Social Determinants in Vulnerable Populations, Impact on Medical Management

Presented by Paul Alexander, MD, MPH at Empower 2016 on May 5, 2016

Many health plan highest utilizers face challenges with basic survival needs that cause the to make trade-offs with their health care needs. Access to housing, food, income and transportation often become barriers for this population in seeking appropriate care. Dr. Alexander discusses how you can identify and address the social determinants your highest utilizing health plan members are facing and efforts to more effectively manage costs and achieve better health outcomes.

Transcript

1. Paul Alexander, MD, MPH Horizon Blue Cross Blue Shield of New Jersey Hosted By
2. Social Determinants In Vulnerable Populations 2 Social Determinants
4. Presentation Outline 4 Social Determinants Social determinants stemming from poverty affect s Medicaid member health Traditional one-size fits all care management models leave vulnerable members struggling Newer chronic care models break away from provider-in-a- box constraints Strategic engagement with members is critical to driving success
5. Social Determinants 5 Social Determinants
6. Social Determinants 6 Social Determinants
7. Social Determinants 7 Social Determinants
8. Social Determinants 8 Social Determinants
9. Social Determinants 9 Social Determinants
10. Social Determinants 10 Social Determinants
11. Social Determinants Impact Health World Health Organization defines social determinants of health as: The conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life. 11 Self actualization Self-esteem Belonging (friends, family, community) Safety (security, shelter, access) Physiological Needs (food, water, warmth, and financial) The Maslow’s Hierarchy of Needs
12. Risk Factors Leading to Premature Death 12 A Robert Wood Johnson Foundation study found as much as a 25-year difference in average life expectancy between poor inner city residents and suburb residents.1 1 . Robert Wood Johnson Foundation Commission to Build a Healthier America. City maps. http://www.rwjf.org/en/library/features/Commission/resources/city-maps.html(www.rwjf.org). 2. https://kaiserfamilyfoundation.files.wordpress.com/2015/11/8802-figure-1.png
13. Horizon NJ Health Medicaid Experience 13
14. Horizon NJ Health Medicaid Experience 14
15. Horizon NJ Health Medicaid Experience 15
16. Member Priorities 16
17. The effect of behavioral health on physical health can not be underestimated…. Disproportionate percentage of high utilizers struggle with behavioral health issues and severe mental issues 17 25% NJ Medicaid high utilizers with identified behavioral health issues, 44% with severe mental illness 25% NJ Medicaid average utilizers with identified behavioral health issues, 10% with severe mental illness Source: Rutgers Center for State Health Policy, Role of Behavioral Health Conditions in Avoidable Hospital Use and Cost, November 2014.
18. Cost Mitigation Starts at the Top High-risk members defined by 4+ IP stays or 6+ ER visits over the course of 1 years, account for 60% of overall cost! 18 5% High Risk 10% – 15% Emerging Risk Low Risk ~5% of Medicaid’s 68 million enrollees account for 60% of overall costs ~ 5% Source: The PEW Charitable Trusts, States Focus on ‘Super-Utilizers’ to Reduce Medicaid Costs, December 5, 2014.
19. Horizon NJ Health Long Term Support Services Experience 19  Coordination and management of long term care services, home visits, Providers, DME and transportation require collaboration, a success factor  Redirecting to community with adequate support will provide the least restrictive setting and is often the most cost effective  A successful MLTSS programs requires significant resources AND deep significant community engagement
20. Horizon NJ Health MLTSS 20
21. Horizon NJ Health MLTSS 21
22. Time to Rethink Traditional Models of Care “Medicaid members are significantly more likely to report having difficulty finding a doctor or delaying care because their health insurance coverage isn’t widely accepted.”2 -Steven Zuckerman, co-director and senior fellow with Urban Institute’s Health Policy Center Demand for physicians continues to grow faster than supply, with a forecasted shortfall of between 46,100 and 90,400 physicians by 2025.3 22 Americans get their health care through Medicaid, 70.5 million in total1 1 in 5 Source 1: Centers for Medicare and Medicaid Services, Medicaid & CHIP: February 2015 Monthly Applications, Eligibility Determinations and Enrollment Report, May 1, 2015. Source 2: U.S. News and World Report, You’ve Got Medicaid – Why Can’t You See the Doctor?, May 26, 2015 Source 3: Association of American Medical Colleges, The Complexities of Physician Supply and Demand: Projections from 2013 to 2025, March 2015.
23. Care Coordination Opportunities for High Utilizers 1. Emergency Room Outreach  Identification of patients at high volume ERs. Set up follow-up appoints with PCP, Dentist, Social Work, BH Therapist 2. In-Home Intensive Programs  Patient-centered in-home models that develops care plans, addresses gaps in care and improves care coordination. Behavioral health specialists can be included if needed 3. Post-Acute Transition of Care Programs  Transition support services to reduce 30-day readmissions 4. Complex Care Management Programs  In-home and telephonic care model that stabilizes health status, closes gaps in care and facilitates care transitions. 23
24. Successful Chronic Care Coordination? 24 1. Engage your high-risk members  Use a multi-level contact method – call, email, text, mail and visit door to door 2. Face-to-face contact with patients  Frequent face-to-face contact with patients (~1/month) 3. Small enough caseload (e.g., 50-80)  Continuous assessments, training and feedback to care managers 4. Rapport with physicians and members  Face-to-face contact, regular hospital rounds, accompanying patients on physician visits, care coordinators assigned to patients 5. Culturally sensitive patient education  Provide evidence-based patient education / intervention, including how to take Rx correctly and treatment adherence 6. Manage care setting transitions  Timely, comprehensive response to care setting transitions (most notably from hospitals) 7. Medication management  Comprehensive Rx management, involving pharmacists and/or physicians 8. Address psychological issues  Staff with expertise in social supports for patients who need it Source: Care Coordination For The Chronically Ill Alliance- Healthcare Reform Briefing- Randy Brown, Mathematica Policy Research Aug 2011
25. Increased Access…Opportunity to Shift Primary Care Volumes 25 Annual Visits to PCPs Annual ED Visits Visits Eligible for NP-Led Care 103M 47M 132M Non-urgent ED Visits Shifted to Other Care Sites 573M 18 percent of PCP visits could be handled by NPs at convenient care sites Non-urgent ED visits could be treated at urgent care, retail or primary care Visits At Risk of Shifting To Other Sites of Care Source: CDC/NCHS, "National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey," 2009-2010; “Primary Care Physician Shortages Could be Eliminated Through Use of Teams, No physicians, and Electronic Communication,” Health Affairs 32:1. Jan 2013. Health Care Advisory Board interviews and analysis. Redistributing Non-Emergent Care to Appropriate Lowest-Acuity Sites
26. Making a Difference in Lives of Our MLTSS Families The Story of Cheryl & Andy… 26
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