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CC4C Orientation Module Two June 2012

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CC4C OrientationModule 2

Objectives1. Define Population Management2. Define how data can be used to

identify the target population3. Define Care Management4. Define the care management

process

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What is Population Management

Population management is the process of using information to identify a target

group of clients that would benefit from care management resulting in improved

health outcomes and reduced health care cost of the total population.

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Total Population

All children ages 0-5 are included in the tree.

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CC4C Funding

To assist in meeting the responsibilities of the CC4C Target Population, the LHDs will:

� receive a Per Member Per Month (PMPM) allocation to serve Medicaid clients; amount of PMPM is based on the number of Medicaid children 0-5 years in each county.

� have the opportunity to draw down CC4C Agreement Addenda funding to serve non-Medicaid children; level of funding is consistent with past CSCP AA funding.

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Carolina Access EnrollmentIn our June CC4C Webinar, we talked a little about Straight Medicaid, CAI & CAII (in relation to a new CCNC/CA MemberHandbook).

� Straight Medicaid = Child who is not linked to a Carolina Access Medical Home.

� CA I MH = Provides medical care & 24/7 phone coverage for medical advice. No access to CCNC CMs.

� CA II or CCNC MH = Provides medical care; 24/7 phone coverage for medical advice; & access to CCNC CMs for help with health problems or medicines.

� Two of our program goals involve linking families to Carolina Access Medical Homes (preferably a CA II MH).

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Data on Straight Medicaid, CA I & CA II Enrollment

(Children Ages Birth to <5)May 2012 Enrollment (N=320,919)

Group Frequency %

Straight

Medicaid

6,147 1.82 %

CA I 5,314 1.57%

CA II 326,687 96.61%


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PMPM Funding Basics� CC4C is funded through a “per member per

month” or PMPM payment structure.

� CC4C payments are not based on a fee-for-service payment system. Claims are not filed for CC4C services.

� Local health departments receive a monthly payment which is determined by a count of the base population at the end of each month prior to the month of payment.

� A PMPM rate is paid for each individual in the base population.

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PMPM Base Population� The base population for CC4C payments is the # of

Medicaid recipients ages birth to <5 who reside in the county. The PMPM rate per individual child in the base population is $4.80 per month.

� Payments are distributed to county health departments using the above formula after calculating the base population at the end of each month.

� There will be minor fluctuations in the payment amount, as the number of individuals in the base population varies slightly from month to month.

� The base population is not the same as the target population for services; CC4C has criteria defining which Medicaid recipients are included in the target population for care management services.

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PMPM Calculation� The PMPM base population number is calculated on a monthly

basis at the state level.

� Payment is for “population management”, not individual services.

� The PMPM calculation is complex & cannot be replicated locally.

� The monthly payment goes to each CCNC Network on the second checkwrite of each month.

� CCNC will provide a payment statement that will show the population count & payment amount for each program locally.

� To create an annual budget, use the figures from the September projections and multiply X 12 months.

� Program funds must be used to achieve the greatest impact within the target population.

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Identifying the CC4C Population

How Do I Decide Who to Pick from the Tree?

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� Claims data can be used to identify the clients who may be in need of services.

� Claims data can be used to identify the population who may over utilize services or are considered high cost.

� Direct referrals obtained from the medical home and community agencies for clients who may benefit from care management, have social barriers to care or have special needs.

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Use the data to fill the baskets


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Priority Patients

� These patients have been identified through a software program called TREO.

� This program groups the clients by clinical risk and looks for clients whose cost exceeds the cost of a similar group of clients.

� These clients have often experienced a crisis in their health or are over utilizing services.

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Priority Population List� The Priority Population List is posted in the

Informatics Center under CC4C reports.

� These reports are based on medicaid paid claims information reported the the Informatics Center database.

� Whenever a “New” PPL Report is posted, this report becomes the priority for follow-up as it will be prioritizing “impactable” patients based on more recent claims history.

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Informatics Center Reports Site

� The Informatics Center (IC) Reports Site allows efficient and secure distribution of reports through a secured web-based report access and management application, with report access permissions determined by the appropriate scope of access of individual users. Network-level administrators authorize their own employees, providers and community partners by customizing their scope of access by practice or region.

