1. MICMT Complex Care Management Course
Care Management Five Step Process
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2. Learning Objectives
Describe goals of risk stratification to identify patients who may benefit from Care Management Services
Relate key work which is completed in each step of the five step care management process
Apply 5 step care management process for episodic and longitudinal care management service delivery

3. Goals of Care Management
Improve patient’s functional health status
Improve quality of life (QOL)
Enhance coordination of care
Eliminate duplication of services
Reduce the need for unnecessary, costly medical services

4. Moderate Care Management
May have newly diagnosed chronic condition
Poorly controlled chronic condition
Transitions of Care
Medication management
Would benefit from episodic care management
2018 & 2019 CPC+ IMPLEMENTATION GUIDE: GUIDING PRINCIPLES AND REPORTING

5. Complex Care Management
Frequent ER visits and/or hospitalizations
Acute medical conditions (post hospital discharge)
TOC from an extended Care Facility/subacute rehab
Multiple comorbidities
Chronic kidney disease
Special needs plan
Extensive SDOH
Co-morbid diabetes conditions
Elderly with psychosocial
High risk pregnancy – with socioeconomic barriers
Children with special needs
Insulin titration/management
Behavioral Health diagnosis
Complex care management

6. Episodic vs. Longitudinal
Otherwise stable patients going through TOC
Newly unstable chronic condition
Short-term, goal oriented
Combination of multiple comorbidities
Complex treatment regimens
Behavioral and social risks
Ongoing relationship
Provide short-term (episodic) CM services to patients with acute or urgent needs, i.e. new diagnoses, medical crisis, decompensation in otherwise controlled chronic condition
2018 & 2019 CPC+ IMPLEMENTATION GUIDE: GUIDING PRINCIPLES AND REPORTING

7. Risk Stratification
Risk stratification is an intentional, planned and proactive process carried out at the practice level to effectively target clinic services to patients
Identifies those who are at high, moderate, and low risk tiers as well as prioritizing management of their care
Care coordination should be focused on patients who will benefit most, maximizing the impact on both quality and costs
Is usually carried out behind the scenes
Helps determine which patient populations will benefit the most from care management services, i.e. those that may be at risk for rehospitalization
Patients are typically placed into high, medium or low risk groups, the goal of risk stratification is to segment patients into distinct groups of similar complexity and care needs. (

8. Risk Stratification Population Health
Highly Complex:
small group, has greatest care needs
Multiple Complex illnesses
Psychosocial concerns
High Risk:
Multiple risk factors
Potential to move into Highly complex
Rising risk
One or several chronic conditions
Move in and out of stability
Manage risk factors more than disease states
Low risk
Stable or healthy
Continue to keep engaged in the healthcare system
Highly complex: usually less than 5% of population. Goal for this group is to avoid costly hospitalizations and ER services
High risk: Work with patient to ensure they receive chronic disease management and preventative services, medical, social and community needs.
Rising risk: common risk factors include obesity, smoking, blood pressure
Low risk: these patients have minor conditions that can be easily managed

9. Stratification Process
Perhaps the most important source of data, - the patient’s voice. Pt voice and the clinician's judgement are essential.
Asking the patient: Do you think your health is “good” , “fair” or “poor”?
Patient reported data; Assessments
Psychosocial factors,
Patient self assessment and experience
Clinical Judgement
Physician Input
Administrative data-utilization
Hospitalization
ER visits
Registry data
Payer data
Clinical data
Medications

10. Managing Populations: Stratified approach to patient care and
IV. Most complex (e.g., Homeless, Schizophrenia)
III. Complex Complex illness Multiple Chronic Disease Other issues (cognitive, frail elderly, social, financial)
II. Mild-moderate illness Well-compensated multiple diseases
Single disease
I. Healthy Population
<1% of population
3-5% of population
50% of population
Managing Populations:
Stratified approach to patient care and
care management
A target caseload for a CM will vary depending on a number of variables
Factors affecting caseload size and complexity include
Experience of the care manager
Clinical and social complexity of patients
Available social supports
Caseload size and manageability should be evaluated on an ongoing basis

