Promising Models of Care Coordination for
Beneficiaries with Chronic Illnesses
Presented by:
Paul Shelton, EdD

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Identify promising care coordination/management interventions for beneficiaries with chronic illnesses
Transitional Care
Comprehensive Care Coordination
Describe internal and external evaluation
Describe key distinguishing features of these programs
Policy Implications
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A person-centered, assessment based, interdisciplinary approach to integrating health care and social support services cost-effectively in which:
 an individual’s needs and preferences are assessed,
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 a comprehensive care plan is developed, and services are managed and monitored by utilizing an evidence-based process and an identified Care
Coordinator (New York Academy of Medicine, National
Coalition on Care Coordination).
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Most healthcare dollars are spent on a small percentage of beneficiaries who have complex chronic conditions
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Causes of high utilization and costs:
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Deviations from evidence-based care
Poor communication among primary providers, specialists, health and community providers, patients and families
Failure to catch problems early/patient compliance
Failure to address psychosocial issues
Lack of coordinated, longitudinal management
Ineffective transitional management (hospital - home, hospital nursing home, nursing home - hospital, nursing home - home)
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Intervention with rigorous evidence that:
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Improves patient outcomes
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Reduces total health care expenditures for participating patients
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Improved satisfaction or clinical indicators not sufficient
Net savings require reduced hospitalizations
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Promising care coordination interventions:
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Transitional Care
Coordination (Coleman et al.
2006; Naylor et al. 2004; Perry et al. 2011)
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2.
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Comprehensive Care Coordination
Medicare/Duals - (Boult et al. 2008; Leff et al. 2009; Dorr et al. 2008; Counsell et al. 2007; Medicare Coordinated Care
Demonstration: Best Practice Sites, Brown
2009).
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These programs:
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Engage patients with chronic illnesses while hospitalized
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Follow patients intensively post-discharge
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Teach/coach patients about medications, selfcare, and symptom recognition and management
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Remind/encourage patients to keep follow-up physician appointments
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Care Transitions: Coleman
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Patient-centered intervention designed to improve quality and contain costs for patients with complex care needs as they transition across care settings
Target Population
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Inclusion:
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A) Patients being discharged from the hospital with: stroke, congestive heart failure, coronary artery disease, cardiac arrhythmias, COPD, diabetes, spinal stenosis, hip fracture, peripheral vascular disease, deep venous thrombosis, pulmonary embolism
B) 30 day Medicare readmission for HF, MI, PNE
C) Risk algorithm for readmission drawn from administration data
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Exclusion:
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Dementia with no caregiver, primary psychiatric diagnosis, with psychotic elements, active drug or alcohol use
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Staffing
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APN or RN or social worker or occupational therapist
Caseload: 1 care coordinator (CC) per 40 patients
Duration: 30 days following hospitalization
Focus
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Continuity of care by helping family maintain a personal
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 health record
Help family understand how/when to obtain timely follow-up care
Coach patients to ask the right questions to the right health
 care providers
Help patients/families be more active in managing condition and in developing/implementing self-care skills (i.e. medication management, increased awareness of symptoms, recognizing “red flags” and warning signs for care, along with instructions on how to respond
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Mary Naylor et al. (2004)
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Care Transitions: Naylor
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Patient-centered intervention designed to improve quality of life, patient satisfaction, and reduce hospital readmissions and cost for elderly patients hospitalized with CHF
Target Population
Inclusion:
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A) Elderly patients (aged 65+) admitted to 6 Philadelphia, PA,
 hospitals with diagnosis of CHF
(DRG 127)
B) Live in the community within a
60 mile radius service area
Exclusion:
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Could not have ESRD, non English speaking
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Mary Naylor et al. (2004)
Staffing
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Advanced Practice Nurses (3)
Caseload: 1 care coordinator (CC) per 39 patients
Duration: 3 months following index hospitalization
Focus
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Continuity of care at hospital discharge to optimize patient’s health status and arrange for needed home care services
After patients discharged home, prevention of medication and other medical errors
Help patients/caregivers with early symptom recognition, management of chronic conditions, and recommendations for future care.
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Implement evidence-based guidelines for care management
Conduct a comprehensive assessment
Collaboratively develop and implement a plan of care
Teach/coach patients about proper self-care, medications, how to communicate with providers
Monitor patients’ symptoms, well-being and adherence between office visits
Advise patients on how to talk with and when to see their physician
Apprise patients’ physician and other providers of important symptoms or changes
Arrange for needed health-related support services
Coordinate communication among physicians, health/community providers and patient/family
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Guided Care
Care Management Plus (CMP)
Medicare Coordinated Care
Geriatrics Resources for Assessment and
Care of Elders (GRACE)
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Comprehensive Care Coordination:
Guided Care
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Guided Care: Boult
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A model of comprehensive health care provided by nurse-physician teams for patients with several chronic conditions
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Comprehensive Care Coordination:
Guided Care
Target Population
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Inclusion Criteria
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Older patients (65+) at high risk of using health services during the following year, as estimated by
Hierarchical Condition Category (HCC) predictive model
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High risk was equated with HCC scores of 1.2 or higher
Exclusion Criteria
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Low HCC scores
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Comprehensive Care Coordination:
Guided Care
Staffing
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Registered nurse based in primary care practice working with 3-5 physicians
Caseload: 1 care coordinator (CC) per 50-60 patients
Duration: Ongoing
Focus
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Enhance primary care by infusing the operative principles of all seven chronic care innovations
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Comprehensive patient evaluation
Individual care planning
Promote adherence with evidence-based guidelines
Empower patient
Promote healthy lifestyle
Coordinate care of multiple conditions
Coordinate care across provider settings
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Caregiver support and education
Access to community resources
Make evidence-based, state-of-the-art, chronic care available continuously from teams of professionals that patients trust
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CMP: Dorr
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Patient-centered intervention designed to reduce mortality and hospital admissions for elderly patients of primary care physicians.
