1. Medical Home for High Risk Patients: Intensive Outpatient Care Program Diane Stewart, MBA Senior Director Link to the Complex Care Toolkit: http://www.calquality.org/

2. ©CQC 20112 Agenda 1.What is High-Risk Care Management? 2.How Does it Work? 3.How Do I get Started?

3. ©CQC 20113 Where Does this Fit in the Medical Home? Complex Care Mgmt patients with multiple, onging medical and social concerns Case Management patients with acute, time-limited medical needs Disease Management patients with single (or non-complicated) chronic conditions Preventive health wellness support and preventive services for healthy patients

4. ©CQC 20114 What is the Intensive Outpatient Care Program? Primary care-based care management for predicted high risk patients.  Trained Care Managers (often RNs) support medically complex patients, working closely with physician practices by focusing on self-management support and behavior change

5. Case Studies Boeing & Atlantic City Resorts (A. Milstein, P. Kothari) o IOCP in 2 self-funded industries o Capitation fee plus FFS for specialized MD-led teams within 3 Medical Groups (Boeing) and free-standing clinic (Atlantic City) o 18%- 20% net reduction per capita spending vs. propensity matched controls Rural IPA with CA State Employees (A. Glaseroff, L. Nedlan); o Disseminated rural county model within a distinguished IPA inserting RN care managers into 25 private practices o 20% savings in first year o Named “Priority Care” by patient advisory group

6. ©CQC 20116 Findings: Priority Care Utilization Metrics Year 1

7. ©CQC 20117 Meet Tom, Priority Care Patient Before Priority Care After Priority Care 6 ED VisitsNo ED Visits 1 Urgent Hospital Admission No Hospital Admission Visits to 1 PCP and 5 Specialists Visits to 1 PCP and 2 Specialists Depression Score= 20 Depression Score= 12 $2,947 per month billed charges $640 per month billed charges www.pbgh.org/news-and-publications/pbgh-videoseo Link

8. ©CQC 20118 Intensive Outpatient Care Model Key Features of the IOCP and Successful Medicare Demonstrations: 1. Target the right patients Predicted high cost: Multiple medical conditions, at risk for hospitalization 2. Provide the right services Patient assessment (including sociobehavioral issues) Face-to-face contact with patients Team-based care Direct access to dedicated care manager Patient-Centered Shared Action Plan Regular, planned, rules-based proactive contact Close interaction with physician(s) Manage care transitions and medications 3. Supported by an organizational infrastructure, including.. Timely information on hospital and ED admissions Behavioral Health back up

9. Two Staffing Options “Intensivist”“Distributed” Patient referred into specialized primary care practice Patient remains with current primary care practice 1 MD for every 500 patients (includes Medicare) Care Coordinators work with a subset of practices  Ideally, no more than 5 3 Team Members for every MD  3 Care (ex: NP, PA, MA, MSW, LVN, health coach) 1 Care Coordinator per 100 Medicare patients or 200 Commercial patients.  Start with a RN and build the team from there. (ex: NP, PA, RN, MA, MSW, LVN, health coach)

10. ©CQC 201110 Dedicated Care Manager Role Establishes Trusting Relationship(s) o Trust created during face-to-face visit o Continuous engagement of patients and providers o Direct access via email and phone Takes a longitudinal view (weeks, months, years) toward patient problem solving and patient self-management skills Creates the shared action plan o “What bothers you the most?” Ensures continuity of care and explores overuse o Medication management o Transitions, including specialists

11. Care Team Patient, PCP, & Care Manager Outreach and Admin Support Specific Services (RT, PT, etc.) Community Services Mental Health Social Services Health Education and Teaching Development Process: 1.Use data on patient needs to build “Dedicated” Team 2.Build linkages to “Designated” resource and services

12. ©CQC 201112 Getting Started: Planning 1.“Intensivist” or “Distributed” Model? 2.Identifying Patients:  With continuing, complex medical conditions, at risk for hospitalizations 1.Claims data 2.Physician Referral 3.Interview 15 patients to refine staffing

13. ©CQC 201113 Segmentation Using Claims Data: CareOregon Health Plan 10% mbrs = 51% Total Paid Cost/12 mos Population Segment# Members % Members Avg Total Paid Cost per Member/ 12 mos % Paid Cost/ 12 mos of Segment # ED visits # IP Admits No inpatient/ 6+ ED visits 813%$87435%7860 1 Non-OB inpatient and 0- 5 ED visits 974%$18,76714%14797 2+ Non-OB inpatient OR 1 Non-OB inpatient AND 6+ ED visits 713%$59,44032%383189 Multnomah County Health Department-NE Clinic Population

14. Learning About Your Patients: What’s getting in the way??

15. ©CQC 201115 Getting Started: Seeing Patients Patient Enrollment and Outreach  50 – 70% enrollment when PCP invites the patient Intake Visit (“Supervisit”)  Face to face, ideally with PCP  Holistic Assessment Training and Support  Initial training for care managers  On-going case conferences, ideally with supervising physician

16. ©CQC 201116 Questions???

17. ...is a multi-stakeholder healthcare improvement organization dedicated to advancing the quality and efficiency of the health care delivery system in California. California Quality Collaborative