Promising Models of Care Coordination for Beneficiaries with Chronic Illnesses

1. Promising Models of Care Coordination for Beneficiaries with Chronic Illnesses Cheryl Schraeder, RN, PhD, FAAN UIC College of Nursing Patricia Volland, MSW, MBA New York Academy of Medicine Robyn Golden, MA, LCSW Rush University Medical Center Aging In America 2011

2. Overview • Define care coordination • Identify proven care coordination/management interventions for beneficiaries with chronic illness • Transitional Care • Comprehensive Care Coordination • Medicare/ Duals • Medicaid • Describe key distinguishing features • Describe internal and external evaluation

3. What is Care Coordination? • N3C defines care coordination as: • “A person-centered, assessment based, interdisciplinary approach to integrating health care and social support services in a cost-effective manner in which an individual’s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an evidence-based process which typically involves a designated lead care coordinator.”

4. What is the Problem? • Most health care dollars are spent on a small percentage of beneficiaries • Those with complex chronic conditions • Causes of high utilization and costs: • Deviations from evidence-based care • Poor communication among primary providers, specialists, health and community providers, patients, and families • Failure to catch problems early • Failure to address psychosocial issues • Lack of coordinated, longitudinal management • Ineffective transitional management

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

6. Promising Interventions • Most evidence shows impacts are unreliable • However, promising care coordination and care management interventions are emerging • Transitional care interventions • Care Transitions Intervention (Coleman) • Transitional Care Model (Naylor) • Enhanced Discharge Planning Program – RUSH (Perry) • Comprehensive Care Management - Medicare/ Duals • Guided Care (Boult) • GRACE (Counsell) • Care Management Plus (Dorr) • MCCD: Best Practice Sites (Brown) • Comprehensive Care Management – Medicaid/ Duals • Integrated Care Management (Douglas) • Community Based Chronic Care Management (Lessler) • Hospital to Home (Raven) • Health Care Management Program (Reconnu & Herndon)

7. Transitional Care: Components • These programs: • Engage patients with chronic illnesses while hospitalized • Follow patients intensively post-discharge • Teach/coach patients about medications, self-care, and symptom recognition and management • Remind and encourage patients to keep follow-up physician appointments • Approaches to achieving these goals differ across programs

8. Transitional Care:Three Promising Models • Care Transitions Intervention (Coleman) • Patient-centered intervention designed to improve quality and contain costs for patients with complex care needs as they transition across care settings • Transitional Care Intervention (Naylor) • Patient-centered intervention designed to improve quality of life, patient satisfaction, and reduce hospital readmissions and cost for elderly patients hospitalized with CHF • Enhanced Discharge Planning Program (RUSH) • Telephone-delivered social work-based transitional care model (hospital to home) designed to promote patient safety and satisfaction, improve quality of life, and reduce preventable re-hospitalizations and ED visits.

9. Transitional Care:Target Populations • Care Transitions Intervention (Coleman) • Included: Patients dc’d from hospital with certain diagnoses; 30-day Medicare readmissions for HF, MI, PNE; additional risk algorithm for readmission drawn from administrative data • Excluded: Dementia with no caregiver, primary psychiatric diagnosis, with psychotic elements, active drug or alcohol use • Transitional Care Intervention (Naylor) • Included: 65+ CHF patient admitted to certain hospitals and residing within 60 miles of designated hospital • Excluded: ESRD, non-English speaking • Enhanced Discharge Planning Program (RUSH) • Included: 65+ returning home after discharge with 7+ prescriptions and 1 additional risk factor including living alone, past admission, no/unstable support system, other psychosocial issue • Excluded: Transplant

10. Transitional Care:Staffing • Care Transitions Intervention (Coleman) • APN, RN, social worker, or occupational therapist • 1 care coordinator per 40 patients • Duration: 30 days following hospitalization • Transitional Care Intervention (Naylor) • Advanced Practice Nurses (3) • 1 care coordinator per 39 patients • Duration: 3 months following index hospitalization • Enhanced Discharge Planning Program (RUSH) • Master’s prepared social worker with experience in health and aging • 1 care coordinator per 48 patients • Duration: Up to 30 days, average 8 days

