Care Management Going Forward Connie Sixta, RN, PhD, MBA

Logistical Clinical Monitoring % of panel <5% 10% 20% Care Coordination Clinical Follow-up Care Clinical Care Management * Clinical Monitoring Navigation, Outreach Transition Care ER visit Follow-up Intense care management intervention Clinical Monitoring

Review: Who are the highest risk patients – who is the CM Managing? Highest risk patients (starting with highest level) – Admitted/discharged from the hospital – Seen in the emergency room – Assessed in the office as highest risk due to: Top 5% of the panel - “highest” of the high risk patients One FTE CCM per 5000 commercial patients or 800 Medicare patients 3

Review: #1 Highest Risk Patients Discharged from hospital Notification system about discharges and discharge plan Give 4 touch phone call transition care Tracking system for transition care includes: – Date/time – Date/time of transition call – Assessment, Plan of Care, Follow-up Plan Communication system with provider (verification of care/follow-up) 4

Review: #2 Highest Risk Patients\ Seen in the ER Notification system about ER visits and ER diagnosis Evaluate ER list for patients needing follow-up Tracking system for discharges that includes: – Date/time – Date/time of follow-up call – Assessment, Plan of Care, Follow-up Plan Communication system with provider regarding ER follow-up 5

Review: #3 Highest Risk Patients Provider/Team Identified in Office Assessed in the office as highest risk due to: – Co-morbidities – Disease severity – Poor self-care – Polypharmacy – High utilization rate – Lack of support mechanisms – Severe socioeconomic factors Top 5% of the panel - “highest” of high risk patients 6

#3 Highest Risk Patients Identified by Provider/Team Patients with transitional care and ER follow-up can be moved to highest risk registry Intense care management – Assessment, problem list, plan of care – Follow-up plan/ schedule – Communication/Verification by Provider Track highest risk patients using the registry 7

How many highest risk patients do you have in your practice? From hospital discharge list? From ER visit list and need ongoing follow-up? Highest risk patients identified by your practice? 8

All Highest Risk Patients Need: Comprehensive Assessment (intake assessment, identification of driver) Problem List Plan of Care Follow-up Plan Provider Communication /Verification Documentation of above Tracking System 9

How are you stratifying interventions for the highest risk? 10

Communication between CCM-Provider-Office Staff ■ Staff alert mechanism for all CCM patients ■ Mechanism for staff to refer patients to CCM ■ Quick communication link amongst front office staff, clinical staff and CCM ■ Mechanism for provider review and verification of highest risk patient registry intake and discharge ■ Routine provider/team/CCM meetings to discuss highest risk patients ■ Provider/team access to highest risk patient care plans 11

Measures for the highest risk patients % of patients who have transition care within 48 hours of discharge. % of patients who have a Care Plan developed by the Care Manager. % of patients in the Highest Risk Registry who have a documented patient action plan. 12

Phase 2: Care Management Implementation (draft participation contract excerpt) “employ or contract with licensed nurse(s) as the Practice’s Care Manager(s), responsible for providing Care Management Services; create, use and maintain a patient-specific Care Management tracking system that identifies patients who are likely to benefit from Care Management Services and tracks those High-Risk Patients who are receiving Care Management Services, including at least the following: patient inpatient admissions and discharges; patient emergency department visits and disposition; all interventions provided by the Care Manager, including without limitation, following an inpatient hospital admission or emergency department visit; ” 13

Phase 2: Care Management Implementation (draft contract excerpt) “regularly conducting patient risk stratification to identify the High-Risk Patients who may benefit from Care Management; contacting identified High-Risk Patients no less frequently than every 30 days; engaging in case review and planning, including completing, analyzing, and updating as necessary medical bio-psychosocial support and self-management support assessments; providing intensive medical and medication management services; developing and implementing a multi-disciplinary care plan, created jointly by the patient or family and the Practice, which is available to the patient or family at all times;” 14

Next Steps CM Assessment with Payer Care Managers and Connie (SEPA and NEPA) CM Monthly Conference Calls Improvement of CM Measures

Questions? 16