Things That You Need To Know about the Virginia Chronic Care Management Program CCM - PowerPoint PPT Presentation

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Things That You Need To Know about the Virginia Chronic Care Management Program CCM

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It is not single condition management. It incorporates a holistic, patient-centric model ... monitoring to individuals with high risk & high cost chronic conditions ... – PowerPoint PPT presentation

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Title: Things That You Need To Know about the Virginia Chronic Care Management Program CCM


1
Things That You Need To Know about the
Virginia Chronic Care Management Program (CCM)
10
by the
  • The Department of Medical Assistance Services

2
What CCM Is.
10
things
and Is Not
to know
  • It is a program that provides specialized care
    management to individuals with chronic illnesses
  • It integrates the management of multiple disease
    states and co-morbidities
  • It is not single condition management
  • It incorporates a holistic, patient-centric model
  • includes medical nursing components,
    psycho-social issues, and behavioral health
    integration
  • It uses a predictive modeling system and
    methodology
  • It is designed to reduce unnecessary utilization
    of Medicaid services
  • It will be operated as an Alternative State Plan
    Benefit
  • It is an Opt-In Voluntary Program for eligible
    enrollees

3
What CCM Is
10
things
to know
  • Five unique aspects of CCM
  • Two Tier Care Management Intervention
  • Predictive Modeling Methodology
  • Call Center
  • Seven days/week 7 am. to 7 pm.
  • Holistic Assessments and Treatment Plans
  • Using evidence-based guidelines and HEDIS
    HEDIS-like outcome measures
  • Provider Support and Coordination

4
What CCM Is Not
10
things
to know
  • Not duplicating current case management or other
    direct services.
  • Not duplicating Virginias Disease Management
    program.
  • Not a Waiver.

5
Two-Fold Purpose of CCM
9
10
things
to know
  • Address the need for enhanced care management
    support services monitoring to individuals
    with high risk high cost chronic conditions
  • This will be accomplished by incorporating care
    management, education, and assistance to assist
    enrollees in managing their disease(s)
  • The coordination of various medical services on
    behalf of the enrollees by a professional medical
    staff and
  • Provide assistance and coordination of services
    with enrollees direct service providers

6
Two-Fold Purpose of CCM
9
things
to know
  • Second Purpose is to reduce health care costs,
    thereby resulting in cost savings to the State.1
  • This is a direct outcome of risk prevention and
    personalized care management, thus avoiding
    unnecessary acute care services, emergency room
    visits, and clinical and physician visits, which
    tend to be more expensive and more readily
    accessed.

7
Two-Fold Purpose of CCM
9
things
to know
  • On the front-end - prevent the unnecessary use of
    services using proven evidence-based guidelines.
  • On the back end - reduce and prevent the
    potential for risks of catastrophic or severe
    illness.
  • CCM focuses on a proactive approach as opposed to
    a reactive approach of care and service
    management.

8
CCM Program Administrator
10
8
things
to know
  • DMAS will contract through a Request for Proposal
    (RFP) process with an experienced and accredited
    company in CCM services.
  • Key Vendor Requirements include
  • Current URAC and/or NCQA accreditation for
    disease management and/or Case Management and
    maintain a good standing with the organization
  • Minimum three years of chronic care management or
    disease management experience, with at least one
    year with Medicaid populations in Virginia or
    other States and
  • Experience in the management of high risk members.

9
CCM Target Population
10
7
things
to know
  • A designated percentage of Medicaid and FAMIS
    (SCHIP) Fee-for-Service participants.
  • Individuals who have been identified through the
    contractors predictive modeling system to be at
    high risk for greater medical costs and/or have
    the highest cost of service utilization.
  • Individuals who are at risk of demonstrating poor
    health outcomes experiencing fragmented health
    care deliver and have high cost utilization of
    services.

10
CCM Target Population
7
things
to know
  • Exclusions to Participation in CCM
  • Have third party liability (TPL)
  • Live in an institutional setting such as a
    nursing facility
  • Are enrolled in Medicaid/FAMIS managed care
    organizations (managed care organizations already
    provide DM services to their beneficiaries)
  • Live in an intensive care facility / mental
    retardation facility

11
CCM Target Population
7
things
to know
  • ContinuedExclusions to Participation in CCM
  • Enrolled in hospice
  • Enrolled in PACE (Program of All Inclusive Care
    for the Elderly)
  • Are qualified for enrollment in the Virginia
    Healthy Returns Disease Management program and
  • Those with dual enrollment (Medicare Medicaid).

