Intensive Home MedicalIntensive Home Medical Management: 

Health Net Partnership with Brown & TolandBrown & Toland

December 20, 2010December 20, 2010

Presentation ObjectivesPresentation Objectives

• IHMM Program OverviewIHMM Program Overview

• Brown & Toland Involvement

l i• IHMM Program evaluation

• Program Return on Investment 

Brown & Toland IHMM ProgramBrown & Toland IHMM Program

• Intensive Home Medical ManagementIntensive Home Medical Management Program developed in 2008

• Staffed by 3 physicians• Staffed by 3 physicians

• Supported by Health Net

• In Kind support by Brown & Toland– Administrative support

– Clinical coordination

IHMM Program Target PopulationIHMM Program Target Population 

• Enrollment eligibility includes MedicareEnrollment eligibility includes Medicare Advantage patients who are:  – Home or bed bound– Home or bed bound 

– Medically complex ( frail, multiple chronic disease burdened)burdened)

– Has acute medical concerns

Experiences access to care issues– Experiences access to care issues

IHMM Program Overview

2008

P

2009

St th B&T

2010

St li• Program evaluated and  restructured

• B&T CM

•Strengthen B&T case management/ IHMM program

• Streamline Program Processes

• Develop moderate• B&T CM involvement initiated 

• Target patient

IHMM program processes

•Initiated electronic clinical

• Develop moderate risk program enrollment criteriaTarget patient 

goal: Enroll Health Net Medicare Advantage Brown 

clinical documentation•Target patient goal: 1%‐2% of Health

• Target patient goal: 1. Reduce unnecessary 

& Toland Members

1% 2% of Health Net Medicare Advantage Brown & Toland membership

utilization                   2. Continue 1%‐2% enrollment 

Toland membership  

Brown & Toland InvolvementBrown & Toland Involvement

Roles & Responsibilities

Brown & Toland Care ManagementBrown & Toland Care Management 

• Coordinate all referrals to IHMMCoordinate all referrals to IHMM

• Support Brown & Toland physicians & IHMM program physiciansprogram physicians 

• Provide care management services to IHMM ll d benrolled members

• Market program to B&T Physician network

• Manage administrative programmatic activities

Brown & Toland PhysiciansBrown & Toland Physicians

• Refer patients to the Brown & Toland IHMMRefer patients to the Brown & Toland IHMM program

• Collaborate with IHMM program physicians on• Collaborate with IHMM program physicians on patient service delivery

C di i i• Coordinate patient services 

Contracted IHMM PhysiciansContracted IHMM Physicians

• Provide medical care to patients who meetProvide medical care to patients who meet criteria

• Coordinate and collaborate plan of care with• Coordinate and collaborate plan of care with the patient’s Brown & Toland Primary Care Physician (PCP) and specialist physiciansPhysician (PCP) and specialist physicians

• Collaborate with Brown & Toland Care MManagement team

• Follow Brown & Toland program protocol

Program EvaluationProgram Evaluation

IHMM Referral ActivityIHMM Referral Activity

2008 2009 2010 (thru 6/30/2010)B&T Ambulatory Care Management 32 43.8% 79 62.7% 57 80.3%B&T Inpatient Care Management 4 5.5% 15 11.9% 7 9.9%

2008 2009 2010 (thru 6/30/2010)

B&T Medical Directors 4 5.5% 3 2.4% 3 4.2%B&T PCP 0 0.0% 5 4.0% 0 0.0%Health Net 0 0.0% 8 6.3% 2 2.8%Home Health 0 0.0% 13 10.3% 2 2.8%Care Level Management 30 41 1% 0 0 0% 0 0 0%Care Level Management 30 41.1% 0 0.0% 0 0.0%Other* 3 4.1% 3 2.4% 0 0.0%Total 73 100.0% 126 100.0% 71 100.0%

Table 1 demonstrates all Program referral activity and referral sources.  *Other includes: Senior Metrix, Patient/Family Member, SNF, Alere

Graph demonstrates program enrollment and total number of patients who expired while enrolled. 

Site of Expiraton in IHMM Program (25-months, 79 deaths) C it 64% ( f t di l & i t id )Community, 64% (sum of custodial & private residence);

Hospital, 27%; SNF, 9%; Hospice Enrolled (41%) Average Age (84.9 yrs), Average LOS in IHMM (192 days)

Sub-acute9%%

Acute27%

Home49%

Custodial15%

Sub-acute Acute Custodial Home

An objective of the IHMM program is for patients and their support network to beAn  objective of the IHMM program is for patients and their support network to be informed of end of life options and resources . In‐home visits by IHMM physicians prevent unnecessary end‐of‐life hospital admissions when death is imminent.  

