State Coverage Initiatives Symposium February 7, 2008 Nashville, Tennessee Charles F. Willson MD Medical Director Community Care Plan of Eastern Carolina State Coverage Initiatives Symposium February 7, 2008 Nashville, Tennessee Charles F. Willson MD Medical Director Community Care Plan of Eastern Carolina

Basic Operating Premise  Regardless of who manages Medicaid, North Carolina’s physicians, hospitals, health departments and other safety net providers will be serving the patients.  Through Community Care, DHHS is partnering with community and safety net providers to build the needed improvements in care for Medicaid and other low-income populations.  An enhanced primary care medical home is the best value in healthcare today.  Regardless of who manages Medicaid, North Carolina’s physicians, hospitals, health departments and other safety net providers will be serving the patients.  Through Community Care, DHHS is partnering with community and safety net providers to build the needed improvements in care for Medicaid and other low-income populations.  An enhanced primary care medical home is the best value in healthcare today.

Primary Goals  Improve the care of the Medicaid population while controlling costs  Develop Community Networks capable of managing recipient care  Develop the systems needed to improve chronic illness  Improve the care of the Medicaid population while controlling costs  Develop Community Networks capable of managing recipient care  Develop the systems needed to improve chronic illness HOME NEXT LAST

Goals Achieved By:  Making sure people get care when they need it  Obtaining quality care  Implementing best practice guidelines  Managing Medicaid costs  Building local care systems  Making sure people get care when they need it  Obtaining quality care  Implementing best practice guidelines  Managing Medicaid costs  Building local care systems HOME NEXT LAST

Community Care of North Carolina  Joins other community providers (hospitals, health departments and departments of social services) withphysicians  Creates community networks that assume responsibility for managing a population of patients  Networks serve as templates for innovation  Joins other community providers (hospitals, health departments and departments of social services) withphysicians  Creates community networks that assume responsibility for managing a population of patients  Networks serve as templates for innovation Builds on PCCM Program HOME NEXT LAST

Community Care of North Carolina  Focuses on improved quality, utilization and cost effectiveness of chronic illness care  14 Networks with more than 3500 physicians  762,814 enrollees  Each community has its medical assets and needs. CCNC tries to align these assets and needs  Focuses on improved quality, utilization and cost effectiveness of chronic illness care  14 Networks with more than 3500 physicians  762,814 enrollees  Each community has its medical assets and needs. CCNC tries to align these assets and needs

AccessCare Network Sites AccessCare Network Counties Access II Care of Western NC Access III of Lower Cape Fear Southern Piedmont Community Care Plan Community Care Plan of Eastern NC Community Health Partners Northern Piedmont Community Care Partnership for Health Management Sandhills Community Care Network Community Care of Wake and Johnston Counties Community Care of North Carolina CCNC Networks as of October 2007 CCNC Networks as of October 2007 Carolina Collaborative Comm. Care Carolina Community Health Partnership Comm. Care Partners of Gtr. Mecklenburg Central Piedmont Access II Central Care Health Network

My Network: Community Care Plan of Eastern Carolina  27 counties, from the Atlantic to I-95 and from the VA border to I-40  >160 primary care practices  >100,000 patients  Local clinical champions  Local project coordinators  27 counties, from the Atlantic to I-95 and from the VA border to I-40  >160 primary care practices  >100,000 patients  Local clinical champions  Local project coordinators

Community Care Networks:  Non-profit organizations  Comprised of primary care practices and other safety net providers  Steering committees  Medical management committees  Receive $3.00 PM/PM from the State  Hire care managers/medical management staff  Non-profit organizations  Comprised of primary care practices and other safety net providers  Steering committees  Medical management committees  Receive $3.00 PM/PM from the State  Hire care managers/medical management staff HOME NEXT LAST

