High Intensity Care Management: An Introduction

HICM Mission High Intensity Care Model is designed to identify at-risk MA members in Michigan and provide them with intensive care management services to meet their needs and improve their quality of life. Targeted members receive a comprehensive and standard range of services consistent with Patient Centered Medical Home (PCMH), Patient Centered Medical Home-Neighbor and Organized Systems of Care principles.

Important Comments About HICM Not a sales pitch Not a pilot project Not a new financial venture Small group of participants Expansion to other POs likely in 2016 Additional “group” participants likely as soon as 2015

Core services to be delivered in 2014 24/7 phone access to clinical decision-maker with access to patient record Comprehensive health care assessment by PCP, NP, or PA with full diagnoses capture, advance planning Comprehensive care management assessment Patient-specific comprehensive care plan Care transitions management for hospital transitions Care coordination

Eligible Population Atrial Fibrillation Cancer Cancer with poor prognosis Cerebral vascular disease Chronic kidney disease Coronary heart disease Pulmonary disease Dementia Depression Diabetes Heart failure Hypertension Peripheral vascular disease Severe chronic liver disease

MNO HICM Team PCP Leads Maureen Murphy, FNP-BC Lori Zeman, PhD Lauren Yaroch, RN Dietitians Certified Diabetic Educators LMSW/MSW Mental Health Providers All of you and more…

MNO Outreach PCPs: Weekly Tuesday webinars Meetings with practice units: both PCMH and not Discussions with various organizations: Hospitalists Home care Community Service Organizations Area Agency on Aging Health Systems DME Virtual monitoring

HICM Development Workgroup Greater Macomb: Dirk DeLange, Teresa Choate Henry Ford Health System: Cara Seguin, Bruce Muma Integrated Health Associates: Brent Woodman Medical Network One: Ewa Matuszewski, Maureen Murphy and Lauren Yaroch Oakland Southfield Physicians: Jerry Frankel, Jeni Hughes, and Natalie Pirkola

HICM Development Workgroup The Physician Alliance: Gina Buccalo, Karen Swanson United Physicians: Mike Williams, Deb Withrow University of Michigan: Linnea Chervenak Trinity: Paul Harkaway Mercy: Advantage Health David Blair Mercy Lakeshore Health Network: David Van Winkle

HICM PO Development Workgroup BCBSM Lori Boctor Barbara Brady Kyle Enger Terri Fabbri Janus Kobernik Jean Malouin Margaret Mason Robin Mitchell Stephanie Nieman BCN James Haskins Alison Pollard

Comprehensive Clinical Model HICM Launch by PO Phase 1 Launch 10-1-14 Full Launch 4-1-15 PO Subset of Core Model Core Model Comprehensive Clinical Model Greater Macomb ● Henry Ford Health System Integrated Health Associates Medical Network One Oakland Southfield Physicians The Physician Alliance United Physicians University of Michigan (pending POM discussion) Advantage Health/Mercy (Grand Rapids)

HICM Common Clinical Model Comprehensive Clinical Model Phase 1 Launch 10-1-14 Full Launch 4-1-15 Services Subset of Core Model Core Model Comprehensive Clinical Model 1.24/7 phone access to clinical decision-maker with electronic access to pt record ● 2. Comprehensive health care assessment by PCP, NP, or PA with full diagnoses capture, advance planning (75% w/in 2 months; all w/in 4 months; in-home for homebound) – top priority 3. In-home health care assessment by PCP, NP, or PA for homebound 4. Daytime home visits by RN, MSW or Care Manager (minimum quarterly), including in-home assessments 5. Patient-specific comprehensive care plan (updated at least quarterly) 6. Care management team includes pharmacist and nutritionist 7. Access to in-home PT and OT 8. Care transitions management – Hospitals

HICM Common Clinical Model Comprehensive Clinical Model Phase 1 Launch 10-1-14 Full Launch 4-1-15 Services Subset of Core Model Core Model Comprehensive Clinical Model 9. Care transitions management – SNFs ● 10. Access to palliative care team 11. Access to hospice 12. Transportation for non-emergent medical visits and Rx 2016 13. Remote patient monitoring (weight, BP, glucose) 14. Standardized staff training 15. Review of all patients on monthly patient lists, common outreach script (2nd outreach by PCP as needed); POs maintain disposition information on all patients on monthly list

