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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
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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
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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)
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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
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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
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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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