medicaid top 5% reporting prioritization make information actionable michel daley rn...
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Medicaid Top 5% Reporting PrioritizationMake Information Actionable
Michel Daley RN UnitedHealthcare Community&State
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Top 5% Report - Medicaid
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
PRIMARY_RISK_FACTORFUTURE_RISK
_COSTSFUTURE_RISK_INPATIENT
PRIOR_TOTAL_COSTS_ANNUALIZED
PRIOR_RX_COSTS_ANNLZD
ER_VISITS
ADMIT
SPCP_VISIT_DATE PRIORITY
Adult rheumatoid arthritis 14.48 3.46
$
75,109
$
9,193 2 0 Higher
Nutritional deficiency and dehydration 12.28 5.73
$
26,577
$
15,969 0 03/18/20
14High
Mood disorder, bipolar 10.89 4.95
$
18,174
$
3,214 0 03/19/20
14High
Nutritional deficiency and dehydration 10.61 6.64
$
15,137
$
5,002 1 0 Higher
Other neurology 6.84 2.29
$
14,639
$
9,916 3 4 Highest
Mood disorder, bipolar 5.29 9.81
$
15,679
$
3,006 3 0 Highest
Hereditary degenerative & Congenital CNS disorders 2.83 3.10
$
16,523
$
2,137 1 0
Other Opportunities
Adult rheumatoid arthritis 1.66 0.58
$
25,959
$
24,658 0 0
Other Opportunities
*The highlighted members primary cost driver is a Behavioral Health condition
regardless of risk category.
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Transitional Case Management
Use the Top 5% report and match it to the daily in-patient census
Identify where member’s have their care primarily coordinated:CTC/ CTC Community Health Team Health HomeHealth Plan Case Management Not receiving coordination through any of these channels
Contact the CTC site NCM with an admission alert and collaborate on a post discharge plan of care
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Who on the high risk list is in the hospital?
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Contact Information
Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Kristin Woods LCSW, MSW Toll Free Office: (877) 561-3813Local Phone: (952) 202-1346
High Risk Inpatient cases only (Acute Care, SNF, AIR, and LTACH). These are the in-patients admissions that Kristin is contacting the practices by email and or
telephone call to alert the NCM that one of their patients is in the hospital. If the discharge planning services or equipment is not being implemented as planned the NCM should
contact Kristin to identify reasons for delay and ensure that an action plan is in place for resolution
Paul Belanger RN Telephone 855-338-9245 extension 73148 High Risk Inpatient cases at Rhode Island Hospital only (Acute Care, SNF, AIR, and LTACH).
These are the in-patients admissions that Kristin is contacting the practices by email and or telephone call to alert the NCM that one of their patients is in the hospital.
If the discharge planning services or equipment is not being implemented as planned the NCM should contact Kristin to identify reasons for delay and ensure that an action plan is in place for resolution
Michel Daley RN, BSN All other urgent issues related to post discharge will be managed by the health plan.
Care Transitions Programs: A mechanism to promote information transfer and follow up care
May 2015
Yvonne Heredia RN, MS, PhDc Manager of Care Manager
UM: Care Transitions ProgramBased on Eric Coleman’s
Model
Goals:
• Face to Face Communication
• Readmission Prevention/Emergency Room Use Reduction
• Redirection to Primary Care Physician (PCP)
• Enhance member’s awareness and management of medical conditions
• Improve patient, family, and provider satisfaction
• Medication Reconciliation
Target Community
• All In Network Hospitals with a goal of being onsite to facilitate a safe transition back to community
• Telephonic collaboration with Out of Network Hospitals
Target Patients • Members discharged from an Acute Inpatient Hospitalization returning back to the community
Care Transitions Team• Transitions Care Manager (RN)• Community Outreach Specialist (COS)• Clinical Coordinator
Care Management Transitions Eric Coleman’s TOC modelGoals:
• Readmission Prevention/Emergency Room Use Reduction
• Redirection to Primary Care Physician (PCP)
• Member/provider satisfaction
• Increased member knowledge/ self efficacy
Active – engaged• Initial TOC outreach• Identify actual/ potential gaps• Coordination of care • Collaboration with healthcare team\
Non-active in CM program• Criteria specific • Coleman’s Model • Coordination of care • Collaboration with healthcare team• Encounter form
Contact information
UM TransitionsJackie Fernandes - Manager – (401) 459-6003 (direct) Andrea McGinn – Team Lead – (401) 459-6521 (direct)
CM TransitionsYvonne Heredia – Manager – (401) 459-6186 (direct)
Donna Bianco – Team Lead – (401) 459 -459-6074 (direct)
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Proprietary & Confidential
High Risk Member Lists and Utilization Reports to support Primary Care
Charlotte Crist, BSN, RN-BC, CCMDirector, Clinical [email protected] May 2015
Identify and Manage your High Risk Patients
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BCBSRI sends a monthly panel of ALL your BCBSRI attributed patients, with detailed information about each member. This list is sorted by RISK. The highest risk (RED) members are specifically referred for Complex Case Management and will require engagement reporting.
RED Highest Risk (approx top 3-4%) Highest Risk conditions Highest Risk probability of Admission or Readmission May or may not be highest cost patients
ORANGE High Risk 3+ inpatient admissions in previous 6 months 3+ ED visits in previous 6 months 3+ chronic conditions
Transition of Care Reports
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Gaps in Transitions of Care planning are frequently the cause of avoidable readmissions.
To support the NCM during transitions, BCBSRI sends TOC reports for identified High Risk patients who have been hospitalized, seen in the ED, or discharged from a SNF. These alerts are meant to prompt your internal TOC workflow, such as:
• Schedule PCP office follow up visit immediately• Medication reconciliation• CM assessment and care plan/goals/frequency of NCM outreach• DME, supportive services in home• Education and Action plan for sx’s to report asap (contact NCM/PCP office)
Need to Reach Blue Cross?
Clinical patient questions: 459-CARE (2273)
General program questions: [email protected]
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