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CARE MANAGEMENT: Bending
in the winds of reform
Patient-Centered
Outcome-Driven
Dana Deravin Carr, Dr. PH, MPH, MS, RN-BC, CCM
Senior Care Manager/ Transitions Coordinator
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Common Themes
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Accountability
Sustainability
Efficiency – Care and System
Effectiveness – Cost, Care and System
Communication
Coordination
Collaboration
Leadership, Followership and Mentorship
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What do we want to accomplish today?
Gain knowledge and understanding of:
 Trends associated with health care reform and identify
changes reflecting the new health care system including
patient-centered deliverables
 The concept of bending the cost curve
 The concept of DSRIP and the goals of the Triple AIM
 The difference between the Medical Care model vs PCMH
model
 The patient role in facilitating self-directed care
 See Motivational Interviewing as an important CM function
in promoting patient self empowerment and self advocacy
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The Stormy Seas of Health Care
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A CHANGING HEALTHCARE INDUSTRY
• Changes in Reimbursement practices
– Fee For Service
– Prospective Payment System
– Managed Care
• Escalating Healthcare Cost
– aging patient population
– increases in chronic illness
– Poorly managed behavioral health component
– medical technological advances
complex, high tech and minimally invasive surgery
life-prolonging treatments
• Increased Patient Acuity
• Shortened Hospital LOS
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Pre-Reform Financial Trends
• The cost crisis of our economy is due in most part to the
health care crisis
– Of the two trillion dollars spent on US health care patients
with chronic diseases account for 75% of health care cost
• Of every dollar spent…75 cents went towards treating
patients with one or more chronic illness AND
• In public programs, treatment of chronic diseases
constitute an even higher portion of spending:
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The great escape to no where…
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Silos - Compartmental
Provider Centered
Uncoordinated
Limited Health
Information sharing
• Little meaningful
accountability for
results (lack of
transparency)
• Underinvestment in
primary and
preventative care
• System fails the most in
need the most often
• Health care
infrastructure that
doesn’t match
community need
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US ranked last among the wealthiest nations:
1. United Kingdom
2. Switzerland
3. Sweden
4. Australia
5. Germany & Netherlands (tied)
7. New Zealand & Norway (tied)
9. France
10. Canada
11. United States
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What we know…
• US healthcare is unsustainably expensive
• As a nation we have terrible healthcare for
populations
• Best healthcare in the world for few of the
very sick
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The Call for Health Reform:
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Health reform is largely built around
the changing role of primary care
• If primary care is to be the hub of the health
care wheel, instead of a feeder for the hospital
and specialty system, it has to be enhanced.
How?
• By changing and integrating systems
• Developing models that support patient
centered care: PCMH and ACO’s
• Innovation, technology and transparency
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Moving towards VALUE
• By focusing on the “Health” in Health Reform
Legislation we can show that:
• Better Health + Better Health Care = Greater
Value (Higher Quality/Lower Cost
BH + BHC = GV (HQ/LC)
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Providing Health Care NOT Sick Care
• Results oriented
• Payments based on
delivering value to
patients
• Continuum based
collaborative care
• Rebalanced Health Care
structure that meets
the community’s need
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Integrated
Patient Centered
Coordinated
Accountable
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What does it mean to bend the healthcare cost curve?
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Evolving MEGA Trends in healthcare
Consumers take charge
The insured consumer leads to increased
engagement and increased consumer
responsibility
More with less – From Volume to Value
Healthcare everywhere – CVS. Walmart
Mega Health Systems – Consolidation
States are key players – Medicaid transformed
through DSRIP
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Trends in healthcare con’t
Integration of medical care, behavioral care, public
health
Movement of high cost/high risk consumers into
Managed Care
Value through data (clinical trials)
Predict prevent and personalize (expanding the role
of life science)
The New “AGED” will increase demand for caregivers
Global Healthcare – medical tourism
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10 Health Care Reform issues transforming case
management
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Chronic disease management
Care transitions
Quality reporting requirements
ACO’s - embedded case management
Large DATA Expansion of health insurance
Primary care provider shortage – solutions-condensed GME/ more physician extenders
• State Action – DSRIP
• Implementation Challenges
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The Role of Case Managers in
Emerging Care Delivery Models
• The changing landscape for care managers in
Medical Homes and ACO’s
• Case Managers gaining increased recognition
as facilitators of patient centered care
• Employ an empowering and supportive role
with patients and caregivers
• Professional case management is a critical
component of improving care coordination
• Embedding Case Managers into primary care
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AND EVOLVE!