� To obtain access to the informatics center, contact your local network

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Informatics Center Uses

� Monitoring of ED and Inpatient Visits.

� Risk Stratification and Identification of High Need Patients.

� Tracking of Care Quality and Performance Indicators.

� Assessment of demographic, cost utilization and disease prevalence.

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Filling The Basket With Those Who Need Care Management

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$0 $1K $2K $3K $4K $5K $6K $7K $8K $9K $10K $11K $12K $13K $14K $15K $16K $17K $18K $19K $20K

Expected Preventable Inpatient Costs for this CRG

Actual-to-Expected Difference

CCNC’s Approach

All individuals within the same

Clinical Risk Group (CRG)Similar Dx

CRG

* From “Targeting the Most Impactable Patients” by Carols Jackson, PhD, and Annette Dubard, MD


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CRG#1

CRG#2

CRG#3

CCNC’s Approach

= Expected preventable costsfor people within that CRG

= PRIORITY PATIENTS for care management using CCNC’s flagging approach

* From “Targeting the Most Impactable Patients” by Carols Jackson, PhD, and Annette Dubard, MD 20




CRG#1

CRG#2

CRG#3

Prioritizing the Priorities



Actual-to- Expected Difference

* From “Targeting the Most Impactable Patients” by Carols Jackson, PhD, and Annette Dubard, MD

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CCNC’s New Approach For Targeting the Most Impactable Patients

With CCNC’s approach, the most impactable people

would be those with the greatest actual-to-expected

difference. There are also indicators on the report for

identifying those on the priority list who are newly CCNC-

enrolled, which may also represent a highly impactable

group.

CCNC’s Approach:

CCNC approach for identifying the most impactable patients.

This approach uses TREO’s methodology for flagging priority

patients based on above-expected potentially preventable

hospital costs given the person’s disease burden.

Two guiding principles:

Clinical Risk Groups (CRGs). 3M™ Health Information System’s Clinical Risk Groups (CRG) is a classification system that helps to predict the

amount and type of healthcare services that individuals should have used in the past or can be expected to use in the future. CRGs are the

basis of a hierarchical clinical model that uses standard claims data—including inpatient, outpatient, physician, and pharmacy data— to

assign each patient to a single mutually exclusive risk category.

“Potentially Preventable.” TREO applies 3M™ methodology for tagging whether an admission, readmission or ER visit was “potentially

preventable.” Patients are flagged for priority based on whether they had more “potentially preventable” hospital services relative to other

people in their risk group (CRG). When applying the new approach, all non-preventable services/costs are removed from consideration.

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Inpatient Hospitalizations/ Emergency Department Utilization

Inpatient stays and emergency department use is a marker that the client may be experiencing a crisis in their medical care, have barriers to care or are not obtaining needed

care or treatment.

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Direct Referrals

Early identification of clients who are newly diagnosed with a medical condition, have

special needs, or have barriers to care may help prevent crisis, promote self management and adherence to the

treatment plan prescribed by the medical home thus resulting in decrease cost.

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Searching the whole Orchard

� Reaching out to the whole orchard for clients at need for Care Management.


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Outreach is Key to Success!

� Population management requires that CC4C staff “touch” many children to improve health & achieve performance outcomes. Strategies to accomplish this include:

� Strong collaboration with CCNC staff to clarify roles/responsibilities for CCNC/CC4C CMs serving children birth to 5 years of age.

� Community outreach, including establishing strong linkages with medical homes.

� Strategizing about the most effective ways to reach the target populations for referral.

� Working with CCNC on getting referrals from their IC Reports to impact admissions, readmissions and ED use.

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Taking Care of that one peach

How do I impact this one peach?

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What is Care Management?

Care management is a collaborative process of assessment, planning, facilitation and advocacy for service options to meet a

consumer’s health needs through communication and linkage to available resources to promote high quality, cost-

effective outcomes.

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Goal of Care Management

The goal of care management is to achieve an optimal level of wellness

and improve coordination of care while providing cost effective, non-

duplicative services.