11. Transitional Care:Intervention • Care Transitions Intervention (Coleman) • Home visit post discharge, three follow-up calls • Based on 4 pillars: medication management, patient-centered record, primary care and specialist follow-up, knowledge of red flags • Transitional Care Intervention (Naylor) • Hospital visit and home visits of varying frequency • Comprehensive assessment in hospital, defining priority needs and services • Ongoing advocacy, education, and communication to ensure plan of care • Enhanced Discharge Planning Program (RUSH) • Pre-assessment through medical chart review to determine potential needs • Telephonic biopsychosocial assessment and care coordination to stabilize situation, ensure medical and home health follow-up, and engage community-based service providers

12. Transitional Care:Evidence • Care Transitions Intervention (Coleman) • Intervention patients had • Lower re-hospitalization rates at 90 days: • For any reason (17% vs. 23%) • For initial condition (5% vs. 10%) • Lowered hospital costs 19% over 180 days ($2,058 vs. $2,546) • Transitional Care Intervention (Naylor) • Intervention patients had: • 54% fewer re-hospitalizations per patient after 12 months (1.18 vs. 1.79) • 10.5% decrease in re-hospitalization rate (44.9% vs. 55.4%) • 39% lower mean total costs ($7,636 vs. $12,481 • Enhanced Discharge Planning Program (RUSH) • Intervention patients had a lower 30 day post discharge mortality rate compared to the usual care group (2.2% vs. 5.3%)

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

14. Comprehensive CC - Medicare/ Duals: Four Promising Models • Guided Care: Boult • A model of comprehensive health care provided by nurse-physician teams for patients with several chronic conditions • GRACE: Counsell • A model to improve the quality of care for low income seniors by the longitudinal integration of geriatric and primary care services across the continuity of care • Care Management Plus (CMP): Dorr • Patient-centered intervention designed to reduce mortality and hospital admissions for elderly patients of primary care physicians • Medicare Coordinated Care: Brown • Provide care coordination services to high risk Medicare beneficiaries with multiple chronic conditions to improve quality and reduce total cost of care

15. Comprehensive CC - Medicare/ Duals:Target Population • Guided Care (Boult) • Included: Older patients (65+) at high risk of using health services during the following year, as estimated by Hierarchical Condition Category (HCC) predictive model (scores of 1.2 or higher) • Excluded: Low HCC scores • GRACE (Counsell) • Included: 65+, established patient of a site primary care clinician, income less than 200% federal poverty • Excluded: Residence in nursing home, receiving dialysis, severe hearing loss, English language barrier, no access to telephone, severe cognitive impairment without an available caregiver • CMP (Dorr) • Included: Older chronically ill patients (65+) of primary care physicians served by Intermountain Health Care, a large health care system in Utah, with multiple comorbidites and beneficiaries of Medicare Part B for at least 11 months prior to enrollment • Excluded: Patient declined to participate • MCCD Best Practice Sites (Brown) • Included: 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 • Excluded: Enrolled in hospice, reside in nursing home or have end stage renal disease (ESRD)

16. Comprehensive CC - Medicare/ Duals:Staffing • Guided Care (Boult) • Registered nurse based in primary care practice working with 3-5 physicians • 1 care coordinator (CC) per 50-60 patients • GRACE (Counsell) • An APN and social worker in collaboration with PCP and a geriatric interdisciplinary team led by a geriatrician • 1 CC/social worker (SW) per 100-125 patients • CMP (Dorr) • All care managers are RNs, generalists, located in primary care clinics • 1 care coordinator per 350-500 patients • MCCD Best Practice Sites (Brown) • Registered nurses trained in comprehensive care coordination • Wash U: 1 CC per 85-95 patients • HQP: 1 CC per 75-85 patients • Mercy: 1 CC per 80 patients • Hospice: 1 CC per 45 patients