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Target Population
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Inclusion:
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A) Elderly (65+), chronically patients of primary care physicians served by Intermountain Health Care, a large health care system in Utah
Medicare Part B for at least 11 months prior to enrollment
Multiple comorbidities, diabetes, frailty, dementia, depression, other mental health needs
Physician referral
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Exclusion:
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Patient declined to participate
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Staffing
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All care managers are RNs, generalists, located in primary care clinics
Caseload: 1 care coordinator (CC)/350-500 patients
Duration: 24 months
Focus
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Continuity of care through specialized information technology system
Education for specific diseases and problem-solving skills
Emphasis on evidence-based treatment plans and protocols
Flexibility of care planning and treatment plans
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MCCD
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Provide care coordination services to high risk Medicare beneficiaries with multiple chronic conditions to improve quality and reduce total cost of care
Evidence
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Intervention patients in the 4 best practice sites had:
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Lower re-hospitalization rates by 8% to 33% among high-risk enrollees
Lower total Medicare expenditures combined 4 sites of $157 per member per month (2010 dollars)
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Comprehensive Care Coordination:
MCCD Best Practice Sites
Target Population (portion of study in each promising practice program)
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Inclusion Criteria
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Medicare beneficiaries with chronic obstructive pulmonary disease
(COPD), congestive heart failure (CHF) or coronary artery disease
(CAD) and at least on hospitalization in the prior year and any of the 12 chronic conditions and two or more hospitalizations in the prior two years
Exclusion Criteria
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Enrolled in hospice, reside in nursing home or have end stage renal disease (ESRD)
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Comprehensive Care Coordination:
MCCD Best Practice Sites
Staffing
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Registered nurses trained in comprehensive care coordination
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Washington University and Health Quality Partners had staff primarily located in community offices (not hospital, clinic, home health); Mercy Medical Center staff located in hospital and primary care clinics and Hospice of Valley staff located in Hospice
Agency
Caseload
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Wash U: 1 CC per 85-95 patients
HQP: 1 CC per 75-85 patients
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Mercy: 1 CC per 80 patients
Hospice: 1 CC per 45 patients
Duration: Ongoing
Focus
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Improved self-care
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Improved symptom recognition and management
Improved medication management
Implementation of evidence-based practices
Improved transitional care
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How to achieve fidelity to model:
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Comprehensive and ongoing training of care coordinators
Established and updated evidence based guides for practice
Regular feedback to care coordinators on whether patients are receiving care consistent with guidelines
Tracking of and feedback to care managers on established contacts (monthly visits, visits within 24 hours of hospital discharge, etc.)
Feedback on implementing self-management and evidencebased guidelines with patients
Tracking and reporting amount of time care coordinator spends on tasks (assessing, planning, monitoring, educating, coaching, documenting, supporting, and coordinating)
Need web-based care management system to measure fidelity and generate feedback
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Effect on hospital admissions and readmissions
Effect on medical costs (by service type, total)
Whether savings exceed intervention costs
Effects on quality of care indicators (e.g., screening tests, preventive care, ED visits, infections, falls, mortality, etc.)
Effects on patients’ quality of life
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What Distinguishes Successful Comprehensive
Care Coordination/Care Management?
Targeting
 Patients with select chronic conditions including co-occurring serious mental health diagnoses and substance abuse.
 Those who were hospitalized in previous year or at time of enrollment
Caseload
 Small enough caseload size (e.g. 40-80)
Training and Feedback CC
 Initial comprehensive training of care coordinators
 Deliver effective patient education and coaching
 Providing a strong, evidence based patient education/coaching intervention for managing health, symptoms, medications
 Performance feedback to care coordinators
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What Distinguishes Successful Comprehensive
Care Coordination/Care Management?
Primary Care Provider
 Strong rapport with primary care provider/specialist/hospital
 Face-to-face contact through co-location, regular hospital rounds, accompanying patients on physician visits
 Assign all of a physician’s patients to the same care coordinator when possible
Contacts
 Frequent face-to-face contact (home, office) with patients
(~1/month)
Intervention
 Conduct comprehensive in-home initial assessment
 Develop a mutually agreed to “action plan” with goals
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What Distinguishes Successful Comprehensive
Care Coordination/Care Management?
 Interventions follow evidence-based practices/guidelines for care management
 Address psychosocial issues: Staff with experts in social supports and community resources for patients with those needs
 Being a communications facilitator: Care coordinators actively facilitating communications among health and community providers and between the patient and the providers
 Implement self management, coaching and support with patient/family
 Implement effective medication management plan
 Manage care setting transitions: Having a timely, comprehensive response to care setting transitions (esp. from hospitals and skilled nursing facilities)
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 Best short run opportunity for reducing costs is improving transition from hospital to home
 Need payment reform to incentivize hospitals and primary care practices to implement these programs
 Medicare and Medicaid incentives to reduce readmissions
 Tying physicians’ compensation to quality and efficiency scores
 Medicare and Medicaid should consider separate reimbursement for care managers implementing proven interventions with target groups
 Special training programs for care coordinators and managers are needed
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Paul Shelton, EdD
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Email: pshelton@illinois.edu
Phone: 1-205-748-0050
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Cheryl Schraeder, RN, PhD, FAAN
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Email: cheryls@uic.edu
Phone: 1-217-586-6039
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