A New Approach to Delivery: POD Model of Care

Presented by Camille Kurtz, RN, BSN, MA at the Executive Leadership Summit on March 24 - 26, 2015.

This presentation concentrates on two key initiatives of Affinity Health Plan in New York. First was to shift medical management from a transactional to a member-focused mindset with higher provider collaboration. Second, the goal was to manage cost of care and maximize better outcomes by identifying the most impactful members. The presentation covers the importance of resourcing a metric-based approach in staff performance and in member outcomes.

Transcript

1. Camille L. Kurtz RN, BSN, MA Executive Director, Medicare Affinity Health Plan, Inc.
2. Member-Centric Medical Management 2
3. Outline • Purpose and Objective • Transactional UM/CM • Disease Management • New Model Highlights • PODs • Care Coordination/Care Management • Productivity Metrics • Member Outcomes • Model Benefits 3
4. Purpose and Objective • Participants will: – Be able to distinguish the differences between transaction and member-centric management – Learn what are the drivers of UM/CM model change – Learn of benefits to the health plan – Learn of benefits to the member – Understand how the change in care delivery requires a change in the medical management model 4
5. Transactional UM/CM • Principles: – Minimize utilization of services in order to reduce costs – Deny services rather than approving appropriate services in order to manage members in lower level of care – Focus on location and duration of services provided in order to reduce cost – UM nurses are not CM or DM nurses 5
6. Disease Management • Principles: – Manage utilization and cost by single focus on one of many prevalent chronic diseases – Develop and advise member on how to master their own disease management – Expect improved outcomes on one disease only 6
7. Member-Centric Medical Management • Principles: – All nurses are Care-Coaches/Managers - Nurses are assigned members, not tasks – Members have multiple diseases – Members would prefer not to be admitted – Standard Clinical Guidelines/Clinical Pathways have solved for the majority of UM decisions – Being in an insurance company requires interdisciplinary member management – Member-Centric Medical Management is not from 9 to 5 – Relationship building between provider, SW, facility of care, caregiver and member is critical – Managing transitions of care well is an imperative 7
8. Member-Centric Medical Management • Focuses on relationship-building between the coach and the member for ongoing continuity of care • Provides the member with a main coach contact both in-house and in the field • Improves provider relationships with facility-based UM/Discharge staff 8
9. How to Execute New Model • Reposition Medical Management from functional/transactional areas to integrated member-centric care management PODS • PODS – member assignment should be either facility, regional, or zip code driven • Focus away from telephonic disease-specific coaching model to mixed telephonic/field-care management • Medical Management model is highly focused on transitions of care, preventing re-admits and keeping members home-based • Model is LOB agnostic 9
10. How to Execute New Model • Member Stratification – Capturing the right members at the right point in their wellness/health/illness continuum: • Ensure sufficient behavior modification toward member compliance with self-management in order to maximize their wellness, independence and normalcy for their illness/chronicity 10
11. How to Execute New Model • Transition of Care: – Reduce excessive use of ER services – Reduce admissions/re-admissions – Reduce use of nonessential ancillary services • Member-Centric Medical Management: – Ensuring the members see their PCP – Explore needed specialty services to manage specialty needs and prevent inpatient care; – Adhere to medication regimes and treatments, including annual preventive services and, – Pursue services in lower level service locations whenever possible 11
12. How to Execute New Model • Stratification Tools: – Predictive Model/Continuance Tables – HCC Coding Home Assessments (Medicare/HIX) – CRG Home Assessments (Medicaid) – HRAs acuity scored (Medicare and Medicaid) – Facility discharges – TOC all products – MBHO referrals and integrated Medical/Behavioral Case Rounds 12
13. Stratification Target 13 Current Targeted CCM New Model Targets $ TIME A B & C A B C
14. Productivity Metrics • 150 cases per Care Coach • 75 percent engagement in CM on all outreached per month • PHQ9s by SW on all cases failing PHQ2 by CC/RN • Failed PHQ9s referred to MBHO 14
15. Impactful Model Follow the “Impactful Model”: • Highly impactful cases (off program within 36 weeks) • Minimum 4 touches per member, per month • Moderately impactful cases (off program within 24 weeks) • Minimum 3 touches per member, per month • Low impactful cases (off program within 6 weeks) • Minimum 2 touches per month 15
16. Outcomes Metrics • Reduce admissions per 1,000 by LOB • Reduce re-admissions rate • Reduce ER visits • Increase use of ALOC • Increase member medication adherence • Increase PCP visit rates • Increase identification and referrals to Palliative/Hospice • Meet select LOB Quality metrics (HEDIS/STAR) 16
17. Programs to Support New Model • Palliative/Hospice - Increase referrals appropriately near end-of-life • Cancer Care - Reduce hospitalizations associated with chemo- induced illness through proper self-management oversight • PCP Referral Program - PCPs can refer member for a home assessment • Fully Integrated Mental Health TOC/CM - Working with MBHO to execute a fully integrated program with bi-directional referrals and interdisciplinary case management 17
18. Some Results • Medicare Populations – Client # 1 (Fully Field Model) • Re-admit rate at onset of program: 40% • Re-admit rate at end of 18 month period: 20% – Client # 2 (Mixed Telephonic and Field Model) • Re-admit rate at onset of program: 22% • Re-admit rate at end of 18 month period: 15% • Medicaid Population (CHP excluded): – Client # 2 (Mixed Telephonic and Field Model) • Re-admit rate at onset of program: 20% • Re-admit rate at end of 18 month period: 10% * Re-admit Rates Average over rolling 8 weeks 18
19. Programs to Support New Model • New Member and Non-Utilizer Outreach - Outreach to new members upon enrollment to • Assist member with the scheduling of initial PCP visit, post- enrollment • Outreach to non-users, on a quarterly basis, to assist in scheduling and follow-up with PCP visits • Community Service Centers (CSC) - based wellness/health maintenance promotion/services – Field staff performing home visits, also servicing CSC sites by conducting one or more services on a monthly basis (includes, but not limited to BP screenings, blood drawing A1C, LDL/HDL, asthma education, diabetes education, vaccinations (e.g. Flu vaccine), mammography 19
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