MICMT Complex Care Management Course Care Management Five Step Process © 2018 by the Regents of the University of Michigan. For questions or permissions please contact micmrc-requests@med.umich.edu

Learning Objectives Describe goals of risk stratification to identify patients who may benefit from Care Management Services Relate key work which is completed in each step of the five step care management process Apply 5 step care management process for episodic and longitudinal care management service delivery

Goals of Care Management Improve patient’s functional health status Improve quality of life (QOL) Enhance coordination of care Eliminate duplication of services Reduce the need for unnecessary, costly medical services

Moderate Care Management May have newly diagnosed chronic condition Poorly controlled chronic condition Transitions of Care Medication management Would benefit from episodic care management 2018 & 2019 CPC+ IMPLEMENTATION GUIDE: GUIDING PRINCIPLES AND REPORTING

Complex Care Management Frequent ER visits and/or hospitalizations Acute medical conditions (post hospital discharge) TOC from an extended Care Facility/subacute rehab Multiple comorbidities Chronic kidney disease Special needs plan Extensive SDOH Co-morbid diabetes conditions Elderly with psychosocial High risk pregnancy – with socioeconomic barriers Children with special needs Insulin titration/management Behavioral Health diagnosis Complex care management

Episodic vs. Longitudinal Otherwise stable patients going through TOC Newly unstable chronic condition Short-term, goal oriented Combination of multiple comorbidities Complex treatment regimens Behavioral and social risks Ongoing relationship Provide short-term (episodic) CM services to patients with acute or urgent needs, i.e. new diagnoses, medical crisis, decompensation in otherwise controlled chronic condition 2018 & 2019 CPC+ IMPLEMENTATION GUIDE: GUIDING PRINCIPLES AND REPORTING

Risk Stratification Risk stratification is an intentional, planned and proactive process carried out at the practice level to effectively target clinic services to patients Identifies those who are at high, moderate, and low risk tiers as well as prioritizing management of their care Care coordination should be focused on patients who will benefit most, maximizing the impact on both quality and costs Is usually carried out behind the scenes Helps determine which patient populations will benefit the most from care management services, i.e. those that may be at risk for rehospitalization Patients are typically placed into high, medium or low risk groups, the goal of risk stratification is to segment patients into distinct groups of similar complexity and care needs. (http://www.nachc.org/wp-content/uploads/2018/02/Action-Guide_Pop-Health_Risk-Stratification-Sept-2017.pdf) http://www.njafp.org/sites/ethos.njafp.org/files/risk_strat_peskin_distribution_final.pdf

Risk Stratification Population Health Highly Complex: small group, has greatest care needs Multiple Complex illnesses Psychosocial concerns High Risk: Multiple risk factors Potential to move into Highly complex Rising risk One or several chronic conditions Move in and out of stability Manage risk factors more than disease states Low risk Stable or healthy Continue to keep engaged in the healthcare system Highly complex: usually less than 5% of population. Goal for this group is to avoid costly hospitalizations and ER services High risk: Work with patient to ensure they receive chronic disease management and preventative services, medical, social and community needs. Rising risk: common risk factors include obesity, smoking, blood pressure Low risk: these patients have minor conditions that can be easily managed http://www.nachc.org/wp-content/uploads/2018/02/Action-Guide_Pop-Health_Risk-Stratification-Sept-2017.pdf

Stratification Process Perhaps the most important source of data, - the patient’s voice. Pt voice and the clinician's judgement are essential. Asking the patient: Do you think your health is “good” , “fair” or “poor”? Patient reported data; Assessments Psychosocial factors, Patient self assessment and experience Clinical Judgement Physician Input Administrative data-utilization Hospitalization ER visits Registry data Payer data Clinical data Medications https://www.rmhpcommunity.org/sites/default/files/resource/Vol.%202%20Issue%202%20Predict,%20Prioritize,%20Prevent.pdf

