STFM Conference November 23, 2013 San Diego, California

 PCMH transformation includes building care management capability within the practice and ultimately being lead on care management responsibilities  With care managers residing within practices and Health plans, opportunities increase for duplication of efforts and confusing communications with patients  Massachusetts PCMH Initiative recognized need to develop processes for Health plan – practice coordination 2

 Care Management Work Group formed with payer and practice representatives who were predominantly seasoned care managers and medical directors 3

 Collaboratively decide whether plan or provider has primary case management responsibility  Identify and make plan resources available  Document results of meeting decisions within the plan’s care management system including health plan carve out services such as mental health and substance abuse and/or disease management 4

 Originally tried to develop categories of patients who would be the responsibility of either plan or provider (e.g., patients with rare conditions would be care managed by the plans)  Could not come to an agreement because exceptions always exist ◦ “Care management decision-making doesn’t work that way.” 5

 Care Management Work Group launched a 6-month pilot with 2 large practices and 1 health plan to develop Guidelines  Participants held weekly conference calls ◦ To protect patient confidentiality, plan “met” with each practice separately 6

 Neutral observer listened in on calls to identify patterns and document process ◦ Guideline development was iterative with participants reviewing numerous versions  Result is a set of detailed Guidelines for coordinating care management resources 7

 Based on conviction that regular, direct communications are necessary to develop: ◦ Trust among participants ◦ Understanding of common language ◦ Understanding of risk drivers for high risk patients ◦ Shared patient-centered goal and coordinated response 8

 Sharing information among plan and practice care managers is not a substitute for direct, oral communications ◦ First month of oral communication dedicated to developing a common language to enable shared decision making  To be effective, the care management process must be patient-centered 9

 Consistent participation and regular meeting time are essential ◦ Weekly 30 minute meeting initially, then less frequently  Health Plan ◦ Director of Care Management or designee ◦ Project Manager with extensive familiarity of plan’s programs and systems ◦ Front line care managers, as appropriate  Practice ◦ Clinical Care Manager ◦ Provider/s working closely with care managers  Community Health Worker, BH provider, PCP, care coordinator, as appropriate 10

 Talking through cases is VERY labor intensive  Vital to identify ways to be efficient and achieve success ◦ Work with high volume providers/plans ◦ Jointly create combined list of highest risk patients ◦ Target specific patients to discuss during call ◦ Prepare in advance of call  Be willing to move on if patient won’t engage 11

 Plan shares as much information in advance of the call as possible (e.g., most recent hospitalizations/ED visits/specialty visits, contact information, principal diagnoses, prescriptions) 12

 If provider last saw patient between 12 and 18 months ago and evidence that patient is receiving care elsewhere, payer will follow-up with patient to affirm current PCP  Agree on a patient-centered goal and focus the discussion around how to achieve that goal  Agree which organization will provide what resources/support to help the patient achieve the goal ◦ Organization which had the closest connection with the patient was usually identified as lead care manager 13

 Set up infrastructure to coordinate resources ◦ Secure (at least)  shared portal (ideal) ◦ Regular meeting times with consistent team ◦ Establish dates for reporting back on requested information or to provide updates on patients ◦ Communicate to patient about coordination activities ◦ Practice generally leads the discussion ◦ Plan sends summary of decisions, list of follow-up items and next 10 patients to discuss ◦ Project Manager follows up with participants, as necessary ◦ Include Project Manager to keep process on track, at least initially 14

15 Services Offered Coordinated Care Management Team Patient/Family identified Problem (s) Patient and /or Family Primary Care Practice Community Resources Primary/Speciality services Health Plan External/Internal Resources

1a Share contact information for all staff members Establish regular conference call days and times 1b Identify top 30 high risk patients based on each organization's specific methodology 1c Through HIPAA compliant process; send high risk list to HPlan. (see detail in guidelines) 1d Combine both lists, reorder level of risk and note the high risk patients common to both lists. Send combined list and identify limited number of patients targeted for discussion. 1e Do pre-work by reviewing clinical information for each high risk patient that is to be discussed( see detail in guidelines) 1f Finalize decision as to which staff will be members of the care team 16

17 2a Confirm the list of high risk patients who will be discussed. Update patient contact information if both entities do not have same information. Start with overlapping names 2b Determine if patient is correctly attributed to PC Practice. If attribution is incorrect, PC Practice contacts patient to determine if new PCP has been selected; patient is removed from HPlan list 2c If patient is correctly attributed but has not engaged with practice or plan within the last months, PC Practice attempts outreach to schedule an appointment. 2d If PC outreach is unsuccessful, place patient on HPlan tracking list with six month follow up. Notify PC Practice if patient receives inpatient services 2e Present high risk patients, isolate key risk drivers, propose patient-centered goal and care management needs and make recommendation for services needed 2f Review demographic information, claims history, care management services provided currently by H Plan, propose patient-centered goal and identify care management needs 2g Reach agreement on patient-centered goal, CM services to provide and by whom. Agree upon which entity is lead for care management

18 2h Lead CCM, outreaches to patient/family to collaborate on implementing proposed care plan, revise plans and goals based on patient/family input 2i Document decisions in respective care management systems. 2j Identify next group of high risk patients for next scheduled conference call 2k Send PC practice the following: the meeting summary, including list of next steps and responsible parties, list of high risk patients for discussion at next conference call along with the demographic information. 2L Begin next conference call with updated information based on patient input on proposed care plans, update respective care management systems

 Patient with sickle cell anemia ◦ Not seeing specialists regularly because they were far from home ◦ Condition not stable, frequent ED visits  Shared goal: improve patient’s ability to manage chronic condition and get treatment/follow-up in timely manner  Steps: plan identified specialists closer to home and contacted patient about interest in switching. Practice worked with patient to implement a smooth transfer to new specialists 19

 Patient with substance abuse issues ◦ Practice tried unsuccessfully to engage patient  Shared goal: connect patient with substance abuse services.  Steps: plan is assigning patient to its Substance Abuse program. Plan will assume primary care management responsibilities and update practice on effectiveness of their attempts. 20

 Health Plan and one provider side are piloting HIE connection that will: ◦ Allow sharing of patient demographics, clinical profile, risk assessment, etc. ◦ Facilitate development of shared care plan ◦ Convey real time care management update information bi-directionally  Currently done via secure system  Will be incorporated into care plan with automatic update notifications 21

 Electronic connections through HIE supports scalability with opportunity for cost savings: ◦ Eliminates meeting time for updates ◦ Allows care managers to focus on high-risk patients that need attention of both provider and plan ◦ Provides opportunity for quick, coordinated response in urgent situations as soon as information is received ◦ Continues to build on trust established through in- person communications, so coordination can be efficient and timely 22

 Establish performance goals, such as ◦ # of high risk patients in active care management ◦ X% reduction in avoidable ED visits ◦ X% reduction in avoidable IP admissions ◦ X% of patients in care management are achieving individual patient-centered goals  Calculate financial impact, such as ◦ Return on Investment ◦ Net savings 23

 Creating a collaborative payer-practice care management process strengthens services provided to patients  Processes will be specific to the participants ◦ Will involve direct communications ◦ Must involve technology to maximize efficiency ◦ Practice care managers may need training  Need to tie back to care management performance (cost and clinical) measurements 24

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