Planning a New Care Management

ProgramNASHP Pre-Conference Sponsored

by AHRQCheryl J. Roberts, J.D.Deputy of Programs and OperationsDepartment of Medical Assistance ServicesCommonwealth of Virginia Sunday, October 2, 2008

Presentation Overview

Virginia Program Overview

Weddings and Care Management?

Wedding and Care Management Planning Tips

Closing and Questions

Virginia Medicaid

Currently cover 700,000 recipients. Expend about $6 Billion per year. 55% of participants are in a Managed Care

Organization; including the ABD population. 70% of funding goes toward long-term care and services

for individuals with disabilities. LTC is community focused: HCBS waivers, 7 PACE

sites, Money Follows the Person, and VALTC pilot (the integration of LTC and managed care).

Virginia has operated a disease management (DSM) program since 2006.

Implementing a chronic care coordination program in 2008.

Disease Management (2006)

Program operational since 2006 under DRA provision. Voluntary enrollment, telephonic program. No of enrollees: high intensity 2,000; low intensity 3700. Five disease states: CAD, CHFD, COPD, asthma, and

diabetes. Developed as a quality initiative and uses HEDIS-like

measures. Health Management Corporation handles DSM contract for

DMAS FFS, state employees, and largest Medicaid contracted MCO.

All VA Medicaid MCOs must have DSM programs for same 5 conditions.

Chronic Care Management(projected implementation date 1/2009) More holistic program for FFS recipients who have

high dollar claims and unmanaged care. Will use predictive modeling tool, assessments and

telephonic and face-to-face case management services.

Voluntary enrollment in two tiers: high and low. Excludes the 5 DSM conditions. Developed as a quality and cost savings measure. Developed SPA under DRA provision. RFP released July 2008, responses due at the end of

September 2008.

Planning a Wedding and Developing a Care Management Program

What could they have in common?

A Lot!

Planning Tips for Weddings and Care Management Programs

Wedding Tip No. 1: The Groundwork

A good wedding starts with a great plan and a great man.

By sticking with the plan, hopefully you will end up with the great plan and man!

Vision Project planning Implementation

Care Management Tip No. 1: The Groundwork

Vision – Select the type of program you want: look at other state models,

private sector, industry trends, your own state structure and infrastructure. Document plans and concepts as a blue print.

Planning : Determine what federal and state approval and budgetary support

you will need and how to obtain it. Find a someone to lead and champion program. Join entities like ARHQ to assist you in network and program

development. Implementation

Develop a project plan. Place contingencies in the plan. Keep track of major items. Get support for interfaces, research, and data analysis Ensure implementation stays in line with vision.

Wedding Tip No. 2:

There is no need to send out formal invitations anymore.

Use Evites, texts, You Tube, web sites and Facebook.

For the few people over age 90 for whom you have to use snail mail; download invitations from the web and generate them on your computer.

No one RSVPs anyway!

Communications Strategy

Care Management Tip No. 2: Communication Strategy

Develop a strong communication strategy with external parties. Make sure your message is simple, clear, and easy to understand.

Program must sound, logical, and doable. Make communications relevant to the audience and use

different mediums. Clients may need several different venues: DVDs, letters,

web, video, interactive materials. For external groups, create materials that explain 1) How the

program will operate; and 2) How it will affect them. Always include WIIFM in the commutation (What’s in it for me?).

Allow interested parties opportunities to respond and provide input.

Provide annual reports and updates.

Wedding Tip No. 3: Invite both of your ENTIRE families

Use this opportunity to invite the entire family: immediate, close, extended, distant, and complicated connections.

The pictures will be more valuable.

Excluding family members will hurt you more in the long run than the pain caused by a few hours of tolerance.

Care Management Tip No. 3:

Invite all stakeholders to the table

Federal and State Authority – Get buy in from CMS and state budget/regulatory authority from the beginning.

• You need an authority GPS

Advocates and Providers - Get their buy in – consider the affect on established care patterns. Spend time to educate and orientate them on your vision and plan. Place them in advisory partnerships.

Vendors – Use the opportunity to talk to vendors. Invite them to visit – hear what they have to offer. Ensure they are inclusionary and flexible.

