PROMISING MODELS OF CARE
COORDINATION FOR BENEFICIARIES
WITH CHRONIC ILLNESSES
Cheryl Schraeder, RN, PhD, FAAN
UIC College of Nursing
Patricia Volland, MSW, MBA
New York Academy of Medicine
Robyn Golden, MA, LCSW
Rush University Medical Center
Aging In America 2011
OVERVIEW


Define care coordination
Identify proven care coordination/management
interventions for beneficiaries with chronic illness

Transitional Care

Comprehensive Care Coordination

Medicare/ Duals

Medicaid

Describe key distinguishing features

Describe internal and external evaluation
WHAT IS CARE COORDINATION?

N3C defines care coordination as:

“A
person-centered, assessment based,
interdisciplinary approach to
integrating health care and social
support services in a cost-effective
manner in which an individual’s needs
and preferences are assessed, a
comprehensive care plan is developed,
and services are managed and
monitored by an evidence-based process
which typically involves a designated
lead care coordinator.”
WHAT IS THE PROBLEM?

Most health care dollars are spent on a small
percentage of beneficiaries


Those with complex chronic conditions
Causes of high utilization and costs:

Deviations from evidence-based care

Poor communication among primary providers,
specialists, health and community providers,
patients, and families

Failure to catch problems early

Failure to address psychosocial issues

Lack of coordinated, longitudinal management

Ineffective transitional management
WHAT IS EFFECTIVE CARE
COORDINATION?

Intervention with rigorous evidence that:

Improves beneficiary outcomes

Reduces total health care expenditures for
participating beneficiaries

Improved satisfaction or clinical indicators not sufficient

Net savings require reduced hospitalizations
PROMISING INTERVENTIONS

Most evidence shows impacts are unreliable

However, promising care coordination and care management
interventions are emerging



Transitional care interventions

Care Transitions Intervention (Coleman)

Transitional Care Model (Naylor)

Enhanced Discharge Planning Program – RUSH (Perry)
Comprehensive Care Management - Medicare/ Duals

Guided Care (Boult)

GRACE (Counsell)

Care Management Plus (Dorr)

MCCD: Best Practice Sites (Brown)
Comprehensive Care Management – Medicaid/ Duals

Integrated Care Management (Douglas)

Community Based Chronic Care Management (Lessler)

Hospital to Home (Raven)

Health Care Management Program (Reconnu & Herndon)
TRANSITIONAL CARE:
COMPONENTS


These programs:

Engage patients with chronic illnesses while
hospitalized

Follow patients intensively post-discharge

Teach/coach patients about medications, self-care,
and symptom recognition and management

Remind and encourage patients to keep follow-up
physician appointments
Approaches to achieving these goals differ across
programs
TRANSITIONAL CARE:
THREE PROMISING MODELS

Care Transitions Intervention (Coleman)


Transitional Care Intervention (Naylor)


Patient-centered intervention designed to improve quality
and contain costs for patients with complex care needs as
they transition across care settings
Patient-centered intervention designed to improve quality
of life, patient satisfaction, and reduce hospital
readmissions and cost for elderly patients hospitalized with
CHF
Enhanced Discharge Planning Program (RUSH)

Telephone-delivered social work-based transitional care
model (hospital to home) designed to promote patient
safety and satisfaction, improve quality of life, and reduce
preventable re-hospitalizations and ED visits.
TRANSITIONAL CARE:
TARGET POPULATIONS



Care Transitions Intervention (Coleman)

Included: Patients dc’d from hospital with certain diagnoses; 30-day
Medicare readmissions for HF, MI, PNE; additional risk algorithm for
readmission drawn from administrative data

Excluded: Dementia with no caregiver, primary psychiatric diagnosis,
with psychotic elements, active drug or alcohol use
Transitional Care Intervention (Naylor)

Included: 65+ CHF patient admitted to certain hospitals and residing
within 60 miles of designated hospital

Excluded: ESRD, non-English speaking
Enhanced Discharge Planning Program (RUSH)

Included: 65+ returning home after discharge with 7+ prescriptions
and 1 additional risk factor including living alone, past admission,
no/unstable support system, other psychosocial issue

Excluded: Transplant
TRANSITIONAL CARE:
STAFFING



Care Transitions Intervention (Coleman)

APN, RN, social worker, or occupational therapist

1 care coordinator per 40 patients

Duration: 30 days following hospitalization
Transitional Care Intervention (Naylor)

Advanced Practice Nurses (3)

1 care coordinator per 39 patients

Duration: 3 months following index hospitalization
Enhanced Discharge Planning Program (RUSH)