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Most Important Goals:� Increasing the quality and access to care by

working with the client and the medical home

� Achieving improved outcomes – Healthier moms, babies and kids!

� Decreasing the cost of care

Benefits of Meeting the Goals� The health of the population is improved

� Ongoing program services are ensured

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What are you trying to do each day?

� Please families?

� Ensure families like you?

� Please supervisors?

� Meet agency’s expectations?

� Impress co-workers?

� Be a shining star?


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Components of Care Management

1. Identification of the Target Population2. Assess CM needs based on available info3. Family engagement4. Assessment (Comprehensive Health

Assessment and Life Skills Progression)5. Developing an individualized care plan6. Individualized client intervention7. Monitoring client outcomes8. Evaluation and deferral

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Finding the peaches to fill the Basket

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#1: Identification of the Target Population

� Clients should be identified from available data, and direct referrals from the medical

home and community agencies.

� The use of available information to identify clients should be prioritized based upon

the CC4C Standardized Plan with possible input from the local network.

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#1: CC4C Target Population� Children with Special Health Care Needs (chronic physical,

developmental, behavioral or emotional conditions) who require health and related services of a type and amount beyond that required by children generally.

� Children exposed to severe stress in early childhood, including:--Extreme poverty in conjunction with continuous family chaos� Recurrent physical or emotional abuse� Chronic neglect� Severe and enduring maternal depression� Persistent parental substance abuse� Repeated exposure to violence in the community or within the

family � Children in foster care who need to be linked to a Medical Home � Children in neonatal intensive care needing help transitioning to

community/Medical Home care. � Children with “potentially preventable” hospital costs identified under

methodology developed by Treo Solutions, Inc.

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State Level Activities to Promote Enrollment of Foster Care Children in CA II

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Prioritize the Population

To one basket

Moving from lots of baskets


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Prioritizing Patients within the PPL List

� PPL patients who have had their most recent potentially preventable activity in the past 6 months should be a priority for CM services.

� PPL patients flagged as newly enrolled in CA IIshould be a priority for CM services.

� PPL patients deferred due to being “well-linked” should still be evaluated for appropriate use/volume/cost of services, effective coordination of care, avoidance of duplication, etc.

� PPL patients with CM status of “deferred” or “inactive” should be a priority for CM services.

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Work in Close Collaboration with Your CC4C Network

� Each CCNC Network has come up with their own plan for how they want to approach working the PPL and Other Reports Available through the Informatics Center.

� Learn from their experience; seek their guidance.

� Don’t assume that because another care manager is listed in the PPL Report OR is involved (based on documentation in CMIS), that you should not engage this patient.

� As you work through the Priorities for engaging patients on the PPL List (see previous slide), contact the other care manager. Together you can decide who will be providing care management services related to this child on your PPL List.

� Review document entitled “Collaboration between Community Care of North Carolina (CCNC) and Care Coordination for Children (CC4C)” for further guidance related to this issue.

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Children who Appear on Sequential PPL Lists

� If a child that you have already care managed (due to their being on the PPL List) reappears on a subsequent PPL List, reassess the patient to determine if there is any further intervention that could make a difference.

� If a child previously “deferred for unable to contact” reappears on the PPL List, attempt to contact the family again.

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CC4C Target Population

� The CC4C Referral Form was designed to assist Referral Sources in identifying children who would be appropriate to refer for CC4C services.

� Clients who are a high cost/high user of services were NOT included on the Referral Form, even though they were a part of the original vision of the CC4C Target Population, as it was felt that they would be identified by means other than Referral Sources, i.e. reports.

� It is important that you work with the medical home and community agencies to identify clients who are in need of CC4C services. The CC4C CM should not rely soley on data reports to identify the target population.

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Looking at that one peach

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#2: Assess CM needs based on available info

� Data available in CMIS, including documentation of previous care management services and claims data available in Provider Portal should be reviewed to determine the clients medical needs and utilization of services.

� Information available at the Medical Home should be reviewed to obtain an overall view of the clients needs and any developed treatment plan.


