Managing High Risk Patients: Implementation and Evaluation of Care Management Strategies

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Managing High Risk Patients Implementation and
Evaluation of Care Management Strategies

• Susan Schooley, MD
• Lois Lamerato, PhD
• Barbara Simons, MSW, CSW, CAC

Department of Family Practice
American Medical Group Association March 13,
2004 New Orleans, Louisiana
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Outline and Objectives

• Introduction of HealthLink program
• Background, rationale
• Case management structure
• informatics structure
• Techniques to identify high risk patients
• HealthLink methodology
• Interactive discussion of local
  applicability/local strategies
• Case management what is it?
• Results outcomes of program
• Beyond HealthLink changing health care,
  changing policy

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At the outset(Assumptions and observations)

• The distribution curve of needs/costs
• The failure of traditional care models
• Disparities
• Context
• That pesky free will thing
• In other words, Systems thinking

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At the outset

• Patient resource consumption is not evenly
  distributed
• Recognition that a small number of pts consume a
  large proportion of resources
• Pt condition complexity of diagnoses
• Adverse utilization practices (eg. ER use for
  primary care, lack of ongoing care with PCP)

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Systems as Fishbones
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Ishikawa fishbone diagram
Influences
Outcome
Interventions
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Ishikawa fishbone diagram
Influences
Biological
Insulin resistance
Personal
Family
Society
Pancreatic insulin production

Health Care
Community
Genetics
End-organ damage Hospitalization Costs of
care Dysfunction
Diabetes
Annual retinal exams
Medications
Screening and detection
Interventions
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Lets fill in the bones
Influences
Biological
Insulin resistance
Access to food options
Personal
Family
Society
Pancreatic insulin production

Health Care
Community
Mealtime rituals
Genetics
Marketing
Access Language
Dietary choices
Medicare policy
Depression
Transportation
Diabetes
Annual retinal exams
Medications
Screening and detection
Interventions
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Lets fill in the bones
Influences
Biological
Education
Insulin resistance
Access to food options
Personal
Family
Society
Pancreatic insulin production

Health Care
Community
Mealtime rituals
Genetics
Marketing
Access Language
Dietary choices
Medicare policy
Depression
Transportation
Diabetes
Annual retinal exams
Case management interventions
Medications
Screening and detection
Interventions
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At the outset

• Project premise

Case management intervention
Improvement in outcomes
Identify high risk pts
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At the outset

• Project premise

Case management intervention
Improvement in outcomes
Identify high risk pts
It works, but how does it work?
How can you predict Who is high risk?
Whats the cost-benefit analysis? Is it practical?
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Background Funding Sources

• Funding
• 1998 - 3 year award from MDCH (CAID1)
• Improve the management of urban high risk
  populations
• Residency education
• Technological development
• 2000 - 1.5 year award from MDCH
• Stronger focus on case management approach
• Making argument that cost effectiveness of
  program warrants internal funding

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PROJECT COMPONENTS

• High risk patient identification
• Case management
• Case management informatics system
• Laptop computers for case management staff
• Outcomes analysis

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Target Population

• Medicaid HMO patients
• Children
• Pregnant and post-partum women (AFDC)
• ABAD
• Dual eligible with Medicare
• Adverse financial outcomes for health system
• Enrollment optimization strategies
• Facilitate care processes
• Overall patient population high
• Family Practice clinics populations
• Referrals from PCPs

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Case Management
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HealthLink Case Management Model

• Screening high risk patients
• Assessing patient health/resource needs
• Development of care plan
• Strategies to interface patient with health care
  team
• Integrate and mobilize available resources
• Community-based delivery model
• Alliance with community resources when possible

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HealthLink Case Management Model (cont.)

• Patient education for symptom management,
  follow-up care
• Intensive interventions during crisis
• Reduction of barriers to care
• Managing tracking system for patient needs,
  outcomes
• Ongoing monitoring of care plan

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Case Management Interventions

• Patient education - most substantial part of
  HealthLink case management
• Both individual and group education programs
• Programs are scheduled at the convenience of the
  patients (evenings and weekends)
• Health care linkages
• Appt scheduling with primary and specialty
  providers
• Scheduling of critical labs/preventive services

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Interventions

• Nutrition counseling
• Individual and group sessions with a nutritionist
• Education Center
• An educational display offers a monthly health
  education theme and reading materials for
  patients
• Food Demonstrations
• Monthly demonstrations in the clinic lobby offer
  tasting of healthy recipes

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Group Education Programs

• LIVE IT UP
• An ongoing series of classes to manage chronic
  disease through a healthy lifestyle
• DOWN WITH POUNDS
• An ongoing series specific to weight loss
• BREATHERS CLASS
• A four week class for patients with respiratory
  problems
• DIABETES MANAGEMENT CLASSES
• Six to seven week sessions concentrating on high
  risk patients

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About the classes

• All classes are managed by Health Link staff,
  with involvement of clinic personnel
• Motivational incentives are provided in the form
  of healthy refreshments, gifts, picnic, social
  support and educational materials
• All classes culminate in graduation ceremonies
  and certificate of completion.