Wedding Tip No. 4: Is a real cake absolutely necessary?

A real cake or fake one?

You only need a wedding cake for the pictures.

So, create one out of Styrofoam and decorate it with icing and flowers for the pictures. Then serve your guests a grocery store sheet cake.

Extra savings $$$: Find a birthday cake that someone did not pick up.

Care Management Tip No. 4: Don’t create a program just for show.

Your program needs to be more than show. It must have definitive outcomes.

Health outcomes – Be able to document that enrollees are better off for participating in the program: managed care, change of treatment plans, change in venue, higher scores, medication management adherence. More than just reporting happy/satisfaction.

Co$t $avings - After determining a reasonable savings expectation, develop a mechanism in which this will be achieved and reported. You will need to isolate program intervention to determine savings.

Managed care + managed savings expectations = success

Focus on Quality:Focus on Quality: Diabetes ManagementDiabetes Management

www.dmas.virginia.gov/dsm.htm

Selected Diabetes Measures

0%

20%

40%

60%

80%

100%

A1c test1/year

Annual dilatedretinal exam

Annualmicroalbumin

test

Annual lipidtest

LDL<100 Home glucosemonitoring

Blood pressurecontrolled(<=130/80)

Per

cen

t

Year 1 (2006) Year 2 (2007)

Best cost saver : Have wedding and reception at sunrise.

You get same orange sun as you do at sunset PLUS much better symbolism.

You can invite everyone without fear of going over budget. A breakfast reception is much cheaper.

Wedding Tip No. 5: Be flexible and open to new ideas

Care Management Tip No. 5: Build in flexibility and be open to new ideas

Project will evolve and need the flexibility to change:• New priorities; new trends and ideas; and• New internal and external pressures.

Build in contract flexibility:• Growth and shrinkage in program;• Ability to stop certain pieces and continue with others

and operate some pieces internally.

Continue to research and learn:• Do not believe you have the golden goose- new ideas are

born everyday.

Compromise is not a bad word:• Keep focused on the goal and plan as you make

decisions.

Wedding Tip No. 6: Times are tight, but don’t skimp on everything!

Don’t skimp on everything….especially not on the photographer!

When its all said and done, all you will have are pictures, memories, and credit card bills as a remembrance of the day.

Care Management Tip No. 6: Times are tight, but don’t skimp on everything!

Don’t skimp on evaluation process!

After a year of operation everyone will want to know the program’s ROI. Decide on the evaluation and reporting processes before you

implement. CHCS has a tool and a program for quality and ROI and there

are a series of research models (e.g., control groups). Look at HEDIS, URAC and QIO for ideas. Find an independent source to evaluate program.

• The vendor’s annual report is not enough. • Think about using State Universities, EQRO, etc.

Ensure that the evaluation terms are in the contract.

Focus on Outcomes: What gets measured gets done

Asthma HEDIS Outcomes 2004 2005 2006

Admits / 1000 50.0 52.7 42.3ED visits / 1000 269.8 265.1 250.5Appropriate Meds Ages 5-56 67.7% 86.9% 88.3%

Actions:• Outreach partnership with community

organization.• Automatic telephone call reminder

system.• Asthma & COPD provider guideline

tools.

Wedding Tip No. 7: Beware of too good to be true

Watch out for bargains that seem too good.

Before you buy the honeymooners that $99.00 Caribbean cruise you saw on eBay- check for references.

Care Management Tip No. 7: Don’t just select the lowest bidder

Care management has become a multi-million dollar business.

And with the gold rush there are many vendors, purchasing ideas, and helpful friends.

There are no bargains – what appears to be too good to be true is.

Choose a vendor carefully. Always include a prenuptial language – not just

sanctions but a way out if both parties do not agree.

These program are not going to save the budget but they should control trends.

The biggest unknown is that you cannot control recipient behavior or participation – you just hope to influence it.

Happily Ever After

Like a wedding, care management programs entail a lot of work and expense:

Vision Planning Implementation

All focused on achieving two outcomes: improving health outcomes and producing cost savings.

Is it all worth it???

Yes

The End….

Thank you!