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The 21st Century Care Manager
• Promotes collaborative partnerships with the entire health
care team that includes the patient and their identified
support system
• Continuously collaborates and communicates with
Healthcare Team and the patient.
• Creates and implements a synchronized care plan that crosses
the boundaries, promotes continuity and builds continuum
based relationships
• Coordinates care and contemplates the patient holistically –
including the social and psychological aspects
• Promotes Client self determination
• Watches the fiscal bottom line regarding care and works with
the entire team to implement the best options
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What skills and knowledge do you need to be even
more successful as a 21st Century Care Manager?
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Step out of your comfort zone
Develop and build relationships
Find/Be a mentor
Understand the numbers
Value your work
Develop yourself professionally
Realign your goals to fit the new paradigm,
AND Develop a patient centered mentality
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“More” does not mean “better”
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Patient Centered Care
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Patient Centered Care: What does it look like?
http://www.pickerinsititute.org
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Medical Model vs. Patient Centered
Model
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By adopting a transition outlook that targets:
Medication Adherence
Care Transitions Management
Reducing Readmissions
Case Management
Patient-Centered Medical Home – Embedded Case
Management
Understanding and Advancing Health Literacy
Coaching strategies that incorporate Motivational
Interviewing techniques
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Empowering the patient’s voice
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Nothing about Me without ME
• A patient is an individual to be cared for not a
medical condition to be treated
• Treatment and care should take into account
patient’s individual needs, preferences and ability
to process and understand health information
• Good communication is essential supported by
evidence based information to allow patients to
reach informed decisions about their care.
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Transforming the Conversation
through Motivational Interviewing
• Encouraging patients to set and achieve goals for
health maintenance and disease management
• Engaging patients in active (non-pharmacological)
management of chronic pain
• Addressing issues of problematic alcohol, opiate, and
other drug use
• Improving patient's medication adherence
• Promoting engagement in other evidence based
behavior changes approaches, such as CognitiveBehavioral Therapy
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Principles of MI
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Expressing empathy
Supporting self efficacy
Rolling with resistance
Developing discrepancy
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Strategies of MI
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Open ended questions
Affirmations
Reflective Listening
Summary Statements
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A Patient’s Voice
If you had any advice to people that work in the clinic to
make information they give you easier to understand, what
would you tell them to do?
“I would tell them that they need to write it – not in
cursive, in print, and to use small words so I can read it.
You see, I can hardly understand those real big words. You
have to break down the syllables to understand the big
words.”
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*Used with permission
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Delivery System Reform Incentive Payment (DSRIP)
• States establish a framework for projects and objectives that
Center for Medicare and Medicaid Services (CMS) approves.
• Entities eligible for DSRIP funds select targets and approaches
from this framework, and shape a tailored plan on how their
entity will meet those goals. This plan must receive state and
federal approval.
• A reporting structure is assembled, activities conducted, and
data driven progress reports are is provided to the state.
• Some DSRIPs require hospitals to partner with other providers
to be eligible for funds. This establishes a common financial
interest and alignment across providers to affect change.
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Core Strategies
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Care Management for all
Global Spending Cap
Health Homes
High Quality Primary Care for All
Address the Social Determinants of Health
Promote Health Literacy across the
continuum
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What is happening in NYS?
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Delivery System Reform Incentive
Payment (DSRIP)
• Started as Medicaid Redesign Team Waiver
Amendment 2011
• Now restructured to DSRIP—incorporates Behavioral
Health, Long term care workforce, and Home health
development.
– Criteria for participation – hospitals must be public , critical
access or sole community hospital
– Minimum threshold of Medicaid, uninsured and dual
eligible patient volume – 30% inpatient and 35%
outpatient OR
– Hospital serving more than 30% of MA, dual eligible or
uninsured in a county or multiple county region
– Must be a safety-net provider
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What is the Current State of NYC HHC
• Complicated delivery system - . The NYC public
health hospital corporation comprises 11 public
hospitals, six SNF’s one home health agencies
spans five boroughs and serves over 250
languages.