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• Another program component Medication Assistance

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MEDICATION ASSISTANCE REFERRAL SCREENING Name_____
__________________________________________________
______________________ Doctor_____________________
__________________________________________________
_____ MRN_______________________________Soc.Sec.
No.___________________________________ Type of
Insurance________________________________________
___________________________ Any prescription
coverage Yes____________________________________
____________________ Income________________monthl
y___________________annual Income
sources__________________________________________
___________________________ Number of
dependents________________________________________
________________________ Medicaid
eligibile__________________________(monthly
income below 716.00 need to apply) World
Medical Relief eligible_______________________(mon
thly income below _______need to apply) Remember
these resources are more permanent than Drug
Company Programs always use these first. Does
applicant qualify for any of the Drug Companies
discount cards? __________________________________
__________________________________________________
If applicant does not know if they have
exhausted their prescription benefit through HAP,
you can call HAP Medi-Pac (800-788-2949) or
patient can also call. Have HAP I.D. number
ready when calling. Any questions call Lisa
Ashby Hamtramck 313-972-9032, Detroit East
313-823-9880 Medication List_____________________
_________________________________________________
__________________________________________________
__________________________________
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MEDICATION CASE STUDY 1 Mrs. P., a 60 year old
divorced African American female with the
diagnosis of diabetes mellitus, hypertension,
dyslipidemia, overweight, arthritis and anemia.
Mrs. P. had Medicaid for 6 months and then lost
it. Mrs. P. receives assistance on four of her
medications from the prescription assistance
program.
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MRS. PS GLYCATED HEMOGLOBIN RESULTS
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MEDICATION CASE STUDY 2 Mr. B.69 year old
Caucasian male with a history of myocardial
infarction, CABG, hypercholesterolemia, multiple
joint pains, coronary artery disease. Mr. B.
receives assistance on one medication, Zocor from
the prescription assistance program.
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MR. BS CHOLESTEROL RESULTS
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LETTER FROM MY PATIENT

• I am a diabetic and I have high blood pressure
  and my medications are quite costlyUntil I came
  to the Hamtramck office I was never ever given
  any help or consideration with medicationsI have
  spent as much as 350 a month for my medications.
  Being on a fixed income with a handicapped son is
  very hard.

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Population Identification
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Population Identification Process
Physician Referral
Administrative Data Review
Case Manager Assessment
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Administrative Data Criteria Development

• Retrospective review of historic data
• Characteristics of suboptimal care processes,
  adverse cost outcomes, high risk disease
  processes
• Demographic characteristics/program enrollment
• Consensus process for criteria
• Physician leaders
• Social work
• Case manager leader
• Epidemiologist

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Population Identification Administrative Data
Screens

• Enrolled in Medicaid ABAD program
• Part of original mission of project and
  requirement from funding agency
• High charges (gt 140 per month) with more than 3
  dx
• One or more admission in past year with more than
  3 dx
• Congestive Heart Failure
• Substance abuse
• Two or more ED visits in past year
• Age 65 and older with more than 3 dx
• Objective criteria applied

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Case Manager Appraisal

• Electronic medical record review
• Subjective review
• Potential for case manager effectiveness
• High specialty needs care coordination
• High utilization
• Non-compliance
• Primary care gaps
• Social problems
• Other issues amenable to case management

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Dual Casefinding Process
Administrative data Electronic record
review
ABAD High cost gt 3 dx IPD gt 3 dx Age 65
gt 3 dx CHF Substance Abuse 2 or more ER visits
High specialty High utilization Non-compliance Pri
mary care gaps Social problems Other
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Discussion

• Critique of risk population identification
  process
• GAPS?
• Who are we missing?
• Other criteria?
• What about pts who dont come in at all?
• Discussion of local applicability
• Available data?

