a new approach to delivery: pod model of care
Post on 07-Aug-2015
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Outline
• Purpose and Objective
• Transactional UM/CM
• Disease Management
• New Model Highlights
• PODs
• Care Coordination/Care Management
• Productivity Metrics
• Member Outcomes
• Model Benefits
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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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
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