Camille L. Kurtz RN, BSN, MA

Executive Director, Medicare

Affinity Health Plan, Inc.

Member-Centric Medical Management

2

Outline

• Purpose and Objective

• Transactional UM/CM

• Disease Management

• New Model Highlights

• PODs

• Care Coordination/Care Management

• Productivity Metrics

• Member Outcomes

• Model Benefits

3

Purpose and Objective

• Participants will:

– Be able to distinguish the differences between transaction and

member-centric management

– Learn what are the drivers of UM/CM model change

– Learn of benefits to the health plan

– Learn of benefits to the member

– Understand how the change in care delivery requires a change

in the medical management model

4

Transactional UM/CM

• Principles:

– Minimize utilization of services in order to reduce

costs

– Deny services rather than approving appropriate

services in order to manage members in lower level

of care

– Focus on location and duration of services provided in

order to reduce cost

– UM nurses are not CM or DM nurses

5

Disease Management

• Principles:

– Manage utilization and cost by single focus on one of

many prevalent chronic diseases

– Develop and advise member on how to master their

own disease management

– Expect improved outcomes on one disease only

6

Member-Centric Medical Management

• Principles:

– All nurses are Care-Coaches/Managers - Nurses are assigned members, not tasks

– Members have multiple diseases

– Members would prefer not to be admitted

– Standard Clinical Guidelines/Clinical Pathways have solved for the majority of UM decisions

– Being in an insurance company requires interdisciplinary member management

– Member-Centric Medical Management is not from 9 to 5

– Relationship building between provider, SW, facility of care, caregiver and member is critical

– Managing transitions of care well is an imperative

7

Member-Centric Medical Management

• Focuses on relationship-building between the coach and the

member for ongoing continuity of care

• Provides the member with a main coach contact both in-house

and in the field

• Improves provider relationships with facility-based UM/Discharge

staff

8

How to Execute New Model

• Reposition Medical Management from functional/transactional areas

to integrated member-centric care management PODS

• PODS – member assignment should be either facility, regional, or

zip code driven

• Focus away from telephonic disease-specific coaching model to

mixed telephonic/field-care management

• Medical Management model is highly focused on transitions of care,

preventing re-admits and keeping members home-based

• Model is LOB agnostic

9

How to Execute New Model

• Member Stratification

– Capturing the right members at the right point in their

wellness/health/illness continuum:

• Ensure sufficient behavior modification toward member

compliance with self-management in order to maximize their

wellness, independence and normalcy for their

illness/chronicity

10

How to Execute New Model

• Transition of Care:

– Reduce excessive use of ER services

– Reduce admissions/re-admissions

– Reduce use of nonessential ancillary services

• Member-Centric Medical Management:

– Ensuring the members see their PCP

– Explore needed specialty services to manage specialty needs and prevent inpatient care;

– Adhere to medication regimes and treatments, including annual preventive services and,

– Pursue services in lower level service locations whenever possible

11

How to Execute New Model

• Stratification Tools:

– Predictive Model/Continuance Tables

– HCC Coding Home Assessments (Medicare/HIX)

– CRG Home Assessments (Medicaid)

– HRAs acuity scored (Medicare and Medicaid)

– Facility discharges – TOC all products

– MBHO referrals and integrated Medical/Behavioral Case Rounds

12

Stratification Target

13

Current Targeted CCM

New Model Targets

$

TIME

A

B & C

A

B

C

Productivity Metrics

• 150 cases per Care Coach

• 75 percent engagement in CM on all outreached per month

• PHQ9s by SW on all cases failing PHQ2 by CC/RN

• Failed PHQ9s referred to MBHO

14

Impactful Model

Follow the “Impactful Model”:

• Highly impactful cases (off program within 36 weeks)

• Minimum 4 touches per member, per month

• Moderately impactful cases (off program within 24 weeks)

• Minimum 3 touches per member, per month

• Low impactful cases (off program within 6 weeks)

• Minimum 2 touches per month

15

Outcomes Metrics

• Reduce admissions per 1,000 by LOB

• Reduce re-admissions rate

• Reduce ER visits

• Increase use of ALOC

• Increase member medication adherence

• Increase PCP visit rates

• Increase identification and referrals to Palliative/Hospice

• Meet select LOB Quality metrics (HEDIS/STAR)

16

Programs to Support New Model

• Palliative/Hospice - Increase referrals appropriately near end-of-life

• Cancer Care - Reduce hospitalizations associated with chemo-

induced illness through proper self-management oversight

• PCP Referral Program - PCPs can refer member for a home

assessment

• Fully Integrated Mental Health TOC/CM - Working with MBHO to

execute a fully integrated program with bi-directional referrals and

interdisciplinary case management

17

Some Results

• Medicare Populations

– Client # 1 (Fully Field Model)

• Re-admit rate at onset of program: 40%

• Re-admit rate at end of 18 month period: 20%

– Client # 2 (Mixed Telephonic and Field Model)

• Re-admit rate at onset of program: 22%

• Re-admit rate at end of 18 month period: 15%

• Medicaid Population (CHP excluded):

– Client # 2 (Mixed Telephonic and Field Model)

• Re-admit rate at onset of program: 20%

• Re-admit rate at end of 18 month period: 10%

* Re-admit Rates Average over rolling 8 weeks

18

Programs to Support New Model

• New Member and Non-Utilizer Outreach - Outreach to new

members upon enrollment to

• Assist member with the scheduling of initial PCP visit, post-

enrollment

• Outreach to non-users, on a quarterly basis, to assist in

scheduling and follow-up with PCP visits

• Community Service Centers (CSC) - based wellness/health

maintenance promotion/services

– Field staff performing home visits, also servicing CSC sites by

conducting one or more services on a monthly basis (includes,

but not limited to BP screenings, blood drawing A1C, LDL/HDL,

asthma education, diabetes education, vaccinations (e.g. Flu

vaccine), mammography

19

©2015 Health Integrated. All rights reserved.