0 redesigning care for those who need it most…. our mission to address the complex problems of...
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REDESIGNING CARE FOR THOSE WHO NEED IT MOST…
Our Mission
To address the complex problems of aging while protecting the precious financial resources of our members and the federal government.
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Las Vegas
3,852
Tucson8,682
Nevada
Arizona
San Jose3,425
Modesto3,828
San Bernardino3,328
LA/OC38,035
A Deployable Model Wrapped in Health Plan
Our Markets
Riverside875
Phoenix3,849
Source: Management estimates for membership for the year ending 12/31/11
California
CONFIDENTIAL MATERIAL
Virginia
Richmond
2013
Expansion
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Our Philosophy of Health Care
Older patients require overtly coordinated care with a care path that takes into account their multiple conditions and treats them simultaneously
A physical and human locus of care is required to create care coordination and a setting where care habits of patients can be sustained.
Clinicians in key roles must be confident generalists, persistent and deliberate, with competence as clinical decision makers, communicators and team players.
All providers of service have a buy-in for the system of care, not just their individual capabilities.
A complete care continuum requires equal attention to medical, social, psychological and pharmacological needs of the patient.
An explicit approach to care is required for each chronic condition, for high-frequency acute episodes, and for end-of-life.
An obsessive attention to detail in both micro matters (individual care) and macro matters (care programs) permits optimal outcomes
A willingness to thoughtfully challenge the status quo provides windows of insight into clinical innovation and care pattern redesign which can optimize patient health and comfort, and conserve financial resources.
Challenging the Status Quo Health care systems should be about improving quality, not maintaining it
At least 35% of health care costs for the chronically ill can be avoided
Prepayment (Capitation) is freedom, not risk
Primary Care is a “team sport” not an “individual sport”
For aging adults, Primary Care should be an outbound activity, not an inbound activity
A high percentage of physician services can be provided by non-physician clinicians
Benefit design should lead with patient access and compliance considerations, not actuarial risk considerations
Patient compliance is more our problem than the patient’s
We have a responsibility for the financial well-being of our physician and hospital partners
Many patients fare better with less complex health care interventions
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The CareMore Model
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Healthcare cost and quality problems are concentrated….not widespread
Healthy Stable Sick Sickestmostly 1 + Chronic Illness mostly 3 + Chronic Illness
Progressive Illness2010 MedicareSpending Projection = $522 B46 Million BeneficiariesSpending Per Beneficiary = $11,347
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
Ann
ual Cos
t/Be
nefi
ciar
y 23 Million Beneficiaries- Spending $1,130 each- Total Spending = 5%
($26 B)
16.1 Million Beneficiaries- Spending $6,150 each- Total Spending = 20%
($104 B)
7 Million Beneficiaries- Spending $55,000 each- Total Spending = 75%
($391 B)
AverageSpending
CHF, DM
85% of Beneficiaries = 25% Spending 15% of Beneficiaries = 75% Spending
ESRD, CANCER
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Non-Frail Population
CareMore’s system functions in parallel with community physicians
Primary Care
Physicians
Extensivists
Member Services
Continuous Frailty Assessment Tools
Provider Relations
CareMore Care
Centers
CareMoreExtensivist
CareMore Care
Centers
Home Based
Services
Specialists
Case Managers
Primary Care Physicians
Close monitoring of non-frail members to proactively identify at-risk members and aggressive management of chronic conditions to prolong the onset of frailty
Intensive management of frail and chronically ill members, identified through predictive models, data scans, PCP referrals or member self-identification
Frail & Chronically Ill Population
The essentials of CareMore’s model
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Chronic Care Management
Acute CareManagement
Predictive Modeling & Early
Intervention
Redefining Primary Care
Operating Principles
Clinical Control - CareMore extensivists determine when a patient requires proprietary services and programs
Speedy Deployment - Proprietary services and programs can be deployed within minutes
Efficient Allocation of Clinical Resources - The model replaces physician labor with skilled, allied health professionals such as NPs, MAs, therapists and dieticians
