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Community Based Care Management Demonstration

Project

May 22nd, 2008

Presenters: Geoff Green, Deputy Commissioner

Deborah Nichols, Director Schaller Anderson in MaineDenise Levis Hewson, Consultant

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Demonstration Project is Important Because We Can:

• Create a model that can be replicated statewide

• Build the capacity at the community level that is needed to sustain a care management program

• Meet the legislative mandate that provided a short time line for development and implementation of project

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Contracting with Schaller Anderson to do the

following:• To create the pilot model in three different

provider sites (FQHC, PHO, and Physician Practice)

• To develop selection criteria and choose the three pilots

• To contract and pay the pilot sites for community based targeted care management

• To administer the pilot program during the demonstration period

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Purpose of this Meeting:

• To provide an overview of the project: Project Assumptions Primary Goals Participation Requirements Quality and Performance Metrics Time Line

• To take a brief look at the North Carolina model

• Questions and answer session at the end of the presentation

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Community Care Plan of North Carolina --

Background• NC is mainly a rural state and not well suited for

traditional managed care

• NC is dominated by small practices and loosely organized medical systems

• The county system remains very strong

• Since the early 1990s, NC has had in place across the state, a medical home program for Medicaid recipients (PCCM – Carolina Access)

• NC Medicaid pays 95% of Medicare FFS

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Community Care Plan of North Carolina

• Built upon a statewide PCCM program: Medical Homes Population Management Approach Quality Improvement Initiatives – Performance Metrics Targeted Care Management

• Focuses on improved quality, utilization and cost effectiveness of chronic illness care

• 14 networks with more than 3500 physicians and over 800,000 enrollees (taken 10 years to get statewide)

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Community Care Plan of North Carolina

• Key Attributes of the Medical Home: Provide 24 hour access Provide or arrange for hospitalizations and specialty

care Coordinate and facilitate care for patients Collaborate with other community providers Participate in disease management / prevention / quality

initiatives Serve as single access point for patients Receives $2.50 PMPM from the State to manage

population

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Community Care Plan of North Carolina

• Community Care Networks: Non-profit organizations Includes safety net providers Steering and medical management committees Receives $3.00 PMPM from the State to hire care

managers and implement quality improvement and disease management initiatives

PCP also gets $2.50 PMPM to serve as medical home and to participate in the disease / care management and quality improvement initiatives

Must partner with health department, department of social services and local hospital (s)

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Community Care Plan of North Carolina

• Lessons Learned Started small and piloted in 9 networks with 100,000

enrollees Can’t do it alone – must partner Community ownership is important Must develop systems that change behavior Change takes time and reinforcement Need to be able to measure change Comprised of safety net providers Can be a win-win-win – for patients, providers and the

State

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Care Management Demonstration Project

Assumptions• Building upon Maine’s PCCM program – the

State is paying the “medical homes” $2.50 PMPM• Recognizing the community based infrastructure

needed to support patient centered medical homes for the chronically ill

• Targeting “high risk” patients will both improve care and contain the costs of care

• Incrementally increasing the FFS payment rate to primary care providers

• Committing to build project upon in-state physicians, hospitals and ancillary providers

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Patient Centered Medical Home Components

• Provides “continuous healing relationship”

• 24 hour access

• Use of care team

• Evidence-based treatment for chronic conditions

• Support for patient self-management

• Systematic follow-up and planned encounters

• Intensive management for high risk patients and for those not meeting goals

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Patient Centered Medical Homes Components (cont.)