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Strengthening the Medical Home Relationship

Goal:

To build strong, collaborative medical home relationships & assure timely communication of information.

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Strengthening the Medical Home Relationship

Why is this important?� Builds medical home support for CC4C Program.� Allows an opportunity for the practice to support the

achievement of CC4C Goals/Performance Measures.� Expands care team working on child’s behalf.� Assures that communication is flowing in both directions.� Allows you to say, “I am the care manager working with

Dr. Smith’s practice.”� Allows provider to be involved in the ongoing

assessment of your child’s needs & to contribute to care plan development.

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Tips for Achieving SuccessCCNC has strong medical home relationships. Build o n this

foundation.� Ask CCNC if you could approach this goal as a “team”.� Find out what CCNC did initially to build this rela tionship.

Face to face contact matters.� Regular contact with practices boosts referrals. S top by weekly,

biweekly, or monthly depending on what is feasible for you & the practice in your urban or rural community.

� Maintain a physical presence in the practice. Drop by to pick up referrals, see patients or provide f/u info on prev ious referrals.

� Provide a basket or mail slot for referral forms, i f desired. Determine if there is office space where you could see patients.

� As the trust relationship is established, perhaps y ou could attend practice medical management meetings, lunch & learn meetings or CCNC Network Pediatric provider meetings.

Must do the work! The proof is in the pudding.� Communicate your efforts & successes. � Be responsive to referrals. � Build respect.

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Good Communication Builds Trust & Encourages Referrals

Thanks to the work of the Medical Home Guidance Sub committee,we have guidelines for communicating with providers (& other referral sources). Those guidelines include:

� Acknowledge receipt of referral within 24-48 hours (1-2 working days).

� Respond to referral source within 30 days re: the outcome of the referral –even if f/u “attempted, but not successful”; even if all needs not yet addressed.

� Beyond the 30 days, ensure that changes in case status, information about the client’s progress or a change in care manager is communicated.

� Ask MHs how they prefer to receive communication updates. CMIS secure email messaging is one option, but MH may prefer phone f/u or weekly updates. If the CCNC CM & MH have developed a communication method that is working, then it may be beneficial for the CC4C to simply adopt that method.

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Good Communication Builds Trust & Encourages Referrals

An additional consideration:

� For Medical Homes, quick updates re: your progress with a referral are important and appreciated! CCNC staff try to reach families within 2-3 days to f/u by phone or schedule a HV.

� Progress updates are shared with the Medical Home either the same day, or in a weekly update of progress on various referrals from the practice.

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A Best Practice Option from Buncombe Co: Referring Children to CC4C who Reside in a

Different County from the Practice

� For practices, it is challenging to keep track of the different programs and their respective referral criteria. Hence the importance of a “No Wrong Door” approach to referrals.

� For practices serving children from surrounding counties, the need to be knowledgeable of “out-of-county” resources is also challenging.

� Clearly the knowledge and expertise of the CC4C CM from the child’s county of residence is key.

� A “best practice” option is for the practice to route all CC4C referrals to the CC4C linked with that practice - whether the child resides in the same county as the practice or not. This simplifies the referral process for the practice.

Continued on Next Slide


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A Best Practice Option: Continued

� For children who reside in a different county from the practice, the CC4C CM would then send the referral to the out-of-county CC4C supervisor +/or designee. That person then assigns the referral to one of the CC4C CMs in that county.

� From that point forward, the out-of-county CC4C CM would communicate directly with the practice regarding his/her follow-up with that child.

� The CC4C linked to the practice can share information re: the best way to communicate with that practice & perhaps assist in the process.

� This will help to minimize the complexity & confusion for practices and ensure a collaborative approach to care.

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Case Management Information System (CMIS)

Coordinating patient care The Case Management Information System (CMIS) is a user-built, patient-centric, electronic record of care

management activities used by CCNC care managers since 2001, with over 1,500 active users

statewide. CMIS contains demographic data and claims data on over 2.8 million Medicaid recipients, of whom approximately 1 million are currently enrolled

with a practice in a CCNC network

Access to CMIS can be obtained by contacting your local network.

