Complex Care Management Program

Faculty Group Practice

Clinical Challenges in Caring for the Un- and Underinsured

Implications for Health System Reform

Brent C. Williams, MD, MPH

Medical Director,

Complex Care Management Program

Goals

• Among high utilizing, low income un- and under-insured patients:– Clinical conditions– Health system utilization– Features of optimal health care

• Challenges and opportunities for health professions education in care of vulnerable populations

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Patient 1 - LM

• 64 y/o female with ESRD on dialysis.• In past 12 months – 13 admissions for

hypotension, C. diff colitis, FTT, etc.• Multiple medical problems, somatic

complaints, limited adherence.• Limited coping skills or insight, lives

with son with DD.

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Patient 2 - KH

• 35 y/o female with Type I DM, CKD, BPD. Hosp 11 times, 13 ER visits in past year for gastroparesis, abdominal pain.

• SSI / medical disability.• Limited social support.• Frequently uncooperative, demanding,

non-adherent.

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Patient 3 - KS

• 45 y/o with MVA 1985 -> crush injury L foot, chronic pain. Recurrent DVTs, h/o PE.

• Homeless, binge drinker• Friendly and articulate, recurrently

drops out of contact, often after blood tests show high INR.

• No hospitalizations, rare outpt visits.

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Patient 4 - JL

• 52 y/o male with alcohol dependence, polysubstance abuse (cocaine, heroin), alcohol induced psychotic disorder with hallucinations.

• Homeless.• Over 1 year – 12 UM ER visits; 1 SJMH

admission, all related to EtOH w/d.• H/O 14 jail sentences.

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Themes – challenging patients

• Clinical complexity – 2+ of:– Major psychiatric disorder– Behavioral disorder– Substance abuse disorder– Multiple, severe medical conditions– Limited social support– Limited resources (housing, transportation)– Limited functional capacity

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Patterns – challenging patients

• Multiple sources of care– Fragmentation

• Patient behavior can drive the system• Frequent interactions with

– Public Mental Health – Substance abuse treatment services– Social services

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Health Service Utilization

• Top 45 BlueCaid pts 2009-2010:– Median $70,000 (range $52 - $200 K)– Total $3.7 million

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Utilization - averages

• 2005-2006:

UMHS Cost PMPY

‘Caid HMO $ 7,900

County Insurance $ 6,500

Dual Eligible >65 $ 8,200

Dual Eligible <65 $11,000

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Patient 5 - BN• 30 year old male with mild chronic low

back pain. Unemployed for 6 months, he fears eviction. Discord with girlfriend. On evaluation he demonstrates depression and anxiety but is not suicidal.

• He is eligible for county insurance but enrollment is currently closed.

• Access to mental health services is• extremely limited. 12

Gaps in health services

• Mental health services for moderately ill patients

• Medications

• Dental services

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Questions

• What are strengths and limitations of primary care practice in caring for complex patients?

• What evidence best guides health system design to care for complex patients?

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Primary Care and Complex Patients

• Time-limited visits

• Limited assessment capabilities

• Limited intervention capacity– Care direction, coordination– Resource / referral management– Behavioral management plan

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History and Evidence• Interventions to improve care

– Disease management– Geriatric Comprehensive Care– Assertive Community Treatment (ACT)– Healthcare for the Homeless – Chronic Care Management (dual eligibles)

• New Practice Models– Chronic Care Model– Integrated Mental / Physical Health Care– Advanced Medical Home– Transition Care Planning

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Key Success Factors: Complex Care

• Effective patient enrollment• Comprehensive, accurate clinical assessment• Clear delineation of responsibilities and team

membership• Effective care planning and implementation

– Real-time communication– Recognition of team members– Timely access to needed information– Skills / experience with behavioral management /

substance abuse• Outcomes measurement / feedback to

stakeholders

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UM Complex Care Management Program (CCMP)

• Independent unit– 4.5 Social Work / Nurses– 3.0 Patient Care Assistants– 1.0 Director (Nurse)– 0.2 Medical Director

• Administratively under Faculty Group Practice (Medical School)

CCMP Functions

1. Callback (ER, Hospital)– Information– Assessment

2. Transitional Care– Bridge transition from ER/Inpatient to

stable care

3. Complex Care Management– Continuous co-management with PCP

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PCP

PCP Hospital, Emerg Rm

PCP

PCP

CCMP

CMH Shelter

Home Care

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Practice Team

Care ManagerPrimary Care

Provider

Practice

NursesClerks

(Protocols)

PATIENT

What are the implications in caring for un- and underinsured patients for health system design under global funding?

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Under broader insurance and global funding…

• Most low-income, un- and underinsured patients will:– Have expanded insurance (mental health?)

– Have problems that could be managed in a well-functioning Patient Centered Medical Home.

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Under broader insurance and global funding…

• For a significant minority of very expensive patients, however, key challenges will not necessarily be addressed….– Fragmentation of care across systems– Uncooperative patients– Barriers among medical, mental health,

substance abuse treatment services

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Ideal Design Features of the “New” system

• Care management within and across systems– Single care manager– Real-time and aggregate communication

across systems• Incentives for patients to remain under

care of a limited number of providers.• Merging of cultures across mental

health and medical systems.26

Health Professions Education and the Underserved

• UM Medical School has a strong and growing commitment to providing every student with meaningful experience in underserved settings.

• Safety net clinics are low capacity teaching settings.– Affects teaching, faculty training, and

financial models

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THANK YOU

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