feedback to care managers on established contacts (monthly visits, visits within 24 hours of hospital discharge, etc.)

Feedback on implementing self-management and evidence- based guidelines with patients

Tracking and reporting amount of time care coordinator spends on tasks (assessing, planning, monitoring, educating, coaching, documenting, supporting, and coordinating)

Need web-based care management system to measure fidelity and generate feedback

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External Evaluation: What we Need to Evaluate to Judge

Success Effect on hospital admissions and

readmissions Effect on medical costs (by service type,

total) Whether savings exceed intervention costs Effects on quality of care indicators (e.g.,

screening tests, preventive care, ED visits, infections, falls, mortality, etc.)

Effects on patients’ quality of life

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What Distinguishes Successful Comprehensive Care Coordination/Care

Management?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

Caseload Small enough caseload size (e.g. 40-80)Training and Feedback CC Initial comprehensive training of care coordinators Deliver effective patient education and coaching

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

Performance feedback to care coordinators

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What Distinguishes Successful Comprehensive Care Coordination/Care

Management?

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

Contacts Frequent face-to-face contact (home, office) with patients

(~1/month)Intervention Conduct comprehensive in-home initial assessment Develop a mutually agreed to “action plan” with goals

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What Distinguishes Successful Comprehensive Care Coordination/Care

Management?

Interventions 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 health and community 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)

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Policy Implications

Best short run opportunity for reducing costs is improving transition from hospital to home

Need payment reform to incentivize hospitals and primary care practices to implement these programs

Medicare and Medicaid incentives to reduce readmissions Tying physicians’ compensation to quality and efficiency

scores Medicare and Medicaid should consider separate

reimbursement for care managers implementing proven interventions with target groups

Special training programs for care coordinators and managers are needed

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Contacts – Questions or Additional Information

Paul Shelton, EdD Email: pshelton@illinois.edu Phone: 1-205-748-0050

Cheryl Schraeder, RN, PhD, FAAN Email: cheryls@uic.edu Phone: 1-217-586-6039