Transcript www.mnaging.org

An Innovative Care
Management Model for
People with Disabilities
2013 Age & Disabilities Odyssey Conference
Jeri Peters, Chief Nursing Officer
June 18, 2013
French River 1, City Side
Objectives
• Participants will learn about UCare’s experience in
designing a care model.
• Participants will gain an understanding of how a
stratification process can be utilized to manage rapid
enrollment of a large group of individuals with
disabilities.
• Participants will understand UCare’s lessons learned
about this new care model and how to work effectively
with internal and external care managers.
Our Mission
UCare will improve the health of our members
through innovative services and partnerships
across communities.
About UCare
• Founded in 1984 by faculty in the Department of Family
Medicine and Community Health at the University of
Minnesota
• Initiated to ensure family medicine residents would have a
clinic setting to complete residency program
• Started as demonstration project serving 100 people;
today, UCare is Minnesota’s fourth-largest health plan
with more than 300,000 members
• Committed to serving Medicaid and Medicare
beneficiaries with innovative, high-quality health care
programs and services
Serving Minnesotans Statewide
Current Membership
323,270 members – 05/2013
150,449:
35,099:
3,081:
19,189:
9,549:
88,487:
6,968:
10,448:
Medical Assistance
MinnesotaCare
Minnesota Senior Care Plus
SNBC (Disability)
MSHO (SNP)
Medicare (Minnesota)
Medicare (Wisconsin)
Supplement & ASO
Member Demographics
UCare serves a culturally diverse
mix of over 300,000 members
PMAP
Caucasian
African origin
Asian origin
Hispanic (all origins)
Native American
Other
35%
30%
19%
11%
2%
3%
69%
12%
9%
4%
1%
5%
MnCare
43%
26%
17%
9%
2%
3%
State Public Prog.
Our Employees are Diverse
CAUCASIAN – 79%
BLACK or AFRICAN AMERICAN – 9%
ASIAN – 8%
TWO or MORE RACES – 2%
HISPANIC – 1%
UCare’s Approach to Managed Care
• Program flexibility and support services tailored
to individual needs
• 40% consumer representation on Board of Directors;
three member advisory committees
• Expertise in cooperative work with federal, state, and
local governments, and community partners
• Innovative risk and service partnerships with care
systems and providers
Getting Started
• Created a workgroup of social workers, nurses, disability
experts and physicians
• Reached consensus agreement on definition of care
coordination
• Established a set of guiding principles to build our model
around
• Selected core model structure
• Defined key requirements & assumptions
• Reviewed contractual obligations
• Analyzed internal & external resources
Care Coordination
"Care coordination is the deliberate organization of
patient care activities between two or more participants
(including the patient) involved in a patient's care to
facilitate the appropriate delivery of health care services.
Organizing care involves the marshalling of personnel
and other resources needed to carry out all required
patient care activities and is often managed by the
exchange of information among participants responsible
for different aspects of care."
AHRQ: Care Coordination Measures Atlas, Chapter 2
Standard Care Models
Medical Model
• Coordinate medical treatments for high-cost beneficiaries, provide chronic care
treatment & support, and pharmacy management.
• Example: PCMH, HCH
Social Model
• Offer information & referral, screening, assessment, care planning, monitoring .
Typically limited to long-term services and do not address medial care.
• Assisted Living
Integrated Model (may be fully or partially integrated)
• Bridge the medial and supportive services. Generally include the coordinated
integration of both Medicare & Medicaid benefits.
• MSHO, PACE
UCare Connect Basics
• Special Needs Basic Care (SNBC) program designed by
the Minnesota Department of Human Services (DHS)
• Be at least 18 years old and under age 65
• Be eligible for Medical Assistance
• Must have a certified physical disability, developmental
disability, and/or mental illness
• Medicaid eligible, however may have dual coverage
Guiding Principles
• High-touch processes that build relationships with
members
• Efficient processes that would work with many members
quickly
• Community partnerships
• Sustainable financial and staffing models
• Must meet payer & regulator requirements
• Include the Triple Aim concept
• Needed to build model that would evolve over time
Key Assumptions
• Input from members was critical to model development
• Feedback from providers and delegates will be
incorporated
• Members have variable needs for support and needs vary
over time
• Case management resources in local communities know
members and offer good services
• Behavioral health issues affect many SNBC members
Model Construction
• Began with minimal clinical and utilization information
• Conducted a literature search
• Consulted with experts
• Evaluated past experience with MnDHO
• Outlined DHS contract requirements for care model
• Reviewed Medicare model of care requirements &
structure
• Built a stratification process
UCare Connect Care Model
• Designed to provide support and assistance to help individuals navigate
complex health systems
• Based on a well accepted risk analysis and case management
identification tool
• Members are stratified and assigned a risk score
• Offers five care management options based on risk score/health needs
• Collaborate with counties and lead agencies on long-term care benefits
• Care coordination provided by both external (delegates) and internal
staff
• Utilizes a combination of field & telephonic staff
• Service area consists of 41 counties in Minnesota
• UCare manages the Medicaid benefits (effective 2012)
UCare Connect Care Model
• All members are stratified based on business rules
• All members are assigned a Care Navigator who may assist the member in:
• Accessing preventive care
• Establishing a primary care provider
• Making referrals for other services as needed
• All members receive a welcome call from Member Services to:
• Help UCare better understand the member’s health care needs
• To promote the member’s engagement in their care
• All members are offered a Health Risk Assessment (HRA) within 30 days of
enrollment
• Model is designed to allow members to move along a continuum of care
• Unique, sophisticated model based on limited data using a validated risk
grouper
Stratification: An Innovative Approach
Inputs
Member
Demographics
Claims History
Business Rules
HRA Data
Business Rules
Business Rules
Business Rules
Outputs
Risk / Need Status
Data Source
Extracts / Data
Processing
Data Outputs
Data Source Extracts / Data Processing Data Outputs
Member Stratification
Care
Management
Assignment
Stratification
(Johns Hopkins ACG grouper)
Clinical stratification based on
interventions/care needs
All members are stratified
initially and then restratified
on a quarterly basis
HRA results
DHS demographic & claims
data
Establishes initial Case
Management Index Score
Stratification Levels
Low
At Risk
High Risk
• 70-80% of the Population
• Lower relative risk based on lower severity, acuity/ chronicity
and utilization
• Minimal Coordination of Care Needs
• 3-5% of Population
• At Risk based on severity, acute events, and comorbidities
• No extensive issues
• May require transition of care
• Referred for Complex Case Management
• 15-20% of Population
• High risk based on CMI (severity, multiplicity of comorbidities, utilization, cost
• Dependent on Community Based, ongoing care coordination
(delegate partners)
Different Needs,
Different Care Management Options
All members, plus those with low-level
needs:
We need more information or assurance
that member’s needs are being met…
Care Navigator
Follow-up
Member needs high-level assessment…
Team Review
Recent hospitalization or serious medical
illness…
Complex Case
Management
Member is likely to have significant
ongoing care needs (medical or
behavioral)…
Delegated Case
Management
Surveillance
Different Needs,
Care Navigator
Different Care Management Options
• Designated employee whose primary focus is to
support and assist the member.