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Development of Informatics
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Informatics Objectives

• Facilitate care management processes
• Workflow
• Allow for evaluation of intervention
• Benefits of case management
• Benefits of specific program components

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System Components

• Patient registration
• Assessments
• Administrative screens
• Care manager review
• Encounters
• Elements
• Workflow

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Main Menu
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Care Manager pop-up
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Allows care manager to plan and manage work
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Generate printed reports for administration
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Patient Form Demographic Info on pt
contact info
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Guardian And Contact Info
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Search for Pts by MRN Or name
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Case mgr screens
Assessment form used when CM is using
electronic Medical to evaluate and document pt
needs
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Administrative Data screens
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Disposition Based on case manager assessment,
patient is enrolled, Held for re-review in
future, not referred for case mgt
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Case mgr sets pt status - indicates the level of
intervention required
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Program pt is referred to
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Every encounter case mgr has with pt is documented
Type content
time of encounter of encounter spent
on each element
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Form for Adding Encounters Type of encounter
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Diagnoses Selected from Pull-down
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Data from these entries collects the type and
time of care mgr processes
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Work flow - allows care mgr to schedule future
activities
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Set time frame for prompting when event is needed
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Type of event scheduled
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Priority rating of event
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Administrative info case manager pt assignments
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Administrative info assessments made by
each care manager
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Administrative info encounters for each case
manager
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Administrative info workflow by case
manager shows what needs to be done
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Printed reports can be generated for each
aspect of system
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HealthLink Informatics System
Case Registry
Encounter System
Workflow
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HealthLink Informatics System
Case Manager Who is in my case load? What do I
need to do today?
Case Registry
Encounter System
Workflow

• Managing and prioritizing work plans
• Efficacy
• Efficiency

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HealthLink Informatics System
Research Team What cost savings is associated
with case management activities?
Case Registry
Encounter System
Workflow

• Outcome data analysis
• Efficacy
• Efficiency

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HealthLink Informatics System
Among pts with CHF, what case management
interventions are most effective in reducing
hospitalizations?
What pt characteristics predict improved
compliance with appointments?
Case Registry
Encounter System
Workflow

• Outcome data analysis
• Efficacy
• Efficiency

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Ishikawa fishbone diagram
Influences
On glycemic control
Personal
Family
Society

Biological
Health Care
Community
On knowledge of DM self-management
Diabetes
What is the impact of group DM education
And compliance with HA1C testing
Interventions
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Outcomes
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Analysis Population

• 1943 patients evaluated
• 1247 (64) enrolled in case management
• Analysis population subset
• Exclusions
• Patients with less than 1 year follow-up
• New patients (no pre-case management data for
  comparison)
• Extreme cost outliers (gt mean charges 3s)
• Final analysis population n 398

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Study Population Characteristics

• Gender
• Male 103 (26)
• Female 295 (74)
• Age distribution
• Range 0 104
• Mean 57

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Case Management Referral Criteria
of enrolled pts
Patients may have more than one criteria
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Impact of Case Management on Costs of Care
Total Population
Pt charges used as proxy for costs, n 398
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Impact of Case Management on Utilization Total
Population
Rate/1,000
n 398
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Impact of Case Management on Costs of Care
Stratified by Age
n 212, n 186
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Impact of Case Management on Utilization Age lt
65
Rate/1,000
n 212
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Impact of Case Management on Utilization Age
65
Rate/1,000
n 186
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Impact of Case Management on Costs of Care Pt
Condition
n 135, n 112, n 54
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Impact of Case Management on Costs of Care Pt
Condition
n 79, n 58, n 33
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Outcomes Risk Reduction
Post-Case Mgt - Control
-

• Population Diabetic patients referred for
  one-on-one case management (n190)
• Outcome Measure Comparison of HA1c control (lt
  8)
• Result Significant improvement for 41 of pts
  within 12 months of case mgt

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Pre- Case Mgt Control
(chi sq 49.74, p lt .001)
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Now what?

• Project premise

Case management intervention
Improvement in outcomes
Identify high risk pts
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Now what?

• Project premise

Case management intervention
Improvement in outcomes
Identify high risk pts
Reduced inpatient days Shift from IP to
ambulatory Reduced/delayed complications
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Now what?

• Project premise

Case management intervention
Improvement in outcomes
Identify high risk pts
It works, but how does it work?
How can you predict Who is high risk?
Whats the cost-benefit analysis? Is it practical?
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Who benefits?
Patient Physician Hospital Insurance
company Employer HMO FFS Other?

• Reduced inpatient days
• Shift from IP to ambulatory
• Reduced/delayed complications

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Who pays?
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Thanks for your interest! A copy of our slide
show can be found on IIHE.org