What Networks Do  Assume responsibility for Medicaid recipients  Identify costly patients and costly services  Develop and implement plans to improve access, manage utilization and reduce cost  Create the systems to improve care  Assume responsibility for Medicaid recipients  Identify costly patients and costly services  Develop and implement plans to improve access, manage utilization and reduce cost  Create the systems to improve care HOME NEXT LAST

Managing Clinical Care Clinical Directors Group Select targeted diseases/care processes Review evidenced-based practice guidelines Define the program Establish program measures Select targeted diseases/care processes Review evidenced-based practice guidelines Define the program Establish program measures I ASTHMA DIABETES PHARMACY HIGH-RISK & -COST ED Local Medical Mgmt. Comm. Implement state-level initiatives Develop local improvement initiatives Implement state-level initiatives Develop local improvement initiatives PRACTICE APRACTICE BPRACTICE C Care Managers and CCNC quality improvement staff support clinical management activities III II GASTRO-ENTERITIS OTITIS MEDIA CHILD DEVELOPMENT ADHD FEVER DEPRESSION CO-LOCATION CAP-C CHRONIC CARE HEART FAILURE MH INTEGRATION DIABETES DISPARITIES DENTAL VARNISHING OBESITY COPD

Key Program Areas in Managing Clinical Care: Key Program Areas in Managing Clinical Care:  Providing timely access to care  Implementing best practices/disease management  Managing high-risk patients  Managing high-cost services  Building accountability through monitoring & reporting  Providing timely access to care  Implementing best practices/disease management  Managing high-risk patients  Managing high-cost services  Building accountability through monitoring & reporting HOME NEXT LAST

 Evidence-based guidelines  Improvement specialists: IPIP  Practice “champions”  Establishing improvement processes within the practice  Benchmarking & goal setting  Evidence-based guidelines  Improvement specialists: IPIP  Practice “champions”  Establishing improvement processes within the practice  Benchmarking & goal setting Implementing Best Practices: HOME NEXT LAST

Implementing Disease Management  Evidence-based guidelines  Clinical directors set performance standards  Local provider buy-in obtained  Improve the care management process  Local & state level technical assistance  Pilot initiatives  Evidence-based guidelines  Clinical directors set performance standards  Local provider buy-in obtained  Improve the care management process  Local & state level technical assistance  Pilot initiatives HOME NEXT LAST

Managing High Risk Patients  Identify high cost through claims analysis  Identify high risk through reporting and referrals  Targeted case management  Coordinate community resources  Set expectations  Identify high cost through claims analysis  Identify high risk through reporting and referrals  Targeted case management  Coordinate community resources  Set expectations HOME NEXT LAST

Managing High-Cost Services:  Pharmacy - Nursing home polypharmacy - Prescription Advantage List (PAL) - Ambulatory, Polypharmacy & Multi-Prescriber  Emergency Department (ED)  Quadrant IV – High Physical and High Behavioral Health Care Needs  Pharmacy - Nursing home polypharmacy - Prescription Advantage List (PAL) - Ambulatory, Polypharmacy & Multi-Prescriber  Emergency Department (ED)  Quadrant IV – High Physical and High Behavioral Health Care Needs HOME NEXT LAST

Building Accountability  Chart audits  Practice profiles  Care management reports – high-risk/high- cost patients  PAL scorecard/ OTC meds  Progress toward goals & benchmarks  Chart audits  Practice profiles  Care management reports – high-risk/high- cost patients  PAL scorecard/ OTC meds  Progress toward goals & benchmarks HOME NEXT LAST

Current Disease and Care Management Initiatives  Asthma  Diabetes  CHF  Chronic Care – (Aged, Blind and Disabled)  High Cost – High Risk  Pilots in Depression, ADHD, Special Needs Children, COPD, Co-Location and Mental Health Integration  Asthma  Diabetes  CHF  Chronic Care – (Aged, Blind and Disabled)  High Cost – High Risk  Pilots in Depression, ADHD, Special Needs Children, COPD, Co-Location and Mental Health Integration