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Provider Portal

About the Provider Portal This CCNC Provider Portal was released in August 2010 to

improve patient care and care coordination for North Carolina Medicaid recipients. Providers and other members of the care team may access care team contact information, visit history, and pharmacy claims history for their Medicaid-

enrolled patients. Population management and quality reporting is also available for primary care medical home

providers. The portal is available to practices, hospitals, and agencies engaged in quality improvement and care

coordination through CCNC.

Provider Portal is part of CMIS and can be accessed via the patients page.

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IC Provider Portal Updates for CC4C Staff:Patient Profile – Care Team Tab

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IC Provider Portal Updates for CC4C Staff:

Patient Profile – Medication Tab


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#3: Engaging the Family� Discussing with the family should occur to

describe CC4C services and how they could benefit from the program.

� Identifying the program as a linkage to the medical home and a service of Medicaid is essential for engaging the family. Note: If the child is not covered by Medicaid, the CC4C CM would need to adapt this statement.

� Getting verbal agreement from the family to engage in services is important for the success of the relationship.

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#3: Engaging the FamilyCC4C CMs should use all available resources for locating and engaging the family, including:

• Phone calls• Letters• Consultation re: current contact info & next appt with:

� Medical Home� WIC� DSS� CDSA, & other possible service providers� School systems

• Home Visits

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Cold Calling Families

My name is ______, I work with your child’s medical provider, _______ and Medicaid*. I am calling to see how your child _______ has been doing and how I can help you and your child obtain the services that your child may need.

I am a care manager for your child for Dr. ________ office and a part Medicaid* services. I see that your child _______ has _______. Please share with me about how he/ she has been in the past few months.

* Note: If the child is not covered by Medicaid, the CC4C CM would need to adapt this statement.

CL32

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Scheduling Home VisitsHi my name is _______ I am your child _______

care manager. I work with your child’s medical provider _________ and Medicaid*. My role is to help you get the things you need for ______ and to make sure you are getting all the things you may need for _______. When can I come to your home to visit with you and _____. I can come tomorrow at 3pm or Friday at 1pm. Which times works best for you?

Note: If the child is not covered by Medicaid, the CC4C CM would need to adapt this statement.

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#4: Comprehensive Assessment

The Comprehensive Health Assessment should contain information gathered during the assessment to give an overall view of the health of the client and include:

� Information gathered from provider portal information� Information gathered from the medical home� Information gathered from the family� Information gathered from other service providersThe Comprehensive Health Assessment should be

updated regularly as changes occur and at least annually.

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Life Skills Progression

The Life Skills Progression or LSP is an assessment tool that provides a framework & a focus for care management services. It assures that:

� Important aspects of family functioning are assessed & discussed, and that

� Progress is monitored routinely.

With the introduction of the LSP Policy Guidelines, our goals are:

� To use the LSP Assessment on a more focused & targeted population;

� And, to invest more effort in the interim between LSP Assessments to assure that families are aided in their efforts to move along the continuum toward a healthy & self-sufficient level of functioning.

� Being able to demonstrate our outcomes in a social/behavioral context will speak well for our program’s impact.

CL32 We will communicate throuh the comments that:

* Sometimes you do not have the parent's name

* You should NOT read this script when taling with the family to ensure that you communicate in a personal, conversational manner.Cheryl Lowe, 6/4/2012


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New Target Population for the LSP Assessment

Target Population for the LSP Assessment:

Children referred for Toxic Stress (as identified in the Toxic Stress Section of the CC4C Referral Form or by others making referrals by phone or through CMIS for that reason)

� The CC4C care manager may also choose to utilize the LSP for other children/families, as appropriate. This may include children, not identified as Toxic Stress, but who have developmental, social or behavioral health issues of concern.

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Target Population for the LSP Follow-up/Monitoring

Follow-up/Monitoring� For those with identified needs that the family is

willing to work on, the LSP will be repeated every 6 months and upon closure.

� Families working on LSP goals will need to be contacted frequently (preferably on a monthly basis) for the first 6 months.

