Care Management for Children with Chronic Conditions:

1. Care Management for Children with Chronic Conditions: Health Plan vs. Primary Care June 24, 2004

2. Project Partners • Maternal Child Health Bureau • Study period: July 1, 2002 – June 30, 2006 • Children’s Hospital & Regional Medical Center (CHRMC) – Center for Children with Special Needs • John Neff, MD • Virginia Sharp, MA • Jean Popalisky, RN, MN • Regence BlueShield • Tracy Fitzgibbon, RN • Kristin Myers

3. Project Goal & Objectives • Develop, implement and evaluate a cost effective quality care management program for children with chronic conditions (CCC) • Identify and classify CCC for case management using Clinical Risk Groups (CRG) software (health plan). • Develop a range of reimbursement strategies case management in other settings (primary care).

4. Health Plan Case Management • Implementation Elements: • Identifying CCC using Clinical Risk Groups software • Developing tools • Contacting members • Project management • Difficulty defining meaningful outcome measures

5. Health Plan: Case Management Identification Summary • 315 CCC identified for CM screening • CRGs + utilization filters • 72 eliminated • 120 unable to contact • 123 CCC contacted • 87 members screened using the 22-item CM screening tool • 46 members (53%) opened case management

6. Health Plan Activities

7. Health Plan Cost Savings • $291,295 • 1.5 FTE Nurse Case Managers • 19 month timeline • Regence cost-savings methodology

8. Health Plan: CM Screening Tool Analysis • Five CM screening tool questions used to identify need for case management: • Areas of concern: • Access/Organization of services (3 questions) • Out-of-pocket expenses (1 question) • Family stress (1 question) • 22-items could be reduced to 5 items

9. Health Plan: Case Management Summary • Predictive Modeling: • CRGs + utilization filters + screening = “actionable” children with chronic conditions • Engagement rate = 37% of members contacted • Interventions: • member education • needs assessment • community resource coordination • benefit management • Value: • Cost savings of $291,295 over 19 months • Members report case management impact

10. Primary Care Case Management • Implementation Elements: • Identify CCC for case management • Develop tools • Define outcome measures meaningful to the health plan

11. Primary Care: Tracking Activities • All clinic staff involved in tracking • Information collected: • Type of intervention (existing CPT codes) • Duration of intervention • Provider type performing intervention • Direct outcome of intervention • Avoided outcome as result of intervention • Tracking forms faxed to health plan at regular intervals for entry into database

12. Primary Care: Tracking Results • Clinic #1 • 454 tracking forms on 83 CCC • Engagement rate = 83% • Clinic #2 • 813 tracking forms on 84 CCC • Engagement rate = 84%

13. Primary Care: Care Planning Activities • MD’s to do WRITTEN care plan • Short-term goals: 3 – 6 months • Include strategies for reaching goals • Include input from families • Revise when indicated • Document progress toward goals • Care plans faxed to health plan when completed

14. Primary Care: Written Care Planning Results • Clinic #1 • Submitted 38 care plans • Family input included on 16 care plans • Clinic #2 • Submitted 5 care plans • Family input included on 3 care plans

15. Primary Care Activities

16. Primary Care Cost Savings • $44,434 Avoided Out-patient services • 241 avoided ER visits @ $146/visit • 136 avoided Pediatric clinic visits @ $68/visit • 32 Avoided In-patient episodes

17. Primary Care: Case Management Summary • Predictive Modeling: • CRGs + utilization filter + staff selection • Engagement rate = 83.5% • Interventions: • family support activities • condition management activities • Cost savings: • avoided services

18. Side-by-Side Comparison

19. Key Learning Points • Health plan case management activities and primary care case management activities are unique • Primary care providers identify, contact, and engage patients more efficiently and effectively than health plan • Both settings produce short-term cost savings from different sources

20. Recommendations • Comprehensive care coordination for the families of CCC should integrate the unique case management activities from the health plan and primary care into a single, cooperative effort

21. John Neff, M.D. Jean Popalisky, MN 1100 Olive Way, Suite 500 1100 Olive Way, Suite 500 Seattle, WA 98101 Seattle, WA 98101 Phone: 206-987-5275 Phone: 206-987-5326 Fax: 206-987-5741 Fax: 206-987-5741 Email: john.neff@seattlechildrens.org Email: jean.popalisky@seattlechildrens.org Tracy Fitzgibbon, RN 333 Gilkey Road, MS: BU270 Burlington, WA 98233 Phone: 360-755-2755 Fax: 360-755-4576 Email: tfitzgib@regence.com Contact Information: