Title: Advanced Illness Care Coordination in a Medicare Advantage Setting Richard Raskin, MD,FACP Chief Med
1Advanced Illness Care Coordination in a Medicare
Advantage Setting Richard Raskin, MD,FACPChief
Medical Officer, East DivisionAvon, CTDanielle
Butin, MPH,OTRDirector, Health Services, East
DivisionWhite Plains, NY Angelina Yearick, JD,
MSPHConsultant to Health ServicesWhite Plains,
NY
2Setting the Stage
- Medicare Advantage
- Geography and Demographics
- Population Selection
- Health Risk Assessment
- HCC Scoring
- Claims Based/Predictive Modeling
- Diagnoses
3Rationale for Development of Program Targeted at
Medicare Advantage Enrollees
- Medicare enrollees have high incidence of chronic
disease and life-threatening illness - Clinical deterioration in these enrollees often
occurs suddenly - Patients facing end-of-life decisions often do
not have the requisite information to make
informed choices about how they would like to
spend their last days, and have not made these
choices proactively. - As a result, coordination of care for enrollees
at end-of-life is inadequate, leading to
suboptimal qualitative and financial outcomes.
4Advanced Illness and Coordinated Care Program
- The Advanced Illness Coordinated Care (AICC)
Program, developed by Dr. Dan Tobin, is designed
to - Target enrollees with specific diagnoses for
appropriate advanced care planning - Offer in home counseling to targeted enrollees.
- Reduce the rate of patients dying in the hospital
by providing patients the opportunity to spend
the end-of-life in the setting of their choice - Empower these enrollees to become more proactive
in the delivery of their end-of-life healthcare
services.
5Program Description
- The program consists of a 3-month intervention of
up to 6 in-home counseling visits, focusing upon - Relief of death anxiety (counseling component).
- Informed decision making about therapeutic
options and communication with surrogates, family
members, caregivers and health care providers. - Identification of opportunities for improved care
coordination.
6Staffing/Training
- No health plan staff is allocated full-time to
this project. - Contracted/Outsourced Models for Care Delivery
- Model 1 Nurse Practitioners credentialed as
Independent Providers in AICC - 68 Trained providers in metro NY area to date
- Model 2 Contracted Nurses and Social Workers
through local Hospice Agency - 12 Trained Registered Nurses
- 10 trained Social Workers
- All staff training is conducted by Dr Dan Tobin
at a full day intensive seminar.
7AICC Visits (Targeted in Borough of Queens, NY)
- Enrollee identified and mailed an introductory
letter about the program. - Follow-up call within 1 week to invite enrollee
to participate - Upon consent, AICC Provider assigned to conduct
home visits
8AICC Visits-What Happens at Home?
- Meeting 1
- Introduce goals of AICCP
- How AICCP interacts with the primary care
physician and the acute care team, and - What to expect.
- Meeting 2
- Evaluate capacity of caregiver
- Discuss psychological, social, financial and
practical concerns - Meeting 3
- Forging the partnership of member and caregiver
in AICCP care plan
9AICC Visits What happens at home?
- Meeting 4
- Care management of functional impairment
- DNR orders
- Meeting 5
- Obtaining feedback from providers on care plan
- Working with family members on care plan
- Meeting 6
- Discuss accomplishments
- Address remaining concerns
10AICC Providers-Need Back-Up
- Coordination of services provided by Education
Outreach Department - Additional service requests were made by
practitioners for - Home health care
- Nutrition consultations
- Prescription assistance
- Meals on wheels
- Transportation services
- DME
- Custodial care
11AICC Visit Tracking
Utilize 5 forms for data collection
- Palliative Care (4)
- Spiritual/Religious Issues (4)
- Life-sustaining treatment (5)
- Psychological and other concerns (5)
- Bereavement needs (5)
- Life closure (5)
- CUP Profile (1-5)
- Curative, Uncertain, Palliative
- Pain Assessment (1-5)
- Coping with diagnosis (1)
- Psychological Status (2)
- Advance Directives (2)
- Quality of Life (2)
- Practical Issues (3)
- Family Concerns (3)
12Demographics of Population
13Diagnoses of Population
- Main Diagnoses for Selection on hospitalization
and predictive modeling - CHF
- COPD
- Metastatic Cancer
- Some additional diagnosis were added in
predictive modeling - Alzheimers disease
- Stroke
14Enrollment in Program By Number of Visits
15Adherence with Advance Directives
- National prevalence of advance directives 15-20
- Compliance with Advance Directives in Program
16Selection of Health Care Proxy
17Financial Results of Program
18Current Status of AICC Participants
19Mortality Data
- Nationally, about 80 die in hospital or facility
- 9.3 of enrollees died within 18 months
- 41 died in the hospital
- 58 died at home, in a snf or with hospice
- Of those who died, the average lifespan was 6
months after start date
20Interpretation of Data
- Impact of Number of Visits on Outcome
- Impact of AICC Provider-2 Models
- Utilization of Palliative Care/Hospice Services
- Medical Utilization Impact
21Conclusions
- AICC can be an effective strategy to improve end
of life care within a Medicare Advantage
population. - Program success requires careful enrollee
selection. - Nurses and nurse practitioners are effective AICC
providers - AICC Providers with case management expertise are
more successful at sustaining member enrollment
and achieving positive outcomes. - Collaboration between hospice organizations and
Medicare Advantage health plans has the potential
for improving hospice utilization and clinical
outcomes.