Care Coordinator

Report
COMPREHENSIVE PRIMARY CARE INITIATIVE
Redefining value and healthcare delivery in Primary Care
SEPT 2013
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“Primary care is critical to promoting health,
improving care, and reducing overall system
costs, but it has been historically under-funded
and under-valued in the United States…
Many studies suggest that it costs less to provide
healthcare to patients who receive care from
primary care practices that offer comprehensive
services compared to those that don’t provide
such services.”
-CMS, 2012
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WHAT IS CPCi?
Definition
A four-year pilot program, incorporating both public and private payors, to
transform the delivery and reimbursement of primary care by placing
emphasis on comprehensive primary care and care
coordination/management.
Cincinnati/Dayton/N. Kentucky Pilot
 10 payors
 44,000 lives
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16 TCHP primary care
9 MOB 440
practices
MOB 334
Delamerced
Hyde Park Family Medicine
Walnut Internal Medicine
Redbank Internal Medicine
Delhi Internal Medicine
Forest Hills
Compton
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Madeira
Norwood Family Medicine
Rookwood Internal Medicine
Westside Internal Medicine
Mason
Hyde Park Internal Medicine
Norwood Internal Medicine
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WHAT IS THE CPCi VALUE PROPOSITION?
 Years 1 & 2:
Payers provide additional per-member, per-month (PMPM) payments for
investment in infrastructure (practice, staffing, IT) which will enable the provision
of more coordinated, comprehensive primary care.
 Years 3 & 4:
Less PMPM payments; opportunity for shared savings
Step 1
Additional PMPM
Payments
$$$$
$$$$
$$$$
Step 2
Step 3
Enable Comprehensive
Primary Care
Achieve Healthcare Triple
Aim
Enhanced
Comprehensive
Primary Care&
CareCoordination
=
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PATIENT CENTERED MEDICAL HOME
PCMH is a philosophy of patient centered care delivered through a
team based approach to provide comprehensive services.
PCMH laid the foundations for comprehensive primary care (CPC)
Key Enhancements to PCMH foundations:
1)
Alternative reimbursement: Additional PMPM funding
a.
2)
Can be used for CPCi purposes only
5 Core Functions
3) 9 Milestones for Year 1 aligned with core functions
4) Quality measures
a.
19 Measures in Year 1 to establish baseline
b.
21 Measures in Year 2 to measure improvement
5) Access to Payor information and internal reports
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BUILDING A TRUE MEDICAL HOME
Care Coordination
Personnel
IT Infrastructure
Enhancements
PCMH FOUNDATION
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WHY IS THIS IMPORTANT... THE TIME IS NOW
• Reimbursement methodologies are changing
•
Change from fee-for-service (FFS) to pay-for-performance (P4P)
•
Government and Payors scrambling to bend the cost curve; many pilots
• Provision of Comprehensive Primary Care has been shown
to drive down costs
•
Reduce redundant tests and services
•
Provide proactive care to keep people healthy and out of more costly sites of care
• Puts practices ahead of the curve; at forefront of change
•
More prepared for more P4P methodologies
•
Get funding to invest in necessary infrastructures
o Care Coordinators, Care Manager
o IT Enhancements to allow patient and population management
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THE FRAMEWORK: 5 CORE FUNCTIONS OF CPC
Risk-Stratified Care
Management
• Identify patients with chronic conditions and more robust
healthcare needs. Deliver intensive care management for
patients with high needs.
Access & Continuity
• Ensure patients and providers can access patient data tools
24/7 for real-time, patient information necessary to
continually provide the highest levels of coordinated care.
Planned Care for
Chronic Conditions
& Preventative Care
• Proactively manage patients to determine their needs and
provide timely preventative care services.
Patient & Caregiver
Engagement
• Actively engage patients and families in goal setting and
decision making to increase patient buy-in and adherence to
care plans.
Care Coordination
Across the
Community
• Primary care teams will coordinate with other health
providers to effectively communicate key patient information
during transitions in care or referring to other providers.
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9 MILESTONES FOR YEAR 1
1)
Budget forecast
2)
Care Management of high risk patients
3)
24/7 access by patients
4)
Improve patient experience
5)
Use data to guide improvement*
6)
Care Coordination
7)
Shared Decision Making
8)
Participation in CPC learning collaborative
9)
Meaningful Use Stage 1
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MODEL FOR CHANGE
Improve Care Coordination and Care Management (CCM) by:
1)
Addition of Care Coordination personnel
i.
Care Managers
ii.
Care Coordinators
2) IT Infrastructure Enhancement
i.
Kryptiq’s Care Manager solution
Focus on 5 priority Conditions
i.
ii.
iii.
iv.
v.
Diabetes
CHF
CAD
COPD
Cancer
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ADDITIONAL CARE COORDINATION PERSONNEL
RN Care Manager
Responsible for care management of the high risk population through
disease management and care transitions. This will be accomplished
through face to face and telephone interactions with patients to promote self
management skills through education and support.
Care Coordinator
Responsible to facilitate pre-visit planning, referral management and
proactive outreach for overdue appointments/labs. The care coordinators will
also be trained in behavior and lifestyle coaching to help your patients reach
their personal health goals.
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IT INFRASTRUCTURE ENHANCEMENT
IT solution needed to allow effective, convenient CCM:
Kryptiq’s Care Manager solution
 Comprehensive, point-of-care and population management solution
 Fully integrated solution in Epic
 Enhances current Epic functionality