Return on InvestmentReturn on Investment

ROI Analysis MethodologyROI Analysis Methodology

• Description:Description:– Analysis timeframe was 6/2008‐6/2010 

IHMM participants with B&T eligibility ≥ 6 months– IHMM participants with B&T eligibility ≥ 6 months and IHMM participation ≥ 1 month

– Average IHMM enrollment was 12 6 months– Average  IHMM enrollment was 12.6 months

– Evaluated In‐patient utilization and cost 6 months prior and post IHMM enrollmentprior and post IHMM enrollment

IHMM Population CharacteristicsIHMM Population Characteristics

N 138Avg Age 85.2% Male 28.2%A Ri k S * 10 9Avg Risk Score* 10.9Avg HCC RAF Score** 1.3Avg # chronic conditions (per enrollee) 4

*Risk score derived from Johns Hopkins ACG ®Case‐Mix System** HCC RAF score derived from Ingenix Clinical Assessment Solutions Software

g (p )

The morbidity burden, illustrated by an average risk score over 10.0, of IHMM participants is particularly high. In comparison, the average risk score for all B&T Health Net Medicare Advantage patients is 3.8. Similarly, the average HCC RAF score for IHMM patients is 1.3 which is higher than the average for all Health Net Medicare Advantage patients (.87).is 1.3 which is higher than the average for all Health Net Medicare Advantage patients (.87).

Utilization MetricsUtilization MetricsColumn1

Prior to IHMM Enrollment  Post IHMM Enrollment  Savings 

ED visits 39 34 10% decreaseED visits  39 34 10% decrease

ED to Acute IP Admits 82 38 46% decrease

Acute Admits  91 40 56% decrease 

Acute Bed Days  497 189 62% decrease 

Acute ALOS  5.5 4.7 .8 day decrease 

30 Day Acute Readmits 25 7 72% decrease30 Day Acute Readmits  25 7 72% decrease 

SNF Admits 29 18 38% decrease

SNF Bed Days  478 432 10% decrease 

* SNF (community based and Hospital based) average length of stays has been longer than expected in 2009 & 2010 Brown & Toland has been responsible for all SNF reviews since July 2010 and is working with all

SNF ALOS*  16.5 24 7.5 days increase 

2010.  Brown & Toland has been responsible for all SNF reviews since July 2010 and is working with all facilities and hospitalists as well as has assigned a dedicated resource to SNF to ultimately reduce SNF ALOS.   

Readmission Diagnosis ProfilingReadmission Diagnosis Profiling 

6

345

# Readmits* Pre IHMM

012

Post IHMM

*Readmissions where the prior admit discharge disposition DC Home*Readmissions where the prior admit discharge disposition = DC Home

Return on Investment

Acute AdmissionsEstimated Facility Cost/Acute Day*: $2 140Estimated Facility Cost/Acute Day :  $2,140 Acute Days Variance (pre vs. post): ‐308 daysEstimated Facility Savings: $659,120

ED to Acute AdmissionsEstimated Facility Cost/Acute Admission**: $10,700Estimated Facility Cost/Acute Admission : $10,700 ED to IP Variance (pre vs. post): ‐44 admitsEstimated Savings: $470,800 

*Estimated cost per senior acute day per Health Net** Based on ALOS of 5 days and estimated cost per senior acute day per Health Nety p y p

IHMM Program Summaryg y• Home visiting physicians provide significant value and service to Medicare Advantage patients by providing g p y p gan alternative to traditional office‐based care

• Provide timely medical careIntervention before home health vendors reach patient– Intervention before home health vendors reach patient.

– Averts unnecessary utilization– Increased patient satisfaction

• ED visits, acute and SNF admissions, acute bed days and acute ALOS significantly decrease for IHMM program participants

• Statistically significant decrease in utilization = significant cost savings 

On the HorizonOn the Horizon• Evaluate 2010 Q3 and Q4 program ROI

• Refine current operational processes– Establish graduation process for participants

– Conduct POLST on all enrolled patients 

– Improve billing mechanism for Physician home p g yvisits

– Implement patient and physician satisfaction surveys