� According to Linda Wollesen, author of the LSP, the greatest impact on families from working on LSP-related goals is realized within the first 6 months.

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#5: Developing a Care Plan

� The care plan should be developed in collaboration with and agreed upon by the family.

� The care plan should include how the care manager can assist the family to link with the medical home and other services.

� The care plan should address any barriers to care experienced by the family.

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Questions to Consider When Developing an Individualized Care Plan

� Concerns and needs of the family� Treatment plan developed by the medical

home� Medical and social barriers that exist for

the family� Available community resources that may

benefit the client and family

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Updating the care plan

The clients care plan should be reviewed and updated on a regular basis to reflect

any needs or concerns that develop throughout the relationship with the client

and family as the clients needs and concerns may often change.

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Often Encountered Barriers to Care

� Difficulty accessing transportation� Lack of knowledge of conditions� Availability/ location of specialized

treatment� Lack of financial resources� Poor linkage to community resources� Duplication of services� Difficulty navigating healthcare system


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What can I do to Impact this One Peach that will affect the Program

Outcomes.

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#6: Individualized Client Interventions

� Should assist the client to:� obtain any needed care or services� remove barriers to accessing care� link with the medical home.

� address any social barriers and minimize toxic stress.

� follow the treatment plan developed by the medical home.

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#7: Monitoring

� The current care plan should be monitored to ensure that the desired outcomes are reached, and if not, the plan needs to be revised.

� The client’s and family’s needs should be reassessed and monitored through out the care management process to identify any new concern, needs or barriers.

� The client’s utilization of services for appropriateness and success in meeting outcomes.

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#8: Evaluation

� When working with the client, the care manager should be mindful of how the work with the client is assisting in meeting the outcomes of the program.

� The Care Manager should regularly evaluate the client’s and family’s need for continuation of services and their readiness for self management.

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How do we know goals are met?

Program Measures and/or Data Reports

How do we assess our attempts to meet goals & determine how

we can improve?

Quarterly Reports, CMIS Data, Claims Data

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CC4C Performance Measures1. Increase the number of NICU graduates who have thei r

first primary care physician visit within one month of discharge.

2. Reduce the rate of hospital admissions for children enrolled

3. Decrease the rate of hospital readmissions for chil dren enrolled

4. Reduce the rate of Emergency Department visits

5. Increase the percent of comprehensive assessments completed for children and families identified as h aving a priority risk factor

6. Increase the Life Skills Progression (LSP) Assessme nts for the targeted population of children ages birth to five (Toxic Stress) receiving care coordination through CC4C on entry into the system, every six (6) months ther eafter and/or upon closing.


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CC4C Program Measures

1. Increase the # (and rate) of infants < 1 year of age referred to Early Intervention (EI) Program.

2. Increase the percent of children with special health care needs enrolled in a medical home.

3. Increase the percent of children in foster care who are enrolled in a medical home.

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Most Important Goals:� Increasing the quality and access to care by

working with the client and the medical home

� Achieving improved outcomes – healthier moms, babies and kids!

� Decreasing the cost of care

Benefits of Meeting the Goals� The health of the population is improved

� Ongoing program services are ensured

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#8: When Should the Client be Deferred from Care Management services?

� The needs of the client and family have been met.

� The client and family are able to self manage their care.

� The client and family will no longer engage in services

� The client and family refuse any further intervention.

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Your CC4C Vision for 2012

Consider how your work with children and families the local level to determine how you can move forward with meeting the IHI Triple Aim goals:

� enhance the patient experience of care (including quality, access, and reliability);

� reduce, or at least control, the per capita cost of care; and

� improve the health of the population.

The Triple Aim initiative is a program of the Institute for Healthcare Improvement (IHI). More info available at: http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx

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Your CC4C Vision for 2012

� A robust primary care system is the foundation for a health care system that delivers high-quality, affordable health care

� NC Community Care Network is nationally known for its model of primary care & the model is being shared nationally

� CCNC functions by having the patient’s primary care physician direct all of the client’s medical care.


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Your CC4C Vision

Take pride in and celebrate the role of care management.

Your

work

does

have an

impact!

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