Population Dashboards

Point–of-Care (POC) tools

Patient Engagement
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CARE MANAGER- POPULATION DASHBOARDS
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CARE MANAGER - POC PATIENT MANAGEMENT TOOL
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CARE MANAGER- PATIENT ENGAGEMENT
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CHALLENGES
Culture Change for Providers
• Team based care
• Proactive management
• Standardized Care
Culture Change for Patients
• Self Management
• Empowerment
Continued Funding
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IS IT WORKING?
Care Transitions
Evelyn is a 72 y.o. with a h/o Angina, HTN and COPD. She admitted to the hospital with c/o HA
and R sided weakness. Upon discharge Evelyn was sent home on Atenolol 75 mg/day. Prior to
admission Evelyn took Tenormin 75 mg/day and once at home continued to take both
medications because she did not understand they are the same drug. The RN Care Manager
called the patient, identified the error and educated the patient on Generic vs. Brand named
medicines. The Care Manager assisted her in creating an accurate medication list to keep with
her at all times. A potential adverse outcome was avoided as a result of this call.
Christina is a 52 y.o. female with a recent emergency room visit. The RN Care manager at her
PCP office received an alert of the visit and reviewed the patient’s chart. She discovered the
patient had not bee seen in the office since January 2012 and is a diabetic. The Care Manager
reached out to the patient and discussed diabetes management. Christina had not been caring
for herself and was receptive to coming in for an appointment and follow up with the Care
manager. She agreed to attend the recommended diabetes education classes and to continue
communicating with the Care manager to make needed lifestyle changes.
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IS IT WORKING?
Chronic Disease Management
Sally is a 64 Y.O female with uncontrolled diabetes. Her PCP asked the RN Care
Manager to start working with Sally to control her blood sugar. The Care Manager
began calling Sally daily to track her morning blood sugars. Her average readings
ranged from 350-400. During their calls they discussed Sally’s diet, medication
regimen and activity. It became apparent that Sally did not have a good
understanding of how to manage her disease nor did she believe she had any
control and was resigned to the idea that nothing could change. The Care Manager
starting researching and found her endocrinologist and made a call to his Nurse
Practioner. The patient was scheduled for an appointment with endocrinology that
week so additional time was added to the appointment to provide education time.
After her appointment the Care Manger continued to call the patient and she noticed
a dramatic improvement in the blood glucose levels. Today the patient is reporting an
average blood glucose of 120 every day and she is feeling empowered to manage
her disease.
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CPCi RECAP
• 4-year pilot to determine if alternative reimbursements and
CPC will accomplish The Triple Aim
•
Triple Aim: Better Population Health, Better Patient Experience, Lower Costs
• CPCi builds upon PCMH foundations
• Funding to be invested into practices’ infrastructure
•
Additional Care Manager and Care Coordinator staff
•
Epic Enhancements through fully integrated Care Manager tool
• Focus on High Risk patients
•
Will expand to all 5 priority conditions
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WHAT ARE YOUR THOUGHTS
QUESTIONS?
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