Master’s prepared social worker with experience in health
and aging

1 care coordinator per 48 patients

Duration: Up to 30 days, average 8 days
TRANSITIONAL CARE:
INTERVENTION



Care Transitions Intervention (Coleman)

Home visit post discharge, three follow-up calls

Based on 4 pillars: medication management, patient-centered record,
primary care and specialist follow-up, knowledge of red flags
Transitional Care Intervention (Naylor)

Hospital visit and home visits of varying frequency

Comprehensive assessment in hospital, defining priority needs and
services

Ongoing advocacy, education, and communication to ensure plan of care
Enhanced Discharge Planning Program (RUSH)

Pre-assessment through medical chart review to determine potential needs

Telephonic biopsychosocial assessment and care coordination to stabilize
situation, ensure medical and home health follow-up, and engage
community-based service providers
TRANSITIONAL CARE:
EVIDENCE

Care Transitions Intervention (Coleman)

Intervention patients had




For any reason (17% vs. 23%)

For initial condition (5% vs. 10%)
Lowered hospital costs 19% over 180 days ($2,058 vs. $2,546)
Transitional Care Intervention (Naylor)


Lower re-hospitalization rates at 90 days:
Intervention patients had:

54% fewer re-hospitalizations per patient after 12 months (1.18 vs. 1.79)

10.5% decrease in re-hospitalization rate (44.9% vs. 55.4%)

39% lower mean total costs ($7,636 vs. $12,481
Enhanced Discharge Planning Program (RUSH)

Intervention patients had a lower 30 day post discharge mortality rate
compared to the usual care group (2.2% vs. 5.3%)
COMPREHENSIVE CARE COORDINATION:
COMPONENTS

These programs:
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
•

Approaches to achieving these goals differ across programs
COMPREHENSIVE CC - MEDICARE/ DUALS:
FOUR PROMISING MODELS

Guided Care: Boult


GRACE: Counsell


A model to improve the quality of care for low income
seniors by the longitudinal integration of geriatric and
primary care services across the continuity of care
Care Management Plus (CMP): Dorr


A model of comprehensive health care provided by nursephysician teams for patients with several chronic
conditions
Patient-centered intervention designed to reduce mortality
and hospital admissions for elderly patients of primary
care physicians
Medicare Coordinated Care: Brown

Provide care coordination services to high risk Medicare
beneficiaries with multiple chronic conditions to improve
quality and reduce total cost of care
COMPREHENSIVE CC - MEDICARE/ DUALS:
TARGET POPULATION




Guided Care (Boult)

Included: Older patients (65+) at high risk of using health services during the following year, as
estimated by Hierarchical Condition Category (HCC) predictive model (scores of 1.2 or higher)

Excluded: Low HCC scores
GRACE (Counsell)

Included: 65+, established patient of a site primary care clinician, income less than 200% federal
poverty

Excluded: Residence in nursing home, receiving dialysis, severe hearing loss, English language
barrier, no access to telephone, severe cognitive impairment without an available caregiver
CMP (Dorr)

Included: Older chronically ill patients (65+) of primary care physicians served by Intermountain
Health Care, a large health care system in Utah, with multiple comorbidites and beneficiaries of
Medicare Part B for at least 11 months prior to enrollment

Excluded: Patient declined to participate
MCCD Best Practice Sites (Brown)

Included: 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

Excluded: Enrolled in hospice, reside in nursing home or have end stage renal disease (ESRD)
COMPREHENSIVE CC - MEDICARE/ DUALS:
STAFFING




Guided Care (Boult)

Registered nurse based in primary care practice working with 3-5
physicians

1 care coordinator (CC) per 50-60 patients
GRACE (Counsell)

An APN and social worker in collaboration with PCP and a geriatric
interdisciplinary team led by a geriatrician

1 CC/social worker (SW) per 100-125 patients
CMP (Dorr)

All care managers are RNs, generalists, located in primary care clinics

1 care coordinator per 350-500 patients
MCCD Best Practice Sites (Brown)





Registered nurses trained in comprehensive care coordination
Wash U: 1 CC per 85-95 patients
HQP: 1 CC per 75-85 patients
Mercy: 1 CC per 80 patients
Hospice: 1 CC per 45 patients
COMPREHENSIVE CC - MEDICARE/ DUALS:
INTERVENTION

Guided Care (Boult)



GRACE (Counsell)




Initial and annual in-home comprehensive geriatric assessment by a GRACE support team consisting
of an advanced practice nurse and social worker
Activation each year of indicated GRACE protocols and corresponding team suggestions
GRACE support team meeting with patient’s primary care physician to review, modify, and prioritize
initial and annual care plan protocols and team suggestions
CMP (Dorr)