Early Intervention - Proprietary resources and predictive modeling allow for early intervention to prevent acute episodes
Secondary Prevention
Redefined Acute Care Episode
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CareMore solution – new model of care
Predictivemodeling
Integrated IT infrastructure
Longitudinal patient record
Point-of-care decision support
Evidence-based protocols
Extensivist Manageme
nt Strength Training
Fall
Coumadin
Exercise
Foot care
Nutritionist
Monitoring
Diabetes
ESRD
COPDCAD
CHF
Palliative Care
Hospice
Mental Health
Social Workers
Pre-Op
Case Manager/
NP
Extensivist
ClinicalCare Centers
(CCC)
PCPEnd of Life Care
Social / Behavioral
Support
Secondary Prevention
Risk Event Prevention
Chronic Disease Support
Frailty Support
Healthy Start
Wound Clinic
Results of the CareMore Model
Primary care physician value proposition
CareMore programs provide the PCP with resources that enable better clinical care
Medical Home (CCC) Chronic programsPreventive care
programs
TechnologyCommunications tools
Increase PCP Compensation
Medicare FFS pays the PCP $67 per visit (CPT code 99213) -- an average of $480 patient / year (assuming 7.2 patient visits a year)
CareMore guarantees the PCP $480 ($40 PMPM) but visits are only 4.5 per year and we pay $107 per visit
Increases PCP Schedule Capacity
Better Patient Care
CareMore clinicians and programs relieve PCPs of their most complex chronically ill and frail patients
Increases PCP capacity by 20% to 30% -- can add more patients to increase pay
More resources used to support the PCP funded by CareMore prepayment
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Unique PCP value proposition has served CareMore well in new markets
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The CareMore model produces dramatically improved outcomes for several costly chronic diseases and conditions
Many patients with out-of-control diabetes were not brought in control through insulin use. Common wisdom was that inability to correctly self administer or improper dosing were driving results. Further, insufficient support in the areas of nutrition and exercise were observed
Established insulin “starts” and insulin “camps”. At the “start” day, patient is trained in all aspects of self-administration of insulin. At “camps”, patients are brought to the center for a full day to observe all of their behaviors and monitor glucose levels at all points of self care. A personal nutrition counselor was assigned
Average HbA1c for those attending our diabetic clinic is 7.08, with 7.0 being considered good control. Patients in the clinic are referred for poor control
50% reduction in hospital admission rate in 5 months
42% fewer admissions than the national average
Established a dedicated case manager and nurse-practitioner who receive referrals from centers in lieu of ER referral. Primary/preventive care is provided and all patients are in the diabetic management program, receiving monthly preventive access line inspection and, if needed, cleaning
Half of all ESRD Admissions were the result of either poor hygiene, poor diabetic control or vascular access limits/clogs. Dialysis centers provided no primary care and patients were referred to the ER. Most ER visits resulted in an admission
56% reduction in hospital admission rate in 3 months
Equip each patient with a wireless scale that sets off alerts if weight gain is 3 lbs overnight or 1 lb per day for more than 3 days. Same-day visit with clinician if alert is triggered. Proactive hospice planning with changes in condition
PCPs were not collecting daily weights, a leading indicator of change of condition. Self-reported weights were inaccurate. PCPs were not adequately responsive to immediate care needs of patients who require intervention within a few hours of onset of symptoms
Diabetes ESRD CHF
Status quo Status quo Status quo
CareMore Redesign CareMore Redesign CareMore Redesign
Result Result Result
The CareMore model produces dramatically improved outcomes for several costly chronic diseases and conditions (cont’d)
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70% of hypertensive patients do not have adequate blood pressure control. This leads to increased stroke (and other cardiovascular) risk. Blood pressures checked in PCP offices frequently are inaccurate.
Equipped patients with labile HTN with wireless blood pressure cuff. CareMore NPs monitor blood pressure & make appropriate changes according to JNC guideline.
• 48% of patients had >10mmHgs drop in blood pressure
• Patients with SBP>160 or higher had average SBP drop of 23 mmHg
• Patients with SBP b/n 150-160 had average SBP drop of 19mmHg
Diabetic amputation rate for CareMore members is 60% lower than the national average.
