P ti tC t dM di lC Patient-Centered Medical Care - Grantmakers In Health


Patient‐Centered Medical Care:  P ti t C t d M di l C Vision to Reality Implementing Care  Management for Complex Management for Complex  Patients in Primary Care Clemens Hong MD, MPH Grantmakers in Health 2012 Fall Forum Health Care Transformed: Better Delivery for Those Most in Need November 16, 2012 1

Outline • Overview of complex care management (CCM) and its relationship to primary care • Review core features of CCM programs • Recommendations to help spread CCM programs


Health Care Costs Concentrated in Sick Few— Sickest 10 Percent Account for 65 Percent of Expenses i e e e A ou o e e o E pe e Distribution of health expenditures for the U.S. population, by magnitude of expenditure, 2009 1% 5% 10%

Annual mean expenditure


50% 50%



65% $26,767

97% $7,978

Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey.

Building Blocks of Building Blocks of  High‐‐Performing  High Primary Care

Willard & Bodenheimer The Building Blocks of High-Performing Primary Care: Lessons from the Field, April 2012 (www.chcf.org)

10 Template of the Future

8 Prompt access to care

9 Coordination of Care




Patient-Team Partnership

Continuity of Care

Population Management





Engaged Leadership

Data-driven Improvement


Team-based Care 4

Complex Care Management Complex Care Management Defined Complex p Care Management g (CCM) ( ) is the organized g delivery of care to address the complex needs of high risk, community dwelling patients


Research Questions Research Questions • What are the core, operational attributes of successful CCM programs? • How do these programs customize for specific populations or contexts?

Methods • Site selection: literature review,, expert p steering g committee, & snowball sampling o Inclusion criteria: • Primary care-aligned CCM program • Existing data on performance • Ongoing operation • Data collection: 3+ Interviews/site • Analysis: 2 independent reviewers identified themes 7

Domains of Study Domains of Study 1. 2. 3 3. 4. 5 5. 6. 7 7. 8.

Team structure Patient selection Patient engagement Integration with primary care & other providers Scope of work & key tasks Integration of information technology C manager (CM) ttraining Care i i Outcomes 8

CCM Program Characteristics g • 18 programs from 14+ States o 5 were partt off a primary i care transformation t f ti initiative i iti ti o 12 urban, 3 rural, 3 mixed

• Program payer mix o 8 multi-payer o 8 Medicaid/uninsured, 10 Medicare, 8 private

• Program “ownership” o 7 payer, 8 delivery system, 2 payer/delivery System, 4 regional CM partnerships


1. Team Structure • Most lead Care Managers (CMs) are nurses (RNs) • “Ti Tight ht vs loose l ” team t structure t t o Integrated multidisciplinary team  Independent CM

• Multidisciplinary teams address different needs: o o o o o o

Administrative support staff Pharmacists Resource specialists/social workers Behavioral health specialists Health coaches Community health workers (CHWs)

More common in Medicaid 10

2. Patient Selection:  Three Common Approaches 1 Quantitative 1. Q tit ti o Claims-based risk prediction (harder for Medicaid) o Event-triggered: post-discharge, high-utilizer tracking 2. Qualitative – Referral 3. Combined The issue of mutability: y o Post-event o Motivation/readiness o Behavioral health

Key issue in Medicaid 11

3. Patient Engagement g g • • • •

Connection to primary care Face-to-face interaction Longitudinal relationships Traits of CM team members o Detective skills & creative problem solving o Ability to build trust o Cultural concordance – CHWs

• Motivational M i i l interviewing i i i o Sell it to patients & ensure early success

Key Strategies in Medicaid

• Mobile M bil workforce kf & technology t h l 12

4. Primary Care Integration y g • “Tight vs loose” integration o Embedded, high touch  off-site, low touch

• Approaches to enhancing integration o o o o o

Co-location p meetings g Face-to-face interaction: accompaniment, Data/EMR Access Early successes/Trust building Education on CM role/benefits


5. Scope of Work & Key Tasks p y • Central task: to build relationships with patients, primary i care teams & hospital/community h i l/ i partners • Touches • Twice weekly to monthly • Telephonic, office, in-home