13. Enrollment and Assessment
Care Management Process
Five Steps:
Referral
Screening
Enrollment and Assessment
Management
Closure

14. Referral Not everyone will benefit from care management services
Look at targeted populations
Patient lists*
Participants may be provided with a list of patients that have been assigned or attributed to their practice. This list will reflect the patients who are attributed for care management services
Providers or practice staff
Hospital discharge list
Emergency room discharge list
Gaps in care reports (electronic registries)
* Patient lists are commonly used for incentive, pilot, and demonstration programs
There are many possibilities on where a referral may originate.
Targeted populations

15. Referral Determination for Care Management
If a patient would benefit from care management services and the screening steps result in a determination that patient will not be enrolled in Care Management at the practice, then consider the resources available to support the patient’s health care needs
Consider options to offer support for patient
Link to community resources
Collaboration and reaching out to the patient’s health care plan care manager
For Medicaid Managed Care – see contact list for the plan’s care management services
For BCBSM Blue Health Connection Program call

16. Case Study Mr. B - Complex Mrs. A - Moderate 70 years old
Increasing symptoms of fatigue, weakness, SOB
Hospitalized 3 months ago, HF exacerbation
History of HTN, CAD, MI
Temporarily living with daughter (only 2 more weeks)
Unsure about his medications
Feeling low
High salt diet
Worried about living arrangements
Wants to be in own home
Trouble sleeping
Requires assistance with ADLs
70 years old
Has type II diabetes for last 10 years without complication
Recently started on insulin
Lives with husband
History of HTN
BP and blood sugar out of control
Mr. B was living at home until his caregiver had an accident and now lives with his daughter.
Daughter is moving in two weeks and Mr. B will not be able to stay
Eats mainly canned goods and microwave dinners

17. Screening Medical record Claims High utilization High costs
Current clinical conditions
High risk
Resource utilization
Recent ED visit(s)
Recent hospitalization (example: >2 admissions within last 12 months.)
Skilled nursing facility with goal to transfer to home setting
Significant health events
Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
Primary Care Physician input
ER use
Hospitalizations
High tech radiology
Rehab
Cancer Treatment
Organ Transplant

18. Screening Risk score Dual-eligible Condition specific-examples
Children with complex needs
CHF
COPD
CHF and COPD are currently at the top of list in terms reducing ED visits and inpatient hospitalizations. These have a large impact on CMS penalties.

19. Screening
Socioeconomic and financial status
Home environment
Physical/emotional/cognitive functioning
Support system
Self - care ability
Note: During Assessment phase this information is gathered in greater depth
Patient characteristics such as ethnicity, age, metabolic risk factors, smoking status, and chronic disease burden, as well as psychosocial issues, such as availability of caregiver support, can help identify individuals and populations that may benefit from CM services. Care Management: Implications for Medical Practice, Health Policy, and Health Services Research. Retrieved from

20. Screening Mr. B Mrs. A Medical record PCP Hospital discharge report
Patient himself
Patients daughter
SDOH screening
Depression screening
Patient herself
PCP
Medical record
Hospital discharge report
SDOH screening
Mr B.
Mrs A.

21. Enrollment Patient Engagement
Patient “how to” Tips – inform about care management
Warm handoff from PCP is best
If warm handoff is not possible
Quick Tools
CM Phone script
Care Management Flyer
Its best if the PCP and patient have a discussion about care management services before hand

22. Enrollment Patient Engagement
Getting started:
Ask patient/caregiver:
“Dr. Smith asked me to contact you. He thinks you may benefit from a service we offer.”
“My name is Beth, a nurse with Dr. Smith’s office. He wanted me to call you regarding a service to help you manage your diabetes.”
“Dr. Smith asked me to call you about the concerns you have about your health.”
If a warm hand-off is not possible and you need to engage the patient by phone or in-person the following statements may help in the transition

23. Enrollment Assessment
Obtain patient consent
Document the enrollment
Complete initial comprehensive assessment
Level of care management
Assessment findings may be discovered over time
This is not static!

