EXECUTIVE SUMMARY
A risk stratification tool identifies members of a Medicaid population that need targeted case management interventions. The eventual goal is self-management, as well as reducing costs.
- More than two out of three Medicaid patients have behavioral health or mental health illness.
- Inpatient admissions dropped by 25%.
- The program provides a $3 return on investment for every $1 spent.
North Carolina’s Medicaid population includes 1.5 million people, about 1 million of which are children.
Among the half-million adults on Medicaid in the state, many have multiple comorbidities, and the 77% that are eligible for complex care management have a behavioral health condition, as well.
If the goal is to reduce costs and improve the population’s health through case/care management services, the tough question is: How do you prioritize limited resources?
“Through continuous analysis of our data, we are aware that approximately 88% of our identified complex care members have at least one social risk in addition to their medical condition,” says Avera T. White, RN, MSN, CCM, clinical informatics specialist for Community Care of North Carolina (CCNC) in Raleigh.
CCNC’s primary goal is to provide quality care through holistic care coordination services and to promote linkage to a medical home. Accomplishing this requires addressing social determinants of health as well as medical and/or behavioral health conditions, White says.
The organization focuses on empowering patients to learn self-care skills and helps North Carolina contain costs, she adds.
“Self-management is a goal for us and a big piece of what we’re trying to do with our interventions,” says Barbara E. McNeill, MSN, RN-BC, clinical education specialist for CCNC.
Their risk stratification tool and targeted care management have worked. Inpatient admissions dropped by 25%. The inpatient admission rate per 1,000 member months was 4.722 in December 2012; in December 2016, this rate was 3.928.
Also, the potentially preventable readmissions rate was 0.371 per 1,000 member months in December 2012, compared with a rate of 0.171 in December 2016.
Other outcomes include a $3 return on investment for every dollar put into the CCNC program and a total net savings of $312 per Medicaid member per year. It saved 9% of overall Medicaid costs and saved the state close to $1 billion over four years.
CCNC’s efforts resulted in the organization receiving a Hearst Health Prize in 2016. It was recognition of outstanding achievement in managing or improving health.
The organization has tried various risk stratification models, keeping some metrics including identifying patients and conditions with the highest costs. But the model has evolved as costs alone did not show the whole picture, White notes.
In 2012, CCNC introduced a transitional care indicator focused on preventing potential admissions and 30-day readmissions. In 2015, the organization revised its indicators, including the following:
• The Transitional Care Impactability Score identifies patients who are most at risk for readmission following a hospital discharge, and could benefit most from receiving care management services. The goal is to prevent readmission.
“If we can engage the patients within three business days post-discharge and get them linked to a primary care physician and ensure discharge needs are meet, then we can decrease the risk of readmission,” White says.
• The Complex Care Management Impactability Score targets patients with above-expected cost and utilization for conditions. Medical providers and community organizations also can make referrals for care management services.
“Disease management services are offered for various reasons, including behavioral, medical, and empowering the patient to self-manage,” White says.
• The Maternal Infant Impactability Score was scheduled for introduction in June 2017. This one has a program that focuses on women at risk of having low-birth-weight babies. “It allows us to target women who would most benefit from services and get them engaged with an obstetrician provider as early as possible,” says White.
These tools help care management staff identify members who could benefit most from CCNC’s services and assist in targeting interventions.
“The impactability scores assist us in identifying who we can help that would have the greatest impact, and they identify the targeted interventions that would have the greatest return on investment,” White says.
This isn’t as easy as just giving services to patients with the highest medical costs in a particular year. For example, patients with chronic renal failure often have very high costs by the very nature of their treatment, which often includes dialysis, McNeill explains.
“Care management intervention for these patients may not have the impact on cost that it would for other patient populations,” she adds.
The model and analytics identify patients who are high-cost outliers for their diagnoses. For example, a patient with diabetes might have medical costs significantly higher than other people with similar demographics and diagnoses.
“If we intervene with this type of patient, we’ll have a great impact,” White says. “We look at the cost over time and hospitalization patterns.”
Once these patients are identified and they agree to receive complex care management services, their results are collected and analyzed.
“We look at what the historical impact is when we had the care management team intervene,” White explains.
This risk stratification method keeps care management focused in the optimal direction — where the resources could result in the most improvement.
“We learn the best patients to target and where a home visit would be beneficial, versus those that need a lighter touch,” White says.
They’ve found that people with the greatest social needs also have the greatest costs.
“We also try to provide care for the whole person, understanding how the mind and body are connected and the implications this has for our care management program,” McNeill says.
Eighty percent of the complex patients have multiple conditions, and they have an average of 14 different billing providers, White says.
One strategy in making these programs most efficient was to identify people who could benefit from each of these programs, coordinate the fragmented care, and track their progress after care management interventions.
This resulted in pinpoint precision for interventions that work with certain at-risk Medicaid patients.
The care management strategies include the following:
- Patients are matched with primary care providers or medical homes to manage and coordinate care.
- They receive medication management services, provided by nurses and pharmacists, to monitor medication adherence and prevent readmissions.
- Many of the hospitals in the state have someone embedded from CCNC’s care management program, and/or CCNC receives automated feeds to inform staff of admissions and discharges.
- Multidisciplinary care management teams are used to provide holistic care coordination.
- Care managers can enroll Medicaid patients in the program, based on their clinical judgment.
- Enrolled patients are contacted via telephone and in person after hospital discharge.
- They’re educated about the care management service, and enrollment is voluntary.
- Often, nurse care managers conduct a full assessment, but if a primary diagnosis is a mental illness, then a social worker also will contact the patient.
- All care management moves toward the goal of empowering patients to take ownership of their health and improve self-care management.
CCNC’s care management program has been recognized nationally as a best practice model. Other programs and states have contacted CCNC to learn more about the model, White says.
“We believe in continuous quality improvement and, therefore, we’re constantly re-evaluating and tweaking the program,” White adds.
A risk stratification tool identifies members of a Medicaid population that need targeted case management interventions. The eventual goal is self-management, as well as reducing costs.
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