• Coordination across settings and professionals

• Patient tracking and alerts• Care management• Electronic tools, such as: EHRs,

registries, etc.• Clinical performance reporting and

physician feedback

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Care Management Demonstration Primary

Goals:• Transfer the care management of

MaineCare members to community based practices

• Create a care management model that can be replicated in urban and rural areas

• Improve care while controlling costs• Fully develop the medical home model• Develop the systems needed to support

chronic illness care• Identify and stratify the population that

will best respond to care mgt. interventions

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Care Management Demonstration Sites

• There will be three pilots: 1) FQHC; 2) PHO and 3) physician practice

• Each pilot will target, at a minimum, 300 high risk MaineCare members with a maximum of 50 high risk patients per physician

• Pilots will need to meet the participation requirements

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Care Management Demonstration Quality and

Performance Metrics• Collect specified HEDIS measures

• Participate in quality reporting program (e.g. pathways, bridges to excellence)

• Pharmacy review Number of enrollees on 10 or more drugs Percent on generic prescriptions Increase in medication adherence

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Care Management Demonstration Quality and

Performance Metrics• Care Management/Coordination

Number of adult members with completed PHQ-9 Number of members with completed HRA Number of members with completed SF-8 Improvement in PHQ-9 scores Improvement in SF-8 scores Increase in self management of chronic illnesses Number of members with a care plan in place

• Cost Metrics Average PMPM costs Total costs

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Care Management Demonstration Quality and

Performance Metrics• Utilization management

Emergency department rates per 1000 Hospitalization rates per 1000 Avoidable hospitalization rates per 1000 Readmission rates per 1000 Average length of stay

• Primary Care Provider Increase in primary care visits to medical home Provider satisfaction rate in coordination of care Number of members with provider consent on care plan

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Care Management Demonstration Sites

Selection Process• Complete Application Process – must

demonstrate ability to meet minimum requirements, such as: 24 hour access Large enough enrollment and physicians to yield 300 high risk

members Ability to report performance metrics Processes to integrate behavioral health Experience and commitment in quality improvement and care

and disease management Willingness to create patient-centered care plans and perform

standardized health assessments and screenings Reconcile care management members on at least a monthly

basis, e.g. new members and members no longer eligible Stratify members by levels of risk and implement outreach

appropriate to risk level

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Care Management Demonstration Sites

Selection Process• Must demonstrate ability to meet minimum requirements,

continued: Proactively reach out to targeted members engaging them in their

healthcare and performing health risk assessments (HRA), PHQ-9 and SF-8

Develop a process to receive referrals for high-risk members not in the targeted group but eligible for care management

Develop a process to receive referral for members being discharged from an inpatient setting and following-up to ensure members are incorporated back into the practice and the community

Targeted education to meet members specific needs Actively use SAMAI web-site tools Identify a physician champion for the project Implement disease management initiatives Assist with social, mental, economic and physical referrals Coordination of services with other health care providers Conduct home visits, as needed

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Care Management Demonstration Sites

Selection Process• Complete sign in sheet and indicate

interest to obtain an application form

• Expert review panel to review applications

• Panel will choose one site only for each provider group for this demonstration

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Schaller Anderson Responsibilities for

Demonstration

• Assume full responsibility for the development and implementation of the pilot

• Develop a care management project work group to monitor the project, share data and develop new disease and care management initiatives

• Utilize the “Predictive Pathways” risk stratification methodology to identify high risk enrollees for each site

• Provide each pilot site with a list of high risk patients and their utilization and cost data on a quarterly basis

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Schaller Anderson Responsibilities for

Demonstration

• In concert with work group and the State, identify the quality and cost metrics to use in monitoring and evaluating the project

• Educate sites on performance metrics• Create quarterly reports for each site that tracks

their impact on the performance measures• Provide regular reports on the progress of the care

management demonstration project• Conduct a patient and provider satisfaction survey• Be available to the projects sites for consultation,

support and technical assistance

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Summary of Key Dates

• May 23, 2008 Application Released• June 6, 2008Written Question Due• June 11, 2008 Responses to Questions• June 18, 2008 Applications Due• June 26, 2008 Award Three Contracts• July 1, 2008 Project Start Date

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Care Management Demonstration Contact

Information

Deborah Nichols, Executive Director

Schaller Anderson Medical Administrators

207 Larrabee Road, Suite 6

Westbrook, Maine 04092

Telephone: 207-464-0350

Email: deborah.nichols@schalleranderson.com