Metrics Metric Optimal Target Minimum Threshold Timeframe Specifications Overall program engagement rate (engagement defined as billing G9001-Comprehensive care management assessment) 80% 50% Fully implemented state – end of 1st quarter 2015. Numerator: Had a claim for G9001 by a HICM PU in the previous 12 months. Denominator: Accepted Members Comprehensive health care assessment with full diagnosis capture completion rate for engaged patients. Capture of diagnoses will include annual wellness visits in addition to other visits with appropriate code submissions (to be measured separately) 95% Fully implemented state -- end of first quarter 2015. Numerator -Claim for Annual Wellness Visit (initial G0438 or subsequent G0439) within each calendar year. Denominator = Engaged Members. Diagnosis Closure rates to be measured separated. Quarterly in-person Care Management interaction for engaged members Minimum one per quarter. Numerator Claim for G9001 or G9002. Denominator = Engaged Members. Monthly care management interaction for engaged members (phone or in-person) Minimum one per month. Numerator Claim for phone visit or G9001 or G9002; or in 2015, claim for bundled care management service or G9001 or G9002. Denominator = Engaged Members.

Additional Care Transition Metrics Hospital to home transition initial contact 100% 75% On the discharge date or the 2 days afterward. Numerator -Claim for care management phone, care management visit, or PCP office visit. Denominator= transitions by Engaged Members. Hospital to home transition follow-up with physician Within 7 days of discharge Numerator -Claim for office visit with physician. Denominator = transitions by engaged members. STARS clinical quality and utilization measures for engaged members as determined by the Centers for Medicare and Medicaid services. 4.5 4.0 Within 6 months of member engagement at minimum

Additional Metrics Clinical Model Goal Outreach to 100% of patients on the “accepted” list within 90 days of finalizing list (outreach defined as initial attempt to reach patient via telephonic or in-person verbal contact) Completion of in-person care management assessment within 3 months of successful outreach for at least 50% of Accepted Members patients, and for 100% of Accepted Members within 6 months Completion of in-person comprehensive health care assessment [for those patients who have not yet received an annual wellness visit in the current calendar year] within 3 months of successful outreach for at least 50% of patients, and for 100% of patients within 6 months Quarterly review/update of care plan for engaged patients Hospital to home transition phone follow-up for 30 days for engaged patients; frequency of phone calls dependent upon patient needs SNF to home transition initial contact within 24-48 hours of discharge for engaged patients SNF to home transition follow-up w/PCP (or specialist, as appropriate) within 7 days of discharge for engaged patients SNF to home transition phone follow-up for 30 days, minimum of one call following discharge for engaged patients; frequency of phone calls dependent upon patient needs

We Want You to be a Change Agent.. Be open to data from the start Network extensively Provide, enhance and document learning Keep you informed No place for fear: ask questions Learn as much as you can: ask questions Finish what you start

Enhance the Speed of Change Positive outlook Focus Pro-activeness Flexibility Organization Encourage innovators Motivate fence sitters Continuously stay in touch with late adapters Care for causalities

Patient Hand Outs All co-branded materials must receive pre approval from the Medicare Advantage team Letters from the practice Posters Handouts

Tell Me Again About HICM Extension of the PCP No patient grabbing by HICM HICM members will all have an in-home assessment (HRA, Physical and Psycho-social) Initial assessment done by 2 clinicians: NP and MSW/LMSW Specific metrics

Why the Assessment? Clinical team ready for various types of engagement ED IP Transition to SNF, PACF, home Hospice Palliative Care

We’re Live… October 1, 2014 MNO signed Agreements: MSSP and HICM Entire team completed fraud, abuse Medicare training Recommend online training for PCP practice teams Macomb County pre-work completed Eligibility file must be returned today

What’s New? Completed 2 day GRACE Model (Geriatric) training Lori Zeman Maureen Murphy Lauren Yaroch Laurie Smith Maria Young Awaiting next steps from BCBSM regarding T-Trainer status

Concerns: Can We Do This Diagnosis capture of all Medicare Advantage patients Smaller practice unit will have MNO oversight and DDDS relationship included in Agreement Training of practice teams included in Agreement

Successes Generate patient list Incorporate patient list into data repository Complete chart review in Macomb County Make house visits a reality

Patient Registry Consistent use very important Supplemental information Accuracy Training

Open Discussion