1. Promising Models of Care Coordination for Beneficiaries with Chronic Illnesses Presented by: Paul Shelton, EdD

2. 2 Identify promising care coordination/management interventions for beneficiaries with chronic illnesses Identify promising care coordination/management interventions for beneficiaries with chronic illnesses Transitional Care Transitional Care Comprehensive Care Coordination Comprehensive Care Coordination Describe internal and external evaluation Describe internal and external evaluation Describe key distinguishing features of these programs Describe key distinguishing features of these programs Policy Implications Policy Implications Goals of Presentation

3. 3 Care Coordination A person-centered, assessment based, interdisciplinary approach to integrating health care and social support services cost-effectively in which: an individuals needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by utilizing an evidence-based process and an identified Care Coordinator (New York Academy of Medicine, National Coalition on Care Coordination).

4. 4 The Problem Most healthcare dollars are spent on a small percentage of beneficiaries who have complex chronic conditions Most healthcare dollars are spent on a small percentage of beneficiaries who have complex chronic conditions Causes of high utilization and costs: Causes of high utilization and costs: Deviations from evidence-based care Deviations from evidence-based care Poor communication among primary providers, specialists, health and community providers, patients and families Poor communication among primary providers, specialists, health and community providers, patients and families Failure to catch problems early/patient compliance Failure to catch problems early/patient compliance Failure to address psychosocial issues Failure to address psychosocial issues Lack of coordinated, longitudinal management Lack of coordinated, longitudinal management Ineffective transitional management (hospital - home, hospital - nursing home, nursing home - hospital, nursing home - home) Ineffective transitional management (hospital - home, hospital - nursing home, nursing home - hospital, nursing home - home)

5. 5 Intervention with rigorous evidence that: Improves patient outcomes Improves patient outcomes Reduces total health care expenditures for participating patients Reduces total health care expenditures for participating patients Improved satisfaction or clinical indicators not sufficient Improved satisfaction or clinical indicators not sufficient Net savings require reduced hospitalizations Net savings require reduced hospitalizations What is Effective Care Coordination?

6. 6 Promising care coordination interventions: Promising care coordination interventions: 1. Transitional Care Coordination (Coleman et al. 2006; Naylor et al. 2004; Perry et al. 2011) Promising Interventions

7. 7 Promising Interventions, cont.: 2. Comprehensive Care Coordination Medicare/Duals - (Boult et al. 2008; Leff et al. 2009; Dorr et al. 2008; Counsell et al. 2007; Medicare Coordinated Care Demonstration: Best Practice Sites, Brown 2009). Medicare/Duals - (Boult et al. 2008; Leff et al. 2009; Dorr et al. 2008; Counsell et al. 2007; Medicare Coordinated Care Demonstration: Best Practice Sites, Brown 2009).

8. 8 Transitional Care These programs: These programs: Engage patients with chronic illnesses while hospitalized Engage patients with chronic illnesses while hospitalized Follow patients intensively post-discharge Follow patients intensively post-discharge Teach/coach patients about medications, self- care, and symptom recognition and management Teach/coach patients about medications, self- care, and symptom recognition and management Remind/encourage patients to keep follow-up physician appointments Remind/encourage patients to keep follow-up physician appointments

9. 9 Transitional Care Intervention: Coleman et al. (2006) Care Transitions: Coleman Care Transitions: Coleman Patient-centered intervention designed to improve quality and contain costs for patients with complex care needs as they transition across care settings Patient-centered intervention designed to improve quality and contain costs for patients with complex care needs as they transition across care settings Target Population Inclusion: A) Patients being discharged from the hospital with: stroke, congestive heart failure, coronary artery disease, cardiac arrhythmias, COPD, diabetes, spinal stenosis, hip fracture, peripheral vascular disease, deep venous thrombosis, pulmonary embolism B) 30 day Medicare readmission for HF, MI, PNE C) Risk algorithm for readmission drawn from administration data Exclusion: Dementia with no caregiver, primary psychiatric diagnosis, with psychotic elements, active drug or alcohol use