24. Enrollment/Assessment
Mr. B
Mrs. A
Warm handoff from PCP
Document consent
Understanding of current medications
SDOH
Transportation
Home environment
Self care ability
Support network
Why patient unable to sleep
Diet
Depression screening
Medication reconciliation
Phone conversation
Document consent
Support network
Level of understanding
Medication reconciliation
How would you explain care management to Mrs. A, Mr. B?
What information would you focus on at the time of the assessment?
How do you document the consent?
Mr. B
Mrs. A
Discuss the cause or behavior that led to the increased blood sugars

25. Management Plan of Care
Develop the individualized plan of care
Getting started
Patient, PCP and Care Manager review and agree on the individualized plan of care
Carrying out the plan
Care Manager collaborates with team members to carry out specific interventions
Do team members in the practice have defined roles?
Collaboration with practice leaders and team members to define areas of responsibility for roles and areas of expertise to carry out the plan
Work flow matters!
What are the current work flows in the practice?
Is the practice currently testing a new work flow(s)?
This is often an ongoing improvement process

26. Management Plan of Care
Mr. B
Mrs. A
Individualized plan of care
Longitudinal
Collaboration with other team members
Community resources
When to call the PCP office
Diabetes action plan
Short-term episodic care
What short and long term goals might you help establish with Mr. B, Mrs. A
What intervention
What team members might you coordinate with
Community resources
What short and long term goals might you establish with each patient?

27. Management Interventions
Action Oriented
Time-specific
Multidisciplinary team involvement
Addresses patient’s needs and concerns
Involves medical neighborhood, care across the continuum

28. Management Interventions
Mr. B
Mrs. A
Team members:
Pharmacist SW
Dietician
Daily weights
When to call the PCP
Teach back on insulin use with patient and husband
Team members:
Diabetic educator
When to call the PCP
Diabetes action plan
Can you think of other interventions to help Mr. B?
What other team members may be helpful for Mr. B or Mrs. A

29. Management Follow up
Key Factors: Building a trusting relationship and patient’s readiness
Conduct follow up visits based on:
Review, evaluation and monitoring
Reassessment of patient’s health condition, progress with meeting SMART goals
Are patient’s identified needs met
Outcomes of the treatment and interventions

30. Management Follow up Mr. A Mrs. B Long-term longitudinal
Weekly to start
Daily weights
Dietary changes
Follow up on transportation
Short-term Episodic
Weekly to start
Follow up on insulin use
Blood sugar monitoring

31. Case Closure Reasons for case closure:
Patient moves out of region/state
Patient has met their goals and is discharged from care management services
Patient expires
Patient is admitted to hospice care
Be sure primary care physician is aware and in agreement

32. Case Closure Mr. B Mrs. A Patient expires Patient shows improvement
No recent exacerbations
Patient has met his goals
Patient referred to hospice
Understand use of insulin
Blood sugars in control

33. Points to Consider
Continuously develop skills in identifying patients who would benefit from complex care management
Understand social determinants of health and health literacy-impact for patient/family/caregiver
Determine how various assessment tools may assist you to optimize patient care
Review and modify the individualized care plan
Document and bill the comprehensive assessment G9001 code for patients receiving ongoing CM services, follow-up care (if this is applicable to your program)
Complete a new patient assessment if enrolled >12
months ago

34. Reference Guide 5 Step Process Care Path…………………………………………………………….….165
5 Step Process Worksheet…………………………………………………………..….167
Risk-Stratified Care Management and Coordination……………………….164
Case Closure Standard Work Activity Sheet…………..…………………….….133
Care Manager Introduction Phone Script..…………………………………………24
Care Management Explanation Flyer………………………………………………...26
CMS Dual Eligible Beneficiaries…………………………………………………….….153