Population Management: The CareMore Experience

David Ramirez

Chief Quality Officer

Fact Base: Medicare Only

2

• 15% of beneficiaries account for 75% of total cost of care

• Approximately 250 APK per year

• 20% of admissions are readmitted within 30 days of discharge

Nearly ¾ of them could have been prevented

• Patients experience the following during hospitalization:

• 50% of acute admissions die or are readmitted within a year of discharge

Sources: Center for Medicare and Medicaid Services, Kaiser, Institute of Medicine, Center for Disease Control and Prevention

> 50% have medication discrepancy 20% experience delirium

30% have functional decline; only 50% return to prior baseline

Decubitus ulcer (pressure sore) occurs within hours of immobilization

5% will have hospital acquired infections

Weight loss, nutritional decline, loss of muscle strength

Health Spending & Chronic Disease

• 15% of the population spends 70% of the dollars (Kaiser Permanente)

• 70% of all healthcare dollars are spent on chronic diseases (Agency for Healthcare Research and Quality)

• Five chronic diseases make up the vast majority of this category* - Diabetes - Congestive Heart Failure - Coronary Artery Disease - Asthma - Depression * Hypertension contributes to complications

Healthcare cost and quality problems are concentrated….not widespread

Healthy Stable Sick Sickest mostly 1 + Chronic Illness mostly 3 + Chronic Illness

Progressive Illness 2010 Medicare Spending Projection = $522 B 46 Million Beneficiaries Spending Per Beneficiary = $11,347

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

Annual

Cost

/Benefi

ciary 23 Million Beneficiaries

- Spending $1,130 each - Total Spending = 5%

($26 B)

16.1 Million Beneficiaries - Spending $6,150 each - Total Spending = 20%

($104 B)

7 Million Beneficiaries - Spending $55,000 each - Total Spending = 75%

($391 B)

Average Spending

CHF, DM

85% of Beneficiaries = 25% Spending 15% of Beneficiaries = 75% Spending

ESRD, CANCER

Community physicians work in parallel with CareMore Extensivists to provide a cohesive,

comprehensive solution

The CareMore model: an innovative healthcare approach that proactively addresses the complex problems of aging

“Extensivists” care for the most ill and frailest patients

NPs in neighborhood Care Centers provide support and care for the chronically ill and frail

Care delivery is coordinated across all sites (PCPs, hospitals, LTC, specialists)

Proprietary resources and programs are deployed within minutes (not hours or days)

Efficient allocation of clinical resources allows all to practice at the highest level of license

Proprietary predictive modeling and condition identification allows us to intervene early, often

CareMore’s operating principles and enabling capabilities coalesce to form a highly effective model of care

Operating Principles

Clinical Control - CareMore Extensivists determine when a patient requires proprietary services and programs

Speedy Deployment – Proprietary resources and programs must be available to adequately intervene and be deployed within minutes (not hours or days)

Efficient Allocation of Clinical Resources – Some types of physician labor is replaced with skilled, allied health professionals such as NPs, MAs, therapists and dieticians

Early, Proactive Intervention - Proprietary predictive modeling and condition identification resources allow us intervene early and often to prevent acute episodes and sentinel events

Intimacy of Contact – Management of complexity requires constant knowledge of the health condition

Key Enabling Capabilities

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Predictive Modeling

Integrated IT Infrastructure

Longitudinal Patient Record

Point-of-care Decision Support

Evidence-based Protocols

Advanced Training

CareMore offers a broad range of SNPs geared toward the frail and elderly

ESRD

Chronic SNP

DIABETES

Chronic SNP

CONNECT Dual Eligible

SNP

TOUCH Institutional

SNP

BREATHE Pulmonary

Chronic SNP

HEART Cardiovascular

Chronic SNP

CareMore COPD Program

• Dedicated Nurse Practitioner lead

• Team approach coordinated with other providers

• Holistic management and education

• Protocols based on national clinical practice guidelines

9%

16%

18%

CareMore In Program

CareMore Not In Program

Medicare Average

COPD Readmissions

CareMore Wireless Monitoring Present State

• CHF: Wireless Scales

• HTN: Wireless BP Cuffs

• Benefits: Patient Compliance, Data Acquisition, Rapid Intervention

• Challenges: Patient Selection, False Alerts, Data Volume, Segmented Care

CareMore Wireless Monitoring Future State

• Integrated monitoring across disease states

• Selection of optimal patients

• Data management

• Provider alert management

CareMore – Sentrian COPD Program

• Identify-Monitor-Analyze-Act Model

• 1000 intervention patients over 12 months

• Use existing data to select optimal patients and wireless monitoring options

• Integrate monitoring across chronic diseases

• Continuous risk stratification

• Create rules for alerts

10,000 Member Initiative

• Goal = Proactively manage top 10% highest risk CareMore members

• Intervention = Early identification and referral to CareMore programs

• Approach = Develop inclusion/exclusion criteria, generate list from EDW, apply risk stratification criteria, prioritize outreach

Technology

EDW

FACETS

Rules Engine

(SAS, SQL, etc)

Criteria, Diagnostic Codes, Risk factors, Episodes, etc.

Criteria

Trigger List

Data Analytics

Analytics Overview

Population Management Overview

Chronic: Care Management Disease Management

Preventative: Member Services Clinical Outreach Pharmacy Outreach Med Therapy Mgmt CCC/ PCP visit Sales/Marketing/ Townhalls Patient Education

Episodic: PCP visit CCC visit ER/Inpatient visit Meds Reconciliation

Oversight: HEDIS QM submission STARs submission CAHPS HOS surveys Appeals Grievances

ACTIVITIES

Coordination

1. 2. 3

Prioritize 1. 2. 3

Categorize 1. 2. 3

Analyze Departments

Programs

Mu

ltip

le T

ou

chp

oin

ts

CRM

Integration Coordination

Risk

Patient Experience

Resource Management

Service Coordination List

CareMore Values

• Accountability

• Coordination

• Urgency to match care desired with care received