10. 10 Transitional Care Intervention: Coleman et al. (2006) Staffing APN or RN or social worker or occupational therapist Caseload: 1 care coordinator (CC) per 40 patients Duration: 30 days following hospitalization Focus Continuity of care by helping family maintain a personal health record Help family understand how/when to obtain timely follow-up care Coach patients to ask the right questions to the right health care providers Help patients/families be more active in managing condition and in developing/implementing self-care skills (i.e. medication management, increased awareness of symptoms, recognizing red flags and warning signs for care, along with instructions on how to respond

11. 11 Transitional Care Intervention, cont.: Mary Naylor et al. (2004) Care Transitions: Naylor Care Transitions: Naylor Patient-centered intervention designed to improve quality of life, patient satisfaction, and reduce hospital readmissions and cost for elderly patients hospitalized with CHF Patient-centered intervention designed to improve quality of life, patient satisfaction, and reduce hospital readmissions and cost for elderly patients hospitalized with CHF Target Population Inclusion Inclusion: A) Elderly patients (aged 65+) admitted to 6 Philadelphia, PA, hospitals with diagnosis of CHF (DRG 127) B) Live in the community within a 60 mile radius service area Exclusion: Exclusion: Could not have ESRD, non English speaking

12. 12 Transitional Care Intervention, cont.: Mary Naylor et al. (2004) Staffing Advanced Practice Nurses (3) Caseload: 1 care coordinator (CC) per 39 patients Duration: 3 months following index hospitalization Focus Continuity of care at hospital discharge to optimize patients health status and arrange for needed home care services After patients discharged home, prevention of medication and other medical errors Help patients/caregivers with early symptom recognition, management of chronic conditions, and recommendations for future care.

13. 13 Comprehensive Care Coordination Programs Implement evidence-based guidelines for care management Implement evidence-based guidelines for care management Conduct a comprehensive assessment Conduct a comprehensive assessment Collaboratively develop and implement a plan of care Collaboratively develop and implement a plan of care Teach/coach patients about proper self-care, medications, how to communicate with providers Teach/coach patients about proper self-care, medications, how to communicate with providers Monitor patients symptoms, well-being and adherence between office visits Monitor patients symptoms, well-being and adherence between office visits Advise patients on how to talk with and when to see their physician Advise patients on how to talk with and when to see their physician Apprise patients physician and other providers of important symptoms or changes Apprise patients physician and other providers of important symptoms or changes Arrange for needed health-related support services Arrange for needed health-related support services Coordinate communication among physicians, health/community providers and patient/family Coordinate communication among physicians, health/community providers and patient/family

14. 14 Comprehensive Care Coordination: Medicare/Duals Guided Care Care Management Plus (CMP) Medicare Coordinated Care Geriatrics Resources for Assessment and Care of Elders (GRACE)

15. 15 Comprehensive Care Coordination: Guided Care Guided Care: Boult Guided Care: Boult A model of comprehensive health care provided by nurse-physician teams for patients with several chronic conditions A model of comprehensive health care provided by nurse-physician teams for patients with several chronic conditions

16. 16 Comprehensive Care Coordination: Guided Care Target Population Inclusion Criteria Older patients (65+) at high risk of using health services during the following year, as estimated by Hierarchical Condition Category (HCC) predictive model High risk was equated with HCC scores of 1.2 or higher Exclusion Criteria Low HCC scores

17. 17 Comprehensive Care Coordination: Guided Care Staffing Registered nurse based in primary care practice working with 3-5 physicians Caseload: 1 care coordinator (CC) per 50-60 patients Duration: Ongoing Focus Enhance primary care by infusing the operative principles of all seven chronic care innovations Comprehensive patient evaluation Individual care planning Promote adherence with evidence-based guidelines Empower patient Promote healthy lifestyle Coordinate care of multiple conditions Coordinate care across provider settings Caregiver support and education Access to community resources Make evidence-based, state-of-the-art, chronic care available continuously from teams of professionals that patients trust

18. 18 Care Management Plus (CMP) CMP: Dorr CMP: Dorr Patient-centered intervention designed to reduce mortality and hospital admissions for elderly patients of primary care physicians. Patient-centered intervention designed to reduce mortality and hospital admissions for elderly patients of primary care physicians.