Manages transitions between sites of care (rounds in hospital, design/execute discharge plan, visits
patient at home within 2 days of discharge, ensures patient return to PCP)
Creates an evidence-based comprehensive “Care Guide” and “Action Plan”
Reorganization of primary care through a team-based approach (RN/PCP)
Intervention based on continuity of care and regular follow-up by CC
Patient-centered assessment, comprehensive care planning, disease and self-management education
MCCD Best Practice Sites (Brown)



Clinical assessment; evidence-based guidelines and protocols
Care planning: mutual, prioritized goals/action plans
Care plan implementation (self-management strategies, service/provider coordination, reporting
changes in symptoms, medications, self-management activities)
COMPREHENSIVE CC - MEDICARE/ DUALS:
EVIDENCE

Guided Care (Boult)

8 month findings of 32 month trial:






GRACE (Counsell)


Patients at high risk of hospitalization (PRA score >= .04) in year two had
significantly lower hospital rates/1000 (396 [n=106] vs. 705 [n=105]) and ED
visits/1000 (848 [n=106] vs. 1314 [n=105]; P = .03)
CMP (Dorr)



24% fewer hospital days
29% fewer home healthcare episodes
37% fewer skilled nursing days
15% fewer ED visits
9% more specialists visits
Reduced 2-year all-cause mortality rates by 24%
For patients with diabetes, reduced 2-year all-cause mortality rates by 34% and
hospitalization rates by 22%
MCCD Best Practice Sites (Brown)

Intervention patients in the 4 best practice sites had:


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)
COMPREHENSIVE CC - MEDICAID/ DUALS:
FOUR PROMISING MODELS

Integrated Care Management (ICM)


Community Based Chronic Care Management – King County
Care Partners (KCCP)


Provides patient-centered community-based, multidisciplinary care
management that empowers patients and enhances coordination,
communication, and integration of services across safety-net providers
to improve clinical outcomes and decrease unnecessary utilization
Hospital to Home


Provides specialized care management services to:
(1) complex, high risk patients; and (2) patients that require various
levels of episodic supportive care management services
Patient-centered intervention designed to address the complex health
and social needs of Medicaid patients to reduce health service
utilization and costs to the state Medicaid program
Health Care Management Program (HMP)

Focused on improving the quality of life for chronically ill individuals
living in Oklahoma, HMP is a disease management program
providing nursing case management services to Medicaid recipients
and practice facilitation services to primary care providers
COMPREHENSIVE CC - MEDICAID/ DUALS:
TARGET POPULATION


Integrated Care Management (ICM)

Intensive Care Management services are provided to complex, high-risk individuals (1% of
patients) with the highest cost, highest ED visits and hospital admissions, and highest
prevalence of mental illness and substance abuse issues

Supportive Care Management services are provided to individuals who have a single care issue
or several issues that will stabilize or resolve within a short period of time
Community Based Chronic Care Management – King County Care Partners (KCCP)



Medicaid patients residing in King County, WA, who have received care from one of the
participating primary care clinics within the past 12 months, and have been identified from
predictive modeling to be at particularly high risk of future healthcare utilization
Hospital to Home

Predictive computer algorithm used to identify individuals as being high cost and high risk for
future hospital admission

Typical patients tend to be frequent users of the ED and hospitals, substance abusers, have
serious health and mental health issues, and tend to be homeless
Health Care Management Program (HMP)

Five percent of the total state Medicaid population (n = 5,000) with chronic illness(es),
determined to be at highest risk for future utilization via predictive modeling algorithms

Patient population is divided into 2 groups: Tier 1 = highest risk (n = 1,000), and Tier 2 = high
risk (n = 4,000).
COMPREHENSIVE CC - MEDICAID/ DUALS:
STAFFING


Integrated Care Management (ICM)

Care Management is provided by clinical care managers (RN or
social worker). Non-clinical staff work on care coordination
activities.

Intensive care managers have a caseload of 30 to 70 patients
Community Based Chronic Care Management – King
County Care Partners (KCCP)



The intensive care management team is composed of 3 RNs, 2 Social
Workers (MSW) with chemical dependency training, and a BA level
individual experienced in chemical dependency counseling
Hospital to Home

Care management teams are comprised of social workers, community-based
care managers, and a housing coordinator

Care manager case loads are capped at 25 patients
Health Care Management Program (HMP)

RNs with special training in care management, quality improvement
methods, and organizational behavior and systems
COMPREHENSIVE CC - MEDICAID/ DUALS:
INTERVENTION

Integrated Care Management (ICM)



Community Based Chronic Care Management – King County
Care Partners (KCCP)