• Complex system leads to failure to deliver
appropriate level of care, over utilization and ED
services and repeated readmissions
• DSRIP Provides and opportunity to provide
transformational change
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HHC Program Goals (1)
• Build Health Literacy
– 2/3rds of U.S. adults ≥ 60 yo have inadequate or
marginal literacy skills
– 81% of patients ≥ 60 yo at a public hospital could
not read or understand basic materials such as
prescription labels
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Appointment
Reminders
Kind,
Supportive
Staff
Medication
Review (Brown
Bag)
Phone FollowUp
Health
Literacy Best
Practices
Shared
DecisionMaking
Confirm
Understanding
(Teach-Back
Method)
Treatment
Simplification
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HHC Program Goals (2)
• Build Care Teams that include the patient
• Engage physicians and the team in the work
flow processes
• Mentor and support patients
• Affect population health by building self
efficacy and self esteem
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“High Risk Transitional Care Teams”
•Identify using combination of clinical and
non-clinical criteria
•In safety net – use a multi-disciplinary team
•Address full complement of medical, social,
logistical needs
•Don’t over medicalize – whole person,
psychosocial
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Jacobi Medical Center
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What keeps you up at night?
The Scream..Edward Munch, 1893
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Dr. Dana’s Transitional Care
Heart Failure Project
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The Portrait of Heart Failure
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Project 2.b.iv: Care Transitions
Intervention Model
• 30- day supported transition period after
hospitalization for patients at high risk of
readmission, particularly those with cardiac,
renal, DM, respiratory, and/or behavioral
health dx
• Transition case manager working 1:1
• Identify risks/barriers and find solutions
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Transforming Care at the Bedside
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Communication is fundamental
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Continuing Patient Centered Care
Post Discharge
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Strengthen weak linkages by adopting a transition
outlook that:
Supports the patient throughout the 30-day high risk
period
Emphasizes patient/caregiver education
Supports Medication Adherence
Builds patient centered collaborative relationships
Reduces ED visits and Readmissions
Empowers and encourages patient/caregivers to take
an active role in their care
Builds Health Literacy
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Post discharge calls & care coordination
• Within 72 hours of discharge
• Over a 30 day period, the Care Manager will:
– Confer with Home Care Provider after initial visit for
medication reconciliation, plan of care and planned visit
frequency
– Collaborate with PCP and care team to resolve problems
and provide clinical updates
– Educate patient regarding disease processes and care
interventions
– Promote self directed care, ensure access to care and
empower patients to facilitate problem solving
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Discharge from Care Transitions Program
• Patient will be discharged from Care Transition
Program:
– If Patient/caregiver request discontinuation of
Care Transition services
– If Patient is admitted to an inpatient setting
• Patient no longer requires this level of intervention
as evidenced by:
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Patient no longer requires this level of
intervention as evidenced by:
• Patient/caregiver ability to self-manage
• Goals of care have been achieved or patient is
progressing to desired state
• Patient has established community Primary
Care Provider engagement
• Risk reduction interventions that address risk
factors implemented
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Ensure a warm “hand off” to the
next provider
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This looks like a good outcome
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This is the IDEAL State..
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And perhaps for some of us….THE BOOMERS..to
this “IDEAL” state!
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References
• Auslander,E. & Carneal, G. (2013). 10 healthcare reform issues
transforming case management. Case –In – Point. 11(11) p. 1.
• Chernof, B. (2014) Achieving Patient Centered Care. United Hospital
Fund.
• Congressional Budget Office (2010). The long-term outlook for
healthcare spending: A CB study. Retrieved from
http://www.cbo.gov
• NPR Blogs (2014) A hospital reboots medicaid to give better care for
less money. Retrieved http://www.npr.org/blogs/health/2014
• United Hospital Fund (2014). A professional coordinators guide to
partnering with family caregivers. Retrieved from
http://www.nextstepincare.org
• Altman, D. (2014) A Perilous Gap in Health Insurance Literacy. The
Wall Street Journal. Retrieved from
http://blogs.wsj.com/washwire/2014/09/04/a-perilous-gap-inhealth-insurance-literacy/
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ACO
PCMH
• Personal physician, focus on
patient-physician relationship
(single practice)
• Physician-led team
• Whole person model of care,
patient and family-centered
• Enhanced access to care
• Care coordinated, integrated
• Comprehensive, continuous care
• Continuous improvement
• Quality and safety, guide all care
individual/population
• Payment supports patientcentered care, and is value
driven
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Provider-led organization, multiple providers,
practices organized
Culture of teamwork
Complete and timely information about
patients and services provided
Resources & support for patient education
and self management
Coordinated relationships of PCP with
specialists and other providers
Population based continuum of care
management
Accountable for quality and safety
Technology and skills for population
management and coordination of care
Ability to measure and report on quality
Accountable for overall costs
Infrastructure and skills for management of
financial risk
Leaders committed to improving value of
health care services
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