Transforming Perspectives

1. Transforming Perspectives Effective use of Care Management services in a Value Based World

2. Disclosure • All presenters and planners of today’s activity do not have any financial relationships with any commercial interest related to the content of this activity • This activity has not received commercial support

3. Objectives • To understand the definition of Longitudinal Care Management • To understand the key strategies and goals of Care Management • To understand the importance of Care Management involvement with the transformation to Value Based Contracts

4. Michelle’s Story “You treat a disease: You win, you lose. You treat a person, I guarantee you win, no matter the outcome.” -Patch Adams Pictured: Michelle Jonassen, BSN, RN Care Manager

5. What is Care Management? • Care management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes (The Case Management Society of America, 2016: http://www.cmsa.org/)

6. Longitudinal Care Management • Supportive care of a patient and family over a period of time • Encompasses a holistic, dynamic, and integrated plan of care • Includes treatment goals and plans reflecting the patients values and preferences

7. Care Management Responsibilities • Engaging patients in their health • Patient education related to disease management and prevention • Self-management support through close follow-up as needed • Comprehensive care planning • Medication reconciliation • Transitions of care • Coordinating referrals and tests • Connecting patients to community resources • Advance care planning

8. Goals of Care Management • Help patients achieve self-management of chronic diseases • Improve coordination of care • Provide cost effective, non-duplicative services • Improve quality outcomes • Improve access to care • Increase patient satisfaction

9. Goals of Care Management Cont. • This Care Management work supports, but does not replace, the work and relationship of the care team

10. Trinity Health: People Centered 2020

11. Population Health • As defined by the CDC, Population Health is “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” It is an approach to health that aims to improve the health of an entire human population. • Care Management is an essential component of successful population health management

12. The Population Health Journey Highly Care Managed Future State ------------------------------------------------------------------ --------------------------------------------------- Traditional Model No or Little Care Management Full-Risk / Value Based Contracts Fee-for-service

13. Value Based Care • Performance-based payment or reimbursement • Payment tied to health outcomes and metrics • A tool for aligning incentives among: • Health systems, suppliers, manufacturers, employers, payers • A shared performance or risk-sharing model

14. Value Based Care

15. Value Based Contracts • Priority Health • Commercial & Medicare Advantage plans • Blue Cross Blue Shield of Michigan • Select Commercial & Medicare Advantage plans • State Innovation Model (SIM) - Managed Medicaid Plans • Trinity Health ACO (TH-ACO) - Medicare • Bundled Payment for Care Improvement (BPCI) - Medicare

16. Who Needs Care Management? • Those at risk for developing complications from poorly controlled chronic disease • Those with a new diagnosis or medication(s) and need education • Those at risk for readmission or exacerbation • Those with high and/or inappropriate service utilization • Those with multiple co-morbidities • Those with identified Social Determinants of Health needs

17. Jill’s Story Pictured: Jill Maciejewski, RN Care Manager and her Family

18. Benefits of Care Management • The shift from fee-for-service to Value Based Care has increased the need for Care Management in the primary care setting • Care Management follows the guide of the Triple Aim in caring for our at risk patient population

19. Better Health • Improving the health of populations overall • Improving quality metrics • Closing gaps in care • Addressing Social Determinants of Health • Utilizing clinical-community linkages

20. Better Care • Improving patient experience • Improving relationships and trust between patient and care team • Patients feel better as their health improves • Patients are able to set and meet health goals • Patients have direct access to their Care Manager for timely care

21. Lower Costs • Reducing hospital admissions • Reducing hospital readmissions • Reducing ED utilization • Reducing length of stay in Hospital and Skilled Nursing Facilities • Avoiding duplicative testing and services • Providing prompt care and treatment to reduce risk of complications

23. “He who has Health has Hope; and he who has Hope, has Everything.” -Unknown