In-person comprehensive assessment and collaborative goal setting
Chronic disease self-management coaching
Joint PCP visits of patients and their care managers
Coordination of community services and care across the medical and mental health system
Hospital to Home




Assessment and Care Planning to identify the individual’s highest priority issues related to their
physical and behavioral health and psychosocial challenges and interventions to help them effectively
manage their own health
Align the care team and all community providers involved in the patient’s care using a
comprehensive electronic health information system that can be accessed by all providers
Multi-disciplinary care management model incorporates motivational interviewing, harm reduction,
and access to housing using a ‘housing first’ approach
Communication with patients via a consistent, care management team, including a first person
contact (care manager), to manage and coordinate care across multiple locations and providers
Emphasis on providing and coordinating needed medical care and mental health support either
within health care or community systems and settings.
Health Care Management Program (HMP)



All patients receive comprehensive health status, health literacy, behavioral health, and pharmacy
assessments
Strong emphasis is placed on self-management education and coordination of and access to
community services
Nurse case management is provided face-to-face for highest risk patients and telephonically for high
risk patients
COMPREHENSIVE CC - MEDICAID/ DUALS:
EVIDENCE

Integrated Care Management (ICM)


Under evaluation
Community Based Chronic Care Management –
King County Care Partners (KCCP)
Preliminary results indicate: increased patient satisfaction with care, increased
patient self-management and self-efficacy skills, increased primary care physician
satisfaction with services provided
 Health service utilization and cost outcomes are being evaluated in an ongoing RCT


Hospital to Home
Evidence from a pilot study suggests reduced hospitalizations by 38% and costs to
Medicaid of $5,000/person
 A formal program evaluation is currently being conducted by the New York State
Department of Health


Health Care Management Program (HMP)


A comprehensive evaluation of HMP is underway
Initial findings suggest significant savings to the Oklahoma State Medicaid program
EVALUATION: INTERNAL

Achieving model fidelity

Comprehensive and ongoing care coordinator
training

Evidence-based practice guides established and
updated


Feedback provided to care coordinators on implementation
of these guidelines

Tracking of and feedback to care managers on
established contacts

Tracking and reporting amount of time care
coordinator spends on tasks
Need web-based method to measure fidelity and
generate feedback
EVALUATION: EXTERNAL

Effect on hospital admissions and readmissions

Effect on medical costs


By service

Total
Return on investment


Effects on quality of care indicators


Did savings exceed intervention costs?
Screenings, preventive care, ER visits, infections,
falls, mortality, etc.
Effects on patients’ quality of life
NYAM/ SWLI LITERATURE REVIEW:
Purpose

Update of Best Practices in Care Coordination for older adults
with one or more chronic conditions
Methodology


Conducted a search in Pubmed, Cinahl,* Ageline, Cochrane,
Psychinfo, and/or Soc/Index/Soc collection articles published
between 2000 and 2010 in English
The Inclusion criteria
 Intervention 3 months or longer
 Explicit link between medical and community and long term
care services
 Quantitative or qualitative health, social, or economic
outcomes
* Cumulative Index to Nursing and Allied Health Literature
WHAT DISTINGUISHES SUCCESSFUL MODELS?
COMPARING EFFORTS:
Targeting
MODEL SYNTHESIS
LITERATURE REVIEW
•Patients with select chronic conditions
including co-occurring serious mental
health diagnoses and substance abuse
•Program targeting to identify the
population who can most benefit from a
given intervention
•Those who were hospitalized in previous
year or at time of enrollment
Intervention
•Conduct comprehensive in-home
initial assessment
•Baseline and ongoing assessment of
health and social needs
•Develop a mutually agreed upon
“action plan” with goal
•Interdisciplinary approach to allow
providers to address a spectrum of
health and social service needs
•Frequent face-to-face contact (home,
office) with patients (~1/month)
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
•Flexible provision of services and
service intensity
•Enhanced communication among
providers, frequently including the
primary care physician
WHAT DISTINGUISHES SUCCESSFUL MODELS?
COMPARING EFFORTS:
MODEL SYNTHESIS
LITERATURE REVIEW
Patient
Education
•Providing a strong, evidence
based patient
education/coaching
intervention for managing
health, symptoms,
medications
•Evidence-based protocols to assess
health and social condition and
develop care plan
Training
•Initial comprehensive
training of CC
•Performance feedback to CCs
•At least 15 percent of articles
included for review report
specialized training for service
providers as intervention
component
Community link
•Coordinate communication
among physicians,
health/community providers
and patient/family
•Connection to existing community
health and supportive services
BEST PRACTICES FOR CARE
COORDINATION/MANAGEMENT MODELS

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
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)
THANK YOU!

Questions?