19. 19 Care Management Plus (CMP) Target Population Inclusion: Inclusion: A) Elderly (65+), chronically patients of primary care physicians served by Intermountain Health Care, a large health care system in Utah A) Elderly (65+), chronically patients of primary care physicians served by Intermountain Health Care, a large health care system in Utah Medicare Part B for at least 11 months prior to enrollment Medicare Part B for at least 11 months prior to enrollment Multiple comorbidities, diabetes, frailty, dementia, depression, other mental health needs Multiple comorbidities, diabetes, frailty, dementia, depression, other mental health needs Physician referral Physician referral Exclusion: Exclusion: Patient declined to participate Patient declined to participate

20. 20 Care Management Plus (CMP) Staffing All care managers are RNs, generalists, located in primary care clinics All care managers are RNs, generalists, located in primary care clinics Caseload: 1 care coordinator (CC)/350-500 patients Duration: 24 months Focus Continuity of care through specialized information technology system Continuity of care through specialized information technology system Education for specific diseases and problem-solving skills Education for specific diseases and problem-solving skills Emphasis on evidence-based treatment plans and protocols Emphasis on evidence-based treatment plans and protocols Flexibility of care planning and treatment plans Flexibility of care planning and treatment plans

21. 21 Comprehensive Care Coordination: MCCD Best Practice Sites MCCD Provide care coordination services to high risk Medicare beneficiaries with multiple chronic conditions to improve quality and reduce total cost of care Evidence Intervention patients in the 4 best practice sites had: Lower re-hospitalization rates by 8% to 33% among high-risk enrollees Lower total Medicare expenditures combined 4 sites of $157 per member per month (2010 dollars)

22. 22 Comprehensive Care Coordination: MCCD Best Practice Sites Target Population (portion of study in each promising practice program) Inclusion Criteria Medicare beneficiaries with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) or coronary artery disease (CAD) and at least on hospitalization in the prior year and any of the 12 chronic conditions and two or more hospitalizations in the prior two years Exclusion Criteria Enrolled in hospice, reside in nursing home or have end stage renal disease (ESRD)

23. 23 Comprehensive Care Coordination: MCCD Best Practice Sites Staffing Registered nurses trained in comprehensive care coordination Registered nurses trained in comprehensive care coordination Washington University and Health Quality Partners had staff primarily located in community offices (not hospital, clinic, home health); Mercy Medical Center staff located in hospital and primary care clinics and Hospice of Valley staff located in Hospice Agency Washington University and Health Quality Partners had staff primarily located in community offices (not hospital, clinic, home health); Mercy Medical Center staff located in hospital and primary care clinics and Hospice of Valley staff located in Hospice Agency Caseload Wash U: 1 CC per 85-95 patients Wash U: 1 CC per 85-95 patients HQP: 1 CC per 75-85 patients HQP: 1 CC per 75-85 patients Mercy: 1 CC per 80 patients Mercy: 1 CC per 80 patients Hospice: 1 CC per 45 patients Hospice: 1 CC per 45 patients Duration: Ongoing Focus Improved self-care Improved self-care Improved symptom recognition and management Improved symptom recognition and management Improved medication management Improved medication management Implementation of evidence-based practices Implementation of evidence-based practices Improved transitional care Improved transitional care

24. 24 Internal Evaluation How to achieve fidelity to model: How to achieve fidelity to model: Comprehensive and ongoing training of care coordinators Comprehensive and ongoing training of care coordinators Established and updated evidence based guides for practice Established and updated evidence based guides for practice Regular feedback to care coordinators on whether patients are receiving care consistent with guidelines Regular feedback to care coordinators on whether patients are receiving care consistent with guidelines Tracking of and feedback to care managers on established contacts (monthly visits, visits within 24 hours of hospital discharge, etc.) Tracking of and feedback to care managers on established contacts (monthly visits, visits within 24 hours of hospital discharge, etc.) Feedback on implementing self-management and evidence- based guidelines with patients Feedback on implementing self-management and evidence- based guidelines with patients Tracking and reporting amount of time care coordinator spends on tasks (assessing, planning, monitoring, educating, coaching, documenting, supporting, and coordinating) Tracking and reporting amount of time care coordinator spends on tasks (assessing, planning, monitoring, educating, coaching, documenting, supporting, and coordinating) Need web-based care management system to measure fidelity and generate feedback Need web-based care management system to measure fidelity and generate feedback