12
Toll-Free Call Center
10
6
things
to know
  • The contractor will provide a Call Center
  • For enrollees and providers and
  • To provide Health related support.
  • Available seven days per week
  • Minimum hours from 700 a.m. to 700 p.m.
  • Contractor will have a process for handling
    emergency situations or calls outside hours of
    operation

13
Two-Tier Care Management Model
10
5
things
to know
  • Based on a risk score from the predictive
    modeling
  • system, enrollees will be placed into either
  • Tier-1 - High Intensity Care Management
  • Who have the highest predicted cost and are at
    highest medical risk
  • Who require a face-to-face initial comprehensive
    health care assessment
  • Will receive telephonic contact from the Care
    Manager at a minimum of once per month and
  • Will receive communication from the Care
    Management Team via mail and other methods on a
    monthly basis.

14
Two-Tier Care Management Model
5
things
to know
  • Tier-2 - Low Intensity Care Management
  • Are at a lower predicted cost and health risk
    than Tier-1 Participants
  • Do not require face-to-face Care Management
    except for unusual circumstances, which are
    determined by the Care Manager or care team and
  • Receive telephonic contact at a minimum once per
    month, as well as mailings and other methods of
    communication on a monthly and quarterly basis.

15
Predictive Modeling
10
4
things
to know
  • Predictive Modeling (PM) is at the core of CCM.
  • It is both a system and methodology that uses
    data to identify persons who have high health
    care needs and are 'at risk' for above-average
    future health care utilization.
  • Assesses prospective health care risk and not
    just current risk to identify high-risk patients
    before they become high-cost patients.
  • Identifies patterns of care that are likely to
    lead to higher (preventable) costs. These
    patterns of care are mapped to specific
    interventions that are expected to improve health
    outcomes and control costs.

16
Predictive Modeling
4
things
to know
  • Uses evidence-based guidelines to suggest the
    appropriate approach and treatment by a care.
  • Performs basic risk scoring tasks, which
    include physical/clinical elements, but also
    psycho-social, mental health, and behavioral
    elements.
  • Recognizes service gaps in care for enrollees.

17
CCM Care Management
10
3
things
to know
  • Each enrollee will have an assigned Care
    Manager(CM) who is a part of a Care Management
    Team.
  • The Care Management Team includes health
    professionals with a diverse knowledge base and
    experience in physical, mental, and psycho-social
    health care.
  • CM must be a healthcare professional who is
    trained and has experience working with
    chronically ill patients and their conditions.

18
CCM Care Management
3
things
Care Manager duties include
to know
  • Provide face-to-face and telephonic
    interventions
  • Participate in the development of holistic health
    care assessments with the enrollee, caregiver or
    legal guardian, and other necessary parties
  • Includes conducting a baseline health status and
    health literacy assessment
  • Participate in the development and monitoring of
    individual treatment plans to promote adherence
    to medical treatment and guidelines
  • Monitor the enrollees care and utilization of
    service while educating and training them for
    self-management.

19
CCM Care Management
3
things
CM duties Continued
to know
  • Educate enrollees on identified health needs and
    self-management activities through group and/or
    private meetings
  • Assist enrollees in making contact with providers
    and community agencies when appropriate
  • Give support to direct health care service
    providers
  • Coordinate participant care including
    establishment of coordination between health care
    service providers, the participant, and the
    community and
  • Develop and implement interventions for
    achievement of treatment plan and care plan
    objectives.

20
Goals of CCM
10
2
things
to know
  • Identify, evaluate, and manage the chronic
    disease state(s) of the highest cost and highest
    risk Medicaid and FAMIS Fee-for-Service clients.
  • Produce a cost savings to the State.
  • A mixture of immediate and long term financial
    savings.
  • Reduce in-hospital admissions, non-emergent
    emergency department use, and other unnecessary
    utilization of services.

21
Goals of CCM
2
things
to know
  • Integrate preventive care into a clinical
    management model for participants.
  • Coordinate and reduce unnecessary or
    inappropriate medication use.
  • Establishment of participant care coordination
    between health care service providers, the
    participant, and the community.

22
Implementation Timeline
1
10
things
to know
  • DMAS posted a Request For Proposal (RFP) on July
    16, 2008.
  • Closing date for accepting proposals is September
    24, 2008.
  • Implementation 2009

23
The End
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