ADSA Chronic Care
Management Program
Controlling Medicaid costs and
improving health outcomes
CHRONIC CARE
MANAGEMENT
National Academy For State Health
Policy
October 5, 2011
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A Look At The Scope of the
Problem:
Making the Case for Chronic
Care Management
• “What is right with you is a lot more
powerful than what is wrong with
you”
•
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Washington State Medicaid Impact
•
Five percent of WA Medicaid
clients account for 50
percent of the costs.
•
They are consumers of LTC
•
Are diagnosed with
depression and chronic pain.
•
Current health care system is
focused on acute care and
misses working with clients
with chronic conditions from
developing complications.
C Goehring
How did we frame the
ADSA Model of Chronic
Care Management?
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Section 2 – The Impact of Chronic Conditions on Health Care Financing and Service Delivery
Health Care Spending Increases with the
Number of Chronic Conditions
Compared to individuals
with no chronic
conditions:
Average Per Capita Health Care Spending
• Spending is almost three
times greater for someone
with a chronic condition
• Spending is over seven times
greater for someone with
three chronic conditions
• Spending is almost 15 times
greater for someone with five
or more chronic conditions
Source: Medical Expenditure Panel Survey, 2006
Robert Wood Johnson Foundation Synthesis Project
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Section 1 – Demographics and Prevalence
Over One in Four Americans Have
Multiple Chronic Conditions
Percentage of All Americans
• In 2006, 28 percent of
all Americans had two
or more chronic
conditions.
Source: Medical Expenditure Panel Survey, 2006
Robert Wood Johnson Foundation Synthesis Project
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Section 2 – The Impact of Chronic Conditions on Health Care Financing and Service Delivery
Health Care Spending Often Doubles for People
With Chronic Illnesses and Activity Limitations
Average Annual Health Care Expense Per Person
Source: Medical Expenditure Panel Survey, 2006
Robert Wood Johnson Foundation Synthesis Project
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Washington State
Aging and Disability Services Administration
Chronic Care Management (CCM)
ADSA Chronic Care Management:
•
Eligible beneficiaries use home & community-based services and are
at high risk for utilization of medical services.
•
Provides interventions for the medical, social, economic, mental
health, chemical dependencies, and environmental factors impacting
health and health care choices.
•
State Plan Amendment Approved 12/2010
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The CCM Intervention
•
Nurse care manager to client ratio 1:50
•
•
Primarily face to face with telephone support as needed.
Evidence-based protocols include:
•
Diabetes management
•
Medication management
•
Pain management
•
Health Action Planning
•
Fall assessment and prevention
planning
•
Coaching for Activation ™
•
Comprehensive Assessment including Patient Activation
Measure (PAM™)
•
Client-centered Health Action Plan and Goal Setting
Worksheet
•
Set goals with client according to activation level
•
Education towards self-management of chronic illness
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Risk Determinants
High medical cost and risk client determinants
Predictive modeling (PRISM)

Past twelve months medical claims, gender and age determine
future medical costs and risk.

Diabetes, cardiovascular disease, mental health and substance abuse
(highest diagnosis frequencies).

Pharmacy, inpatient care, and emergency room utilization (highest
cost utilization)

Care opportunities identified (avoidable or reducible care)

Risk Score in top 20%
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LTC Risk Determinants
Comprehensive Assessment Resource Evaluation (CARE) LTC
risk criteria (presence of one)
1.
Client lives alone
2.
High risk moods/behaviors (agitation/irritable)
3.
Self health rating is fair or poor
4.
Overall self-sufficiency declined in last 90 days
5.
Greater than six medications
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Tailored Client Coaching Approach
The client:

Is in charge of the care plan;

Sets the pace for change based on perception of need and readiness
for change.
The nurse’s role:

Encourage client confidence - that their actions can make an impact
on their health and independence

Discuss and offer options and education that allow the client to
increase their ability to manage their own care to improve quality of
life and/or health outcomes

Ask the client what ideas they have to better manage their health
care.
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Health Action Plan
•
Identify diagnosis affecting health outcomes.
•
Identify client identified goals, interventions, and goals.
•
Use Goal and Action Planning Worksheet with the client and
their identified supports.
•
Update with the client at each contact reflecting client;

Barriers

Successes

Changing priorities
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Predictive Risk Intelligence System
(PRISM)
• Decision support tool designed to support care
management interventions for high-risk Medicaid patients

Identification of clients most in need of comprehensive care
coordination based on risk scores developed through predictive
modeling

Integration of information from medical, social service, behavioral
health, and long term care payment and assessment data systems

Intuitive and accessible display of client health and demographic
from administrative data sources
• Serves over 200 users with 28 distinct population groups,
and continues to evolve to meet changing program needs
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PRISM Screens
Episodes
Eligibility
Claims
Office
RX
IP
ER
LTC
Lab
Providers
AOD
MH
CARE
HRI
Key medical and behavioral health risk areas
Detailed eligibility and demographic data
All medical claims and encounters
Office visits
Prescriptions filled
Inpatient admissions
Outpatient emergency room visits
Long term care services
Laboratory
Provider list with links to contact information
Alcohol and Drug treatment
Mental health services
Long-term care functional assessments
Health risk indicators
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C Goehring
EXAMPLE 1.
Episodes
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Uses of PRISM
•
Medical evidence gathering for determining eligibility for
disability-related medical coverage
•
Triaging high-risk populations to more efficiently allocate
scarce care management resources; for example, stratifying
by recent inpatient and emergency department activity
•
Identification of child health risk indicators for high-risk
children [mental health crisis, substance abuse, ED use,
nutrition or feeding problems]
•
Identification of behavioral health needs [redacting
information where required by state and federal law]
•
Medication adherence monitoring
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Uses of PRISM continued
•
Identification of other potential barriers to care,

Patient’s housing status (e.g., whether they are homeless)

Hearing impairment

Non-English primary language
•
Access to treating and prescribing provider contact
information for care coordination
•
Creation of child health summary reports for foster
parents and pediatricians
•
A source of regularly updated contact information from
the medical eligibility determination process
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Strengths of PRISM
•
“One-stop shopping” for information from administrative
data systems across medical, behavioral health and longterm care systems
•
An intuitive user interface
•
Data refreshed weekly
•
The ability to create and share a comprehensive profile of a
client
•
State-of-the-art prediction of prospective medical costs
•
Data on psychosocial risk factors, including behavioral health,
homelessness, and functional limitations from care
coordination assessments.
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Limitations of PRISM
•
The relationship between traditional measures of medical
risk and “impactability” is not well understood
•
Many quality measures derived from payment data have
limited empirical data to support their relationship to health
outcomes in complex populations
•
Data quality issues, such as the accuracy of behavioral health
diagnoses recorded by medical professionals (e.g.,
misdiagnosis of bipolar disorder as depression)
•
PRISM is not an electronic medical record: lab results and
clinical notes are not currently linked into the application
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Limitations of PRISM
•
Potential for incomplete information

Lags in processing claims and submitting encounter data

Claims paid through separate coverage like Medicare or private
insurance

Services paid out-of-pocket

Redaction of chemical dependency treatment system data where
written consent documentation process is not in place
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Contact Information
Candace (Candy) Goehring RN MN
Washington State DSHS
Aging and Disability Services Administration
360-725-2562
[email protected]
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ADSA Chronic Care Management