17. Comprehensive CC - Medicare/ Duals:Intervention • Guided Care (Boult) • Manages transitions between sites of care (rounds in hospital, design/execute discharge plan, visits patient at home within 2 days of discharge, ensures patient return to PCP) • Creates an evidence-based comprehensive “Care Guide” and “Action Plan” • GRACE (Counsell) • Initial and annual in-home comprehensive geriatric assessment by a GRACE support team consisting of an advanced practice nurse and social worker • Activation each year of indicated GRACE protocols and corresponding team suggestions • GRACE support team meeting with patient’s primary care physician to review, modify, and prioritize initial and annual care plan protocols and team suggestions • CMP (Dorr) • Reorganization of primary care through a team-based approach (RN/PCP) • Intervention based on continuity of care and regular follow-up by CC • Patient-centered assessment, comprehensive care planning, disease and self-management education • MCCD Best Practice Sites (Brown) • Clinical assessment; evidence-based guidelines and protocols • Care planning: mutual, prioritized goals/action plans • Care plan implementation (self-management strategies, service/provider coordination, reporting changes in symptoms, medications, self-management activities)

18. Comprehensive CC - Medicare/ Duals:Evidence • Guided Care (Boult) • 8 month findings of 32 month trial: • 24% fewer hospital days • 29% fewer home healthcare episodes • 37% fewer skilled nursing days • 15% fewer ED visits • 9% more specialists visits • GRACE (Counsell) • Patients at high risk of hospitalization (PRA score >= .04) in year two had significantly lower hospital rates/1000 (396 [n=106] vs. 705 [n=105]) and ED visits/1000 (848 [n=106] vs. 1314 [n=105]; P = .03) • CMP (Dorr) • Reduced 2-year all-cause mortality rates by 24% • For patients with diabetes, reduced 2-year all-cause mortality rates by 34% and hospitalization rates by 22% • MCCD Best Practice Sites (Brown) • 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)

19. Comprehensive CC - Medicaid/ Duals: Four Promising Models • Integrated Care Management (ICM) • Provides specialized care management services to: (1) complex, high risk patients; and (2) patients that require various levels of episodic supportive care management services • Community Based Chronic Care Management – King County Care Partners (KCCP) • Provides patient-centered community-based, multidisciplinary care management that empowers patients and enhances coordination, communication, and integration of services across safety-net providers to improve clinical outcomes and decrease unnecessary utilization • Hospital to Home • Patient-centered intervention designed to address the complex health and social needs of Medicaid patients to reduce health service utilization and costs to the state Medicaid program • Health Care Management Program (HMP) • Focused on improving the quality of life for chronically ill individuals living in Oklahoma, HMP is a disease management program providing nursing case management services to Medicaid recipients and practice facilitation services to primary care providers

20. Comprehensive CC - Medicaid/ Duals:Target Population • Integrated Care Management (ICM) • Intensive Care Management services are provided to complex, high-risk individuals (1% of patients) with the highest cost, highest ED visits and hospital admissions, and highest prevalence of mental illness and substance abuse issues • Supportive Care Management services are provided to individuals who have a single care issue or several issues that will stabilize or resolve within a short period of time • Community Based Chronic Care Management – King County Care Partners (KCCP) • Medicaid patients residing in King County, WA, who have received care from one of the participating primary care clinics within the past 12 months, and have been identified from predictive modeling to be at particularly high risk of future healthcare utilization • Hospital to Home • Predictive computer algorithm used to identify individuals as being high cost and high risk for future hospital admission • Typical patients tend to be frequent users of the ED and hospitals, substance abusers, have serious health and mental health issues, and tend to be homeless • Health Care Management Program (HMP) • Five percent of the total state Medicaid population (n = 5,000) with chronic illness(es), determined to be at highest risk for future utilization via predictive modeling algorithms • Patient population is divided into 2 groups: Tier 1 = highest risk (n = 1,000), and Tier 2 = high risk (n = 4,000).