Asthma and Diabetes Initiatives  Adopted nationally accepted best practice guidelines  Physicians set performance measures  Provide regular monitoring and feedback  Implement CQI at practice level  Adopted nationally accepted best practice guidelines  Physicians set performance measures  Provide regular monitoring and feedback  Implement CQI at practice level

Asthma Initiative Key Process Measures % with asthma who had documentation of staging % with asthma who had documentation of staging 2 % staged II – IV on inhaled corticosteroids 3 % staged II – IV who have an AAP

Diabetes Initiative  Second program-wide initiative – began July 2000  Adopted best practice guidelines (ADA)  Implement continuous quality improvement processes at each practice  Physicians set performance measures  Provide regular monitoring and feedback  Second program-wide initiative – began July 2000  Adopted best practice guidelines (ADA)  Implement continuous quality improvement processes at each practice  Physicians set performance measures  Provide regular monitoring and feedback HOME NEXT LAST

Diabetes Initiative Process Measures Community Care of NC Diabetes Quality Initiative Summary (Established) Baseline 2001 R R R R R5 2005

CCNC - Cost Savings  Mercer Human Resource Consulting Group found, when compared what the access model would have cost in SFYs without any concerted efforts to control costs, the CCNC program saved: □ SFY 03 $ 60 million □ SFY 04 $ 124 million □ SFY $ 240 million  Mercer Human Resource Consulting Group found, when compared what the access model would have cost in SFYs without any concerted efforts to control costs, the CCNC program saved: □ SFY 03 $ 60 million □ SFY 04 $ 124 million □ SFY $ 240 million

 Networks beginning to implement  Improving Quality of Care  Guidelines and Toolkit  Heart Failure Reports  Performance Measures  Links with local Heart Failure programs and Hospitals  Case Management Program  Telephone Case Management Initiative  Video telehealth visits  Networks beginning to implement  Improving Quality of Care  Guidelines and Toolkit  Heart Failure Reports  Performance Measures  Links with local Heart Failure programs and Hospitals  Case Management Program  Telephone Case Management Initiative  Video telehealth visits Heart Failure Program

Modifiable Factors Leading to Hospital Readmissions for HF*:  Inadequate patient and caregiver education and counseling  Poor communication among health care providers  Failure to organize follow up care  Clinician failure to emphasize non-pharmacologic aspects of HF care (dietary, activity, and symptom monitoring)  Inadequate patient and caregiver education and counseling  Poor communication among health care providers  Failure to organize follow up care  Clinician failure to emphasize non-pharmacologic aspects of HF care (dietary, activity, and symptom monitoring) *From 2006 HFSA Guideline on HF Disease Management

Lessons Learned  Choose initiatives that can demonstrate quality improvement and impact cost  Use evidence-based best practice guidelines  Local Physician buy-in and input during the development is very important  Build confidence at the provider level with your data and reporting  Choose initiatives that can demonstrate quality improvement and impact cost  Use evidence-based best practice guidelines  Local Physician buy-in and input during the development is very important  Build confidence at the provider level with your data and reporting

Lessons Learned (continued)  Build meaningful and provider friendly reports  Choose performance measures that can be obtained consistently and “painlessly”  Sell your program to providers with “quality impact” and sell your program to legislators with “cost impact and quality”  Physicians want to practice highest quality  It will take you time to show results – stay under the radar screen  Build meaningful and provider friendly reports  Choose performance measures that can be obtained consistently and “painlessly”  Sell your program to providers with “quality impact” and sell your program to legislators with “cost impact and quality”  Physicians want to practice highest quality  It will take you time to show results – stay under the radar screen

Lessons Learned (continued)  Incentives must be aligned  Must be able to measure change  Modifiable measures – measures which can be impacted  Feedback should be educational not punitive  Don’t lose site of the goal Continuous Quality Improvement  Incentives must be aligned  Must be able to measure change  Modifiable measures – measures which can be impacted  Feedback should be educational not punitive  Don’t lose site of the goal Continuous Quality Improvement

Q U E S T I O N S THANK YOU