Care Management for
Children with Chronic
Conditions:
Health Plan vs. Primary Care
June 24, 2004
Project Partners

Maternal Child Health Bureau


Children’s Hospital & Regional
Medical Center (CHRMC) –
Center for Children with
Special Needs




Study period: July 1, 2002 – June
30, 2006
John Neff, MD
Virginia Sharp, MA
Jean Popalisky, RN, MN
Regence BlueShield


Tracy Fitzgibbon, RN
Kristin Myers
June 24, 2006
2
Project Goal & Objectives

Develop, implement and evaluate a
cost effective quality care management
program for children with chronic
conditions (CCC)


Identify and classify CCC for case
management using Clinical Risk Groups
(CRG) software (health plan).
Develop a range of reimbursement
strategies case management in other
settings (primary care).
June 24, 2006
3
Health Plan Case Management

Implementation Elements:




Identifying CCC using Clinical Risk Groups
software
Developing tools
Contacting members
Project management

June 24, 2006
Difficulty defining meaningful outcome
measures
4
Health Plan: Case Management
Identification Summary

315 CCC identified for CM screening




CRGs + utilization filters
72 eliminated
120 unable to contact
123 CCC contacted

87 members screened using the 22-item CM
screening tool
 46 members (53%) opened case
management
June 24, 2006
5
Health Plan Activities
Health Plan Case Management Activities,
N=165
1%
Education: Health Care
System & Services
2%
Needs & Health
Assessment
13%
32%
Community Service
Referral & Coordination
Assistance with Health
Plan Issues
22%
30%
Financial Planning
Assistance
Transition Assistance
June 24, 2006
6
Health Plan Cost Savings

$291,295



1.5 FTE Nurse Case Managers
19 month timeline
Regence cost-savings methodology
June 24, 2006
7
Health Plan: CM Screening
Tool Analysis

Five CM screening tool questions used
to identify need for case management:

Areas of concern:




Access/Organization of services (3 questions)
Out-of-pocket expenses (1 question)
Family stress (1 question)
22-items could be reduced to 5 items
June 24, 2006
8
Health Plan: Case Management
Summary

Predictive Modeling:



Engagement rate = 37% of members contacted
Interventions:





CRGs + utilization filters + screening = “actionable” children
with chronic conditions
member education
needs assessment
community resource coordination
benefit management
Value:


Cost savings of $291,295 over 19 months
Members report case management impact
June 24, 2006
9
Primary Care Case Management

Implementation Elements:



Identify CCC for case management
Develop tools
Define outcome measures meaningful to
the health plan
June 24, 2006
10
Primary Care: Tracking
Activities


All clinic staff involved in tracking
Information collected:






Type of intervention (existing CPT codes)
Duration of intervention
Provider type performing intervention
Direct outcome of intervention
Avoided outcome as result of intervention
Tracking forms faxed to health plan at regular
intervals for entry into database
June 24, 2006
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Primary Care: Tracking Results

Clinic #1



454 tracking forms on 83 CCC
Engagement rate = 83%
Clinic #2


813 tracking forms on 84 CCC
Engagement rate = 84%
June 24, 2006
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Primary Care: Care Planning
Activities

MD’s to do WRITTEN care plan






Short-term goals: 3 – 6 months
Include strategies for reaching goals
Include input from families
Revise when indicated
Document progress toward goals
Care plans faxed to health plan when
completed
June 24, 2006
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Primary Care: Written Care
Planning Results

Clinic #1

Submitted 38 care plans


Family input included on 16 care plans
Clinic #2

Submitted 5 care plans

June 24, 2006
Family input included on 3 care plans
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Primary Care Activities
Primary Care Case Management Activities,
N=1083
10%
Family Support
13%
Disease Mgmt
49%
28%
June 24, 2006
Medication &
Equipment Mgmt
Referrals for Specialty
Care
15
Primary Care Cost Savings

$44,434 Avoided Out-patient services



241 avoided ER visits @ $146/visit
136 avoided Pediatric clinic visits @
$68/visit
32 Avoided In-patient episodes
June 24, 2006
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Primary Care: Case Management
Summary

Predictive Modeling:



Engagement rate = 83.5%
Interventions:



CRGs + utilization filter + staff selection
family support activities
condition management activities
Cost savings:

avoided services
June 24, 2006
17
Side-by-Side Comparison
Factor
HPCM
PCCM
Predictive Modeling
CRG + Utilization filters +
Screening
CRG + Utilization filters +
Staff selection
Engagement rate
37% of CCC contacted
83.5% of CCC identified
Type of
interventions
Educational, Financial
Family Support, Condition
management
Cost savings
$291,295 by 1.5 FTE over
19 months
OP: $44,434 in 7 months;
IP: 32 episodes in 7
months
Fee negotiation, lower
level care, network
providers, etc
Avoided services
Type of cost savings
June 24, 2006
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Key Learning Points



Health plan case management activities
and primary care case management
activities are unique
Primary care providers identify, contact,
and engage patients more efficiently
and effectively than health plan
Both settings produce short-term cost
savings from different sources
June 24, 2006
19
Recommendations

Comprehensive care coordination for
the families of CCC should integrate the
unique case management activities
from the health plan and primary care
into a single, cooperative effort
June 24, 2006
20
Contact Information:
John Neff, M.D.
Jean Popalisky, MN
1100 Olive Way, Suite 500
Seattle, WA 98101
Phone: 206-987-5275
Fax: 206-987-5741
Email: john.neff@seattlechildrens.org
1100 Olive Way, Suite 500
Seattle, WA 98101
Phone: 206-987-5326
Fax: 206-987-5741
Email: jean.popalisky@seattlechildrens.org
Tracy Fitzgibbon, RN
333 Gilkey Road, MS: BU270
Burlington, WA 98233
Phone: 360-755-2755
Fax: 360-755-4576
Email: tfitzgib@regence.com
June 24, 2006
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