Designed a wound clinic, staffed with wound-certified CareMore NPs.
PCPs have inadequate time/resources to deal with diabetic wounds, which results in specialty (surgical) referrals that delay treatment, increases cost and increases chance of amputations.
Early diagnosis and then intervention at CareMore’s mental health centers
(19% of screened)
All new CareMore members receive a comprehensive health exam that includes PHQ-9 & dementia screen.
Depression is a underdiagnosed problem in seniors. Underdiagnosed depression leads to a variety of health problems and costs including ER visits & unnecessary tests.
System Failure System Failure System Failure
Result Result Result
CareMore RedesignCareMore Redesign CareMore Redesign
Stroke Prevention Amputations Depression
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Inactivity and some staffing issues (one monthly visit/60 days), lack of primary care in facilities resulted in wound development or exacerbation (for example bed sores)
Deployed nurse practitioner teams to nursing homes weekly to proactively tend to skin or create early intervention in patients likely to develop wounds
The CareMore model produces dramatically improved clinical outcomes for several costly chronic diseases and conditions (cont’d)
CareMore sends a nurse practitioner to the nursing home once a week to keep patients stabilized. If an acute event emerges, an NP is available 24x7 for telephonic consultation and in-person visits if needed
Patients in institutional settings were being hospitalized at a rate of 5x the general populations for untreatable conditions, largely because nursing homes do not have skilled clinical staff to make timely interventions
CareMore assembled a team of clinical social workers, mental health professionals, lawyers, physicians and NPs who assume a home-based multi-disciplinary care approach for these patients
A small fraction of the Medicare population are hospitalized >10 times per year because of lack of home-based or social support resulting in falls, malnutrition, dehydration. Most live alone and suffer from dementia or other mental illnesses
Wounds Institutional CIT1
Status quo Status quo Status quo
CareMore Redesign CareMore Redesign CareMore Redesign
The usual rate per year for development of pressure ulcers for nursing home patients in California is 13% Only 4% of CareMore’s institutionalized patients developed pressure ulcers
Preventive intervention resulted in reduction in bedsores and reduction in falls. Hospital admission rates are 80% less than national norms
Reduced hospital and SNF admissions by 60%. Resulted in placement rate of >30% for participants
Result Result Result
1 CareMore Intervention Team, which includes the Company’s expert team of providers
Sharing the CareMore Model
PCP Capitation
Variable-Cost BasedHospital per Diem
All else actual cost
Physician Services
Hospital Services
Market Branding
MA License & Marketing
Chronic Care Infrastructure
Existing Membership
Presbyterian Community Hospital (Whittier CA) Experiment
Results sharing with hospital and physicians
10-Year Contract
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Lowest Medicare Variable CostReduction in Surgical ComplicationLowest rate of Death-in-Hospital
4% better readmission rate7 minute response-time
Joint Steering Committee
CareMore Supplies the Architecture to Succeed in Risk Based Environment
Creates Primary Care Capacity
Enables Primary Care Profitability
Improves clinical outcomes in chronic care management
Improves hospital quality
Lowers hospital variable costs
Embraces transition to risk-based payments
Supports Evidence-based documentation
Partnering, Sharing the CareMore Model
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CareMore
CareMore Inside
CareMore Essentials
• Transference of care delivery competency
• Provide enabling infrastructure
• Share in HCC savings
• Direct care delivery
• High risk populations
• HCC savings accrue to client
• Fee-based structure
Patient Care
Disease Mgmt
Data Integrati
on
Clinical Protocols
Risk Coding
Analytics
Reporting
Payment Models
Case Mgmt
Predictive
Modeling
Quality Initiative
s
Training
Realizing Value From Your Integration Journey
• Vision of Improving the Health of Your Communities
• Proactive and Targeted Population Health Initiatives
• Turning a Health Improvement into an Accretive Event
• Seeing Capitation as Freedom, Not Just Risk
• Imagine a Delivery System that Creates Value From:
• Better Management of Chronic Conditions
• Better Quality of Life for Your Frail Aged Community
• Better/Safer Care
• Rethinking How You Measure Market Share
• % of Volume?
• % of Population Under Your Care?
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