Managing Populations: Stratified approach to patient care and IV. Most complex (e.g., Homeless, Schizophrenia) III. Complex Complex illness Multiple Chronic Disease Other issues (cognitive, frail elderly, social, financial) II. Mild-moderate illness Well-compensated multiple diseases Single disease I. Healthy Population <1% of population 3-5% of population 50% of population Managing Populations: Stratified approach to patient care and care management A target caseload for a CM will vary depending on a number of variables Factors affecting caseload size and complexity include Experience of the care manager Clinical and social complexity of patients Available social supports Caseload size and manageability should be evaluated on an ongoing basis http://www.nachc.org/wp-content/uploads/2018/02/NACHC-Care-Management-Action-Guide_02.13.18.pdf

Enrollment and Assessment Care Management Process Five Steps: Referral Screening Enrollment and Assessment Management Closure

Referral Not everyone will benefit from care management services Look at targeted populations Patient lists* Participants may be provided with a list of patients that have been assigned or attributed to their practice. This list will reflect the patients who are attributed for care management services Providers or practice staff Hospital discharge list Emergency room discharge list Gaps in care reports (electronic registries) * Patient lists are commonly used for incentive, pilot, and demonstration programs There are many possibilities on where a referral may originate. Targeted populations

Referral Determination for Care Management If a patient would benefit from care management services and the screening steps result in a determination that patient will not be enrolled in Care Management at the practice, then consider the resources available to support the patient’s health care needs Consider options to offer support for patient Link to community resources Collaboration and reaching out to the patient’s health care plan care manager For Medicaid Managed Care – see contact list for the plan’s care management services For BCBSM Blue Health Connection Program call 800-775-2583

Case Study Mr. B - Complex Mrs. A - Moderate 70 years old Increasing symptoms of fatigue, weakness, SOB Hospitalized 3 months ago, HF exacerbation History of HTN, CAD, MI Temporarily living with daughter (only 2 more weeks) Unsure about his medications Feeling low High salt diet Worried about living arrangements Wants to be in own home Trouble sleeping Requires assistance with ADLs 70 years old Has type II diabetes for last 10 years without complication Recently started on insulin Lives with husband History of HTN BP and blood sugar out of control Mr. B was living at home until his caregiver had an accident and now lives with his daughter. Daughter is moving in two weeks and Mr. B will not be able to stay Eats mainly canned goods and microwave dinners

Screening Medical record Claims High utilization High costs Current clinical conditions High risk Resource utilization Recent ED visit(s) Recent hospitalization (example: >2 admissions within last 12 months.) Skilled nursing facility with goal to transfer to home setting Significant health events Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline Primary Care Physician input ER use Hospitalizations High tech radiology Rehab Cancer Treatment Organ Transplant

Screening Risk score Dual-eligible Condition specific-examples Children with complex needs CHF COPD CHF and COPD are currently at the top of list in terms reducing ED visits and inpatient hospitalizations. These have a large impact on CMS penalties.

Screening Socioeconomic and financial status Home environment Physical/emotional/cognitive functioning Support system Self - care ability Note: During Assessment phase this information is gathered in greater depth Patient characteristics such as ethnicity, age, metabolic risk factors, smoking status, and chronic disease burden, as well as psychosocial issues, such as availability of caregiver support, can help identify individuals and populations that may benefit from CM services. Care Management: Implications for Medical Practice, Health Policy, and Health Services Research. Retrieved from https://www.ahrq.gov/sites/default/files/publications/files/caremgmt-brief.pdf

Screening Mr. B Mrs. A Medical record PCP Hospital discharge report Patient himself Patients daughter SDOH screening Depression screening Patient herself PCP Medical record Hospital discharge report SDOH screening Mr B. Mrs A.