• Works with county social workers, medical and
mental heath professionals, and other community
programs.
• Assists members in accessing medical, mental
health, and chemical dependency services.
• Assists members in accessing other benefits.
Different Needs,
Different Care Management Options
Team Review
• Includes medical director, navigator, and care manager.
• Use structured discussion tool and HRA summary.
• Goal is to disposition the case.
• Up to 50+ reviews in ~ 90 minutes.
• 598 reviews completed through June.
Different Needs,
Complex Case Management
Different Care Management Options
Two types:
Acute Medical Case
Management
Transition Management
• Focus on short-term, episodic
care coordination.
• Focus on admission and/or
readmissions.
• Provide condition specific
education.
• Members have acute
chronic needs.
• Assist with arranging home care
services, etc.
• Make referrals to community
resources.
Different Needs,
Delegated Case Management
Different Care Management Options
• Contracts with community agencies and counties.
• Delegates have expertise in serving adults with disabilities.
• Members assigned to delegated case management receive:
• Face-to-face assessment.
• Comprehensive plan of care.
• Quarterly check-in with case manager.
Different Needs,
Different Care Partners
Counties
Medical
Services
Long-term
Care
Providers
Community
Agencies
Health
Plan
Different Needs,
Different Care Partners
• Counties: Chippewa, Lac Qui Parle, Faribault, Martin, Mille Lacs,
Olmsted, Pine, Sherburne, Stearns
• Community Agencies: AXIS Healthcare, Brain Injury Assn – MN,
BlueStone Physicians, Mental Health Resources *, Minnesota Visiting
Nursing Agency*, South Metro Human Services, The Guild, Lutheran
Social Services**
• Medical Services: > 7,000 primary care providers, >15,000 specialty
providers, medical homes where available
• Long-term care providers: collaborate with counties for PCA, PDN,
and waiver services
• Health Plan: Care Navigators, Benefits Specialists, TOC Management
*Complex case management ** legacy members
Key UCare Connect Member Benefits
• No premiums or co-pays
• Dental benefit includes UCare’s See-A-Dentist Guarantee℠,
UCare’s Mobile Dental Clinic, and DentaQuest’s network
providers
• Transportation through UCare’s Health Ride for all eligible
members, including those who need to see providers located
outside of their county of residence
• Free monthly membership at a SilverSneakers®-participating
fitness club
• Fitness kit with tools and information to help improve fitness at
home
• A second dental cleaning and exam each year
UCare Connect Clinical Advantages
• Disease management:
• Members have access to disease management programs for
asthma, diabetes and heart failure
• Health and wellness:
• Members have access to all of UCare’s health and prevention
programs, including annual check-ups, maternity care,
fitness programs
• Health risk assessments:
• The assessment is designed for individuals with physical
disabilities, developmental disabilities, and behavioral health
disabilities
• Offered online in multiple languages
Measuring Health Outcomes
• HEDIS scores
• CAPHS/HOS surveys
• Internal clinical & quality indicators:
• PCP visit rate
• Preventive care screenings
• ER visit rate
• Dental visit rate
• Admission/Readmission
rate
• Member satisfaction
Lessons Learned
• Member-centric, holistic care is the focus
• It takes a team
•
•
•
•
•
Members
Families/ significant others
Both internal & external care management partners
Primary care providers
Regulators & payers
• Active, Interdisciplinary Care is critical
• Integrate care strategies are organized around the members need
• Ongoing, close collaboration with providers and care givers to coordinate all
aspects of medical, behavioral, social, spiritual, and community needs
• Team composition and respective roles are based upon member needs and
practice capacity
Lessons Learned
• There is no gold standard care model
• It depends on the needs of your members
• It depends on your local circumstances
• It depends on your goals
• Positive health outcomes
• Client satisfaction
• Cost containment
• Building a model with multiple subsets requires a high
degree of flexibility.
• Partner closely with providers & community agencies.
• The only constant in care management is the member.
Member Stories
Judy
“I keep losing track
of time and don’t
remember how I got
places”
Ralph &
Mary
A couple with
Diabetes
Mike
“I need a dentist”
For More Information
Jeri Peters
Chief Nursing Officer, UCare
[email protected]
612-676-3655