AMERIGROUP Community Care: Chronic Illness Management Approaches

2. AMERIGROUP Community Care • Entered Maryland market in 1999 • Largest MCO in Maryland • Serving over 143,000 members in Baltimore City and 20 counties in Maryland • Located in Maryland

3. AMERIGROUP Community Care • Care Management • Utilization of overarching approaches and programs aimed at improving healthcare • May include programs addressing provider availability, pharmacy, hospital admissions, case management, etc. • Case Management • “A collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health care needs through communication and available resources to promote quality cost-effective outcomes” (Case Management Society of America) • Case managers are usually nurses or social workers

4. AMERIGROUP Community Care Care Management of Chronic Illness • Management of lifelong illness or disease that requires high level of ongoing intense medical care by multiple providers • Examples of Chronic Illness • diabetes • heart failure • emhpysema • sickle cell disease • asthma

5. AMERIGROUP Community Care: Chronic Disease Risk Groups Who Are They • SSI members • 15,000 SSI population: individuals that qualify for Medicaid based on illness or disease • 80% Adults • Average length of membership: 3.5 years • 45% of SSI medical expenses spent on inpatient hospital care • 2% (300 members) account for 50% of inpatient hospital care: over $25 million inpatient hospital costs • Behavioral health care: 20% substance abuse; 30% mental health

6. AMERIGROUP Community Care: Care Management for Chronic Illness Challenges Presented • Severely ill with multiple chronic diseases • Overwhelmed and exhausted • Difficulty navigating the health care system • Concurrent mental health or substance abuse issues

7. AMERIGROUP Community Care: Care Management for Chronic Illness Approaches to Care • Hospital Readmission Program • Nurses and medical directors visit members and providers in the hospital • Ensure members receive post discharge medication; receipt of home health care; access to PCP within 2 weeks of hospital discharge; transportation • Risk Rank List • Predictive tool for future admissions

8. AMERIGROUP Community Care: Care Management for Chronic Illness Approaches to Care (Cont’d) • Disease management: specific optimal care guidelines, expectations, pathways and desired outcomes • Disease specific pathways • Graded approach, intervention proportional to need • Telephonic management • Case management • Field case management

9. AMERIGROUP Community Care: Care Management for Chronic Illness Network Development • Specific highly skilled providers • Use of community resources • Centers of Excellence • Community and home based providers

10. AMERIGROUP Community Care:Care Management for Chronic Illness Key Elements for Success • Proactive identification and engagement of member • Develop an individualized care strategy • Empower member • Education • Community based case management and outreach • Incentives • Encourage provision of care • Partnership among providers and MCO • Adherence to care plan

11. AMERIGROUP Community Care: Care Management for Chronic Illness Outcomes • Improved Quality of Life • Decreased Morbidity and Mortality • Reduced Costs • Efficient Use of Resources