Enrollment Patient Engagement Patient “how to” Tips – inform about care management Warm handoff from PCP is best If warm handoff is not possible Quick Tools CM Phone script Care Management Flyer Its best if the PCP and patient have a discussion about care management services before hand

Enrollment Patient Engagement Getting started: Ask patient/caregiver: “Dr. Smith asked me to contact you. He thinks you may benefit from a service we offer.” “My name is Beth, a nurse with Dr. Smith’s office. He wanted me to call you regarding a service to help you manage your diabetes.” “Dr. Smith asked me to call you about the concerns you have about your health.” If a warm hand-off is not possible and you need to engage the patient by phone or in-person the following statements may help in the transition

Enrollment Assessment Obtain patient consent Document the enrollment Complete initial comprehensive assessment Level of care management Assessment findings may be discovered over time This is not static!

Enrollment/Assessment Mr. B Mrs. A Warm handoff from PCP Document consent Understanding of current medications SDOH Transportation Home environment Self care ability Support network Why patient unable to sleep Diet Depression screening Medication reconciliation Phone conversation Document consent Support network Level of understanding Medication reconciliation How would you explain care management to Mrs. A, Mr. B? What information would you focus on at the time of the assessment? How do you document the consent? Mr. B Mrs. A Discuss the cause or behavior that led to the increased blood sugars

Management Plan of Care Develop the individualized plan of care Getting started Patient, PCP and Care Manager review and agree on the individualized plan of care Carrying out the plan Care Manager collaborates with team members to carry out specific interventions Do team members in the practice have defined roles? Collaboration with practice leaders and team members to define areas of responsibility for roles and areas of expertise to carry out the plan Work flow matters! What are the current work flows in the practice? Is the practice currently testing a new work flow(s)? This is often an ongoing improvement process

Management Plan of Care Mr. B Mrs. A Individualized plan of care Longitudinal Collaboration with other team members Community resources When to call the PCP office Diabetes action plan Short-term episodic care What short and long term goals might you help establish with Mr. B, Mrs. A What intervention What team members might you coordinate with Community resources What short and long term goals might you establish with each patient?

Management Interventions Action Oriented Time-specific Multidisciplinary team involvement Addresses patient’s needs and concerns Involves medical neighborhood, care across the continuum http://www.cmbodyofknowledge.com/content/case-management-knowledge-2

Management Interventions Mr. B Mrs. A Team members: Pharmacist SW Dietician Daily weights When to call the PCP Teach back on insulin use with patient and husband Team members: Diabetic educator When to call the PCP Diabetes action plan Can you think of other interventions to help Mr. B? What other team members may be helpful for Mr. B or Mrs. A

Management Follow up Key Factors: Building a trusting relationship and patient’s readiness Conduct follow up visits based on: Review, evaluation and monitoring Reassessment of patient’s health condition, progress with meeting SMART goals Are patient’s identified needs met Outcomes of the treatment and interventions http://www.cmbodyofknowledge.com/content/case-management-knowledge-2

Management Follow up Mr. A Mrs. B Long-term longitudinal Weekly to start Daily weights Dietary changes Follow up on transportation Short-term Episodic Weekly to start Follow up on insulin use Blood sugar monitoring

Case Closure Reasons for case closure: Patient moves out of region/state Patient has met their goals and is discharged from care management services Patient expires Patient is admitted to hospice care Be sure primary care physician is aware and in agreement

Case Closure Mr. B Mrs. A Patient expires Patient shows improvement No recent exacerbations Patient has met his goals Patient referred to hospice Understand use of insulin Blood sugars in control

Points to Consider Continuously develop skills in identifying patients who would benefit from complex care management Understand social determinants of health and health literacy-impact for patient/family/caregiver Determine how various assessment tools may assist you to optimize patient care Review and modify the individualized care plan Document and bill the comprehensive assessment G9001 code for patients receiving ongoing CM services, follow-up care (if this is applicable to your program) Complete a new patient assessment if enrolled >12 months ago

Reference Guide 5 Step Process Care Path…………………………………………………………….….165 5 Step Process Worksheet…………………………………………………………..….167 Risk-Stratified Care Management and Coordination……………………….164 Case Closure Standard Work Activity Sheet…………..…………………….….133 Care Manager Introduction Phone Script..…………………………………………24 Care Management Explanation Flyer………………………………………………...26 CMS Dual Eligible Beneficiaries…………………………………………………….….153