25. 25 External Evaluation: What we Need to Evaluate to Judge Success Effect on hospital admissions and readmissions Effect on hospital admissions and readmissions Effect on medical costs (by service type, total) Effect on medical costs (by service type, total) Whether savings exceed intervention costs Whether savings exceed intervention costs Effects on quality of care indicators (e.g., screening tests, preventive care, ED visits, infections, falls, mortality, etc.) Effects on quality of care indicators (e.g., screening tests, preventive care, ED visits, infections, falls, mortality, etc.) Effects on patients quality of life Effects on patients quality of life

26. 26 What Distinguishes Successful Comprehensive Care Coordination/Care Management? Targeting Patients with select chronic conditions including co-occurring serious mental health diagnoses and substance abuse. Patients with select chronic conditions including co-occurring serious mental health diagnoses and substance abuse. Those who were hospitalized in previous year or at time of enrollment Those who were hospitalized in previous year or at time of enrollmentCaseload Small enough caseload size (e.g. 40-80) Small enough caseload size (e.g. 40-80) Training and Feedback CC Initial comprehensive training of care coordinators Initial comprehensive training of care coordinators Deliver effective patient education and coaching Deliver effective patient education and coaching Providing a strong, evidence based patient education/coaching intervention for managing health, symptoms, medications Providing a strong, evidence based patient education/coaching intervention for managing health, symptoms, medications Performance feedback to care coordinators Performance feedback to care coordinators

27. 27 What Distinguishes Successful Comprehensive Care Coordination/Care Management? Primary Care Provider Strong rapport with primary care provider/specialist/hospital Strong rapport with primary care provider/specialist/hospital Face-to-face contact through co-location, regular hospital rounds, accompanying patients on physician visits Face-to-face contact through co-location, regular hospital rounds, accompanying patients on physician visits Assign all of a physicians patients to the same care coordinator when possible Assign all of a physicians patients to the same care coordinator when possibleContacts Frequent face-to-face contact (home, office) with patients (~1/month) Frequent face-to-face contact (home, office) with patients (~1/month)Intervention Conduct comprehensive in-home initial assessment Conduct comprehensive in-home initial assessment Develop a mutually agreed to action plan with goals Develop a mutually agreed to action plan with goals

28. 28 What Distinguishes Successful Comprehensive Care Coordination/Care Management? Interventions follow evidence-based practices/guidelines for care management Interventions follow evidence-based practices/guidelines for care management Address psychosocial issues: Staff with experts in social supports and community resources for patients with those needs Address psychosocial issues: Staff with experts in social supports and community resources for patients with those needs Being a communications facilitator: Care coordinators actively facilitating communications among health and community providers and between the patient and the providers Being a communications facilitator: Care coordinators actively facilitating communications among health and community providers and between the patient and the providers Implement self management, coaching and support with patient/family Implement self management, coaching and support with patient/family Implement effective medication management plan Implement effective medication management plan Manage care setting transitions: Having a timely, comprehensive response to care setting transitions (esp. from hospitals and skilled nursing facilities) Manage care setting transitions: Having a timely, comprehensive response to care setting transitions (esp. from hospitals and skilled nursing facilities)

29. 29 Policy Implications Best short run opportunity for reducing costs is improving transition from hospital to home Best short run opportunity for reducing costs is improving transition from hospital to home Need payment reform to incentivize hospitals and primary care practices to implement these programs Need payment reform to incentivize hospitals and primary care practices to implement these programs Medicare and Medicaid incentives to reduce readmissions Medicare and Medicaid incentives to reduce readmissions Tying physicians compensation to quality and efficiency scores Tying physicians compensation to quality and efficiency scores Medicare and Medicaid should consider separate reimbursement for care managers implementing proven interventions with target groups Medicare and Medicaid should consider separate reimbursement for care managers implementing proven interventions with target groups Special training programs for care coordinators and managers are needed Special training programs for care coordinators and managers are needed

30. 30 Contacts – Questions or Additional Information Paul Shelton, EdD Email: pshelton@illinois.edu Phone: 1-205-748-0050 Cheryl Schraeder, RN, PhD, FAAN Email: cheryls@uic.educheryls@uic.edu Phone: 1-217-586-6039