21. Comprehensive CC - Medicaid/ Duals:Staffing • Integrated Care Management (ICM) • Care Management is provided by clinical care managers (RN or social worker). Non-clinical staff work on care coordination activities. • Intensive care managers have a caseload of 30 to 70 patients • Community Based Chronic Care Management – King County Care Partners (KCCP) • The intensive care management team is composed of 3 RNs, 2 Social Workers (MSW) with chemical dependency training, and a BA level individual experienced in chemical dependency counseling • Hospital to Home • Care management teams are comprised of social workers, community-based care managers, and a housing coordinator • Care manager case loads are capped at 25 patients • Health Care Management Program (HMP) • RNs with special training in care management, quality improvement methods, and organizational behavior and systems

22. Comprehensive CC - Medicaid/ Duals:Intervention • Integrated Care Management (ICM) • Assessment and Care Planning to identify the individual’s highest priority issues related to their physical and behavioral health and psychosocial challenges and interventions to help them effectively manage their own health • Align the care team and all community providers involved in the patient’s care using a comprehensive electronic health information system that can be accessed by all providers • Community Based Chronic Care Management – King County Care Partners (KCCP) • In-person comprehensive assessment and collaborative goal setting • Chronic disease self-management coaching • Joint PCP visits of patients and their care managers • Coordination of community services and care across the medical and mental health system • Hospital to Home • Multi-disciplinary care management model incorporates motivational interviewing, harm reduction, and access to housing using a ‘housing first’ approach • Communication with patients via a consistent, care management team, including a first person contact (care manager), to manage and coordinate care across multiple locations and providers • Emphasis on providing and coordinating needed medical care and mental health support either within health care or community systems and settings. • Health Care Management Program (HMP) • All patients receive comprehensive health status, health literacy, behavioral health, and pharmacy assessments • Strong emphasis is placed on self-management education and coordination of and access to community services • Nurse case management is provided face-to-face for highest risk patients and telephonically for high risk patients

23. Comprehensive CC - Medicaid/ Duals:Evidence • Integrated Care Management (ICM) • Under evaluation • Community Based Chronic Care Management – King County Care Partners (KCCP) • Preliminary results indicate: increased patient satisfaction with care, increased patient self-management and self-efficacy skills, increased primary care physician satisfaction with services provided • Health service utilization and cost outcomes are being evaluated in an ongoing RCT • Hospital to Home • Evidence from a pilot study suggests reduced hospitalizations by 38% and costs to Medicaid of $5,000/person • A formal program evaluation is currently being conducted by the New York State Department of Health • Health Care Management Program (HMP) • A comprehensive evaluation of HMP is underway • Initial findings suggest significant savings to the Oklahoma State Medicaid program

24. Evaluation: Internal • Achieving model fidelity • Comprehensive and ongoing care coordinator training • Evidence-based practice guides established and updated • Feedback provided to care coordinators on implementation of these guidelines • Tracking of and feedback to care managers on established contacts • Tracking and reporting amount of time care coordinator spends on tasks • Need web-based method to measure fidelity and generate feedback

25. Evaluation: External • Effect on hospital admissions and readmissions • Effect on medical costs • By service • Total • Return on investment • Did savings exceed intervention costs? • Effects on quality of care indicators • Screenings, preventive care, ER visits, infections, falls, mortality, etc. • Effects on patients’ quality of life

26. NYAM/ SWLI Literature Review: Purpose • Update of Best Practices in Care Coordination for older adults with one or more chronic conditions Methodology • Conducted a search in Pubmed, Cinahl,* Ageline, Cochrane, Psychinfo, and/or Soc/Index/Soc collection articles published between 2000 and 2010 in English • The Inclusion criteria • Intervention 3 months or longer • Explicit link between medical and community and long term care services • Quantitative or qualitative health, social, or economic outcomes * Cumulative Index to Nursing and Allied Health Literature

27. What Distinguishes Successful Models? Comparing Efforts:

28. What Distinguishes Successful Models? Comparing Efforts:

29. Best Practices for Care Coordination/Management Models • 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 • Being a communications facilitator • Care coordinators actively facilitating communications among providers and between the patient and the providers • Implement self management, coaching and support with patient/family • 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)

30. Thank You! • Questions?