• Patient case load: 50-300 patients per CM o Depends on training, resources, & intensity of intervention o Use of teams, risk stratification & IT enable larger case loads


5. Scope of Work & Key Tasks p y • Comprehensive assessment & creation of care plans • Care coordination • With Hospitals/EDs, SNFs, Specialists, VNA, behavioral health & community-based resources • Focus on Transitions of Care • Health H lth coaching/self-management hi / lf t supportt • Address behavioral health needs • Address barriers to access/care • Address social service needs

Key S Strategies i in Medicaid

• Patient advocacy/activation 15

8 Outcomes 8. Outcomes QOL/ Qualityy of Admit/ Q ED Total Cost Provider Patient Mortality Functional Care Readmit Utilization of Care Experience Experience Status





What’s Needed? • Financial o Incentives that reduce unnecessary utilization and accelerate i t interoperable bl HIT o Up-front investment in CCM infrastructure & programs o Reimbursement for uninsured post-ACA

• Organizational/Technical o o o o o o

Stronger primary care Accelerated adoption of interoperable HIT M lti Multi-payer alignment li t to t promote t provider id integration i t ti Technical Assistance Regional CM structures to help smaller/rural practices Workforce development (professional & paraprofessional) 17

Acknowledgements • Principal i i l Investigator: i Timothy Ferris • RA: Allie Siegel • Funding:

• Program Officer: Melinda Abrams • Steering Committee:

Tom Bodenheimer d h i Randy Brown Nancy McCall Melanie Bella Rushika Fernandopulle o Steven Kravet o Joanne Sciandra o Annette Watson o o o o o

Questions? Contact: [email protected]


6. Integration of IT g • Little advanced care management IT infrastructure • Limited: Li i d o Data availability o Support for care plans o Decision Support or task assignment ability o Population management functionality o QI ffunctionality ti lit o Referral tracking 20

7 CM Training 7. CM Training • Most pair classroom didactics with on on-the-job the job training (shadowing/mentorship) • Motivational Interviewingg – most important p skill



P ti tC t dM di lC Patient-Centered Medical Care - Grantmakers In Health

Patient‐Centered Medical Care:  P ti t C t d M di l C Vision to Reality Implementing Care  Management for Complex Management for Complex  Patients in ...

217KB Sizes 0 Downloads 0 Views

Recommend Documents

p lc serie s - Electrocomponents
9.5mm OD. PLC14006. PLCD14006 .94. 2.09. (See page 138 for JG accessories). Coupling Bodies. All measurements are in inc

Challenges in health and health care for Australia | The Medical
Changes in demography and disease patterns as the population ages, and the burden of chronic illness grows;. Increasing

Application Note LC-126 Health Care Guidelines - TSI Incorporated
GUIDELINES AND STANDARDS. APPLICATION NOTE LC-126. INTRODUCTION. This publication provides excerpts from some of the man

complexes, Crystal field stabilization energies, Ideal gas equation, van der Waal Gas Equation; Properties of Liquids: .

LC-80LE940X LC-60LE940X LC-52LE840X LC-46LE840X
is made of glass. Therefore, it can break when the product is struck forcefully or with a sharp object. If the LCD panel

Medical Billing Terms Glossary | Aurora Health Care
Get clear, easy-to-understand explanations of common medical terms that may appear on your hospital bill or other medica

Primary Health Care - Electronic Medical Records (EMR)
Mar 27, 2014 - ​​​​What is an Electronic Medical Record (EMR)?. An electronic medical record (EMR) is a digital

T ti Testing… - IDEA Network
último año de cada ciclo educativo. En Guatemala se viene aplicando desde el. 2004 a los grados primero, tercero y sex

The State of Seniors Health Care in Canada - Canadian Medical
Sep 19, 2016 - Progress Toward a National Seniors Strategy . .... Canadian health care is not working as it could, or sh

askep dm pdf - P(1) - Docs-Engine.com
ASUHAN KEPERAWATAN KELUARGA Tn. B DENGAN ... asuhan keperawatan Diabetes Mellitus, membuat analisis data, diagnosa, ...