Community Care of North Carolina: Improving Medicaid & Low-Income Healthcare

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

2. 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.

3. HOME NEXT LAST 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

4. 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

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

6. 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

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

8. 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

9. HOME NEXT LAST 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

10. 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

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

12. HOME NEXT LAST 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

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

14. 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

15. 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

16. 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

17. 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

18. 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

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

20. 1 2 3 3 1 2 Asthma Initiative Process Measures Key % with asthma who had documentation of staging % staged II – IV on inhaled corticosteroids % staged II – IV who have an AAP

21. HOME NEXT LAST 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

22. Diabetes InitiativeProcess Measures Community Care of NC Diabetes Quality Initiative Summary (Established) R4 2004 R5 2005 R2 2002 R3 2003 Baseline 2001 R1 2002

23. 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 05-06 $ 240 million

24. Heart Failure Program • 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

25. 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) *From 2006 HFSA Guideline on HF Disease Management

26. 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

27. 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

28. 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

29. Q U E S T I O N S THANK YOU