North Carolina uses population management tack
Community Care of North Carolina, an enhanced Primary Care Case Management (PCCM) program, uses a "population management" approach to manage high-cost Medicaid clients.
Evidence-based guidelines are used, with outreach and care management targeting the patients with the highest risk and cost. These individuals receive disease management, team-based care, and treatment of acute episodes and prevention.
"Care management is outcome-focused, and monitors the population and service delivery system using meaningful information," says Denise Levis Hewson, RN, BSN, MSPH, the program's director of clinical programs and quality improvement. Primary care providers are given information after quality audits identify gaps in care, such as a diabetic who has not had an annual foot exam.
ID affected patients
One challenge for a successful care management program is determining which subsets of the enrolled population will benefit from the care management interventions. "Identifying those impactable patients is an ongoing skill-building process," says Ms. Hewson.
Reports are generated from administrative claims data to help the primary care providers, care managers, and networks identify potential individuals who could benefit from targeted interventions.
"An effective population management approach builds in the patient self-management component through member education and care support," says Ms. Hewson. "In North Carolina, we have built our enhanced PCCM program around the medical home model."
This means that the networks work in concert with primary care providers to manage the high-risk and high-cost patients. "This approach aims to increase the number of individuals with chronic conditions that are able to manage their disease, and lower over time the percentage of high-risk and high-cost patients in the population," says Ms. Hewson. "It is important to engage primary care providers in the development and implementation efforts. They have, and continue to be, the 'leaders' of our program."
Care management processes and interventions are standardized. "This enables the program to share best practices, establish meaningful expectations, and monitor and evaluate program activities," says Ms. Hewson.
Once identified, recipients who agree to participate are given a comprehensive health assessment. This covers medical conditions, interventions, and goals.
If a patient in the aged, blind, and disabled population has two or more chronic conditions, including mental health, he or she is considered high-risk. The patient is defined as "unstable" by meeting two or more of the following criteria:
one or more inpatient admissions within the past six months;
three or more ED visits within the past 6 months;
eight or more prescriptions over the past month, or 24 over three months;
three or more outpatient providers over six months;
no primary care physician visit within the past year;
two Activities of Daily Living deficits requiring hands-on assistance.
Patients meeting these criteria are tracked in the central data repository in Community Care's Informatics Center. "All 14 networks have access to available and appropriate patient information for those individuals receiving care from the participating practices/primary care providers," says Ms. Hewson.
Self-management is key
"Transitional care is designed to ensure the coordination and continuity of health care during the movement between health care practitioners and settings, as the patient's condition and care needs change during the course of a chronic or acute illness," says Ms. Hewson. "Transitional care is essential for persons with complex care needs."
For instance, older adults who suffer from a variety of conditions often get health care services in different settings to meet their many needs.
"Most transitional care begins while a patient is hospitalized and before discharge planning," says Ms. Hewson. "The network care managers aim to see the patient before discharge from the hospital. This develops a rapport and increases the likelihood that they will wish to participate in the program after discharge."
Care managers work with patients to promote self-management skills. "These are essential to improve patient outcomes," says Ms. Hewson. Here are some of the things they do:
facilitate interdisciplinary collaboration across transitions;
encourage the patient and caregiver to play a central and active role in the formation and execution of the plan of care;
promote direct communication between the patient or caregiver with providers;
achieve medication reconciliation. This is done through consultation with the network pharmacist, the hospital, the primary care physician, the specialists, and the patient or caregiver.
"Medication reconciliation is a critical component of transitional care," says Ms. Hewson. "The network care manager may be the only person with all the data needed to put the medication puzzle together."
Duals are next step
These same population management strategies are now used to manage dual-eligibles. "The networks and participating practices serving Medicaid recipients are also serving the duals and the straight Medicare population," says Ms. Hewson. "It was a natural next step to explore opportunities to manage additional populations with our community-based statewide infrastructure."
Over the past several years, the Community Care of North Carolina program has consistently saved the state over $100 million a year. The state's budget shortfall has put additional pressures on the program, however.
Efforts have increased in the areas that have achieved the highest cost savings. These are preventing readmissions, increasing the use of generic prescribing, mental health integration efforts, and preventing unnecessary emergency department utilization.
"There are expectations for the program to continue to achieve savings. and to even achieve greater savings," says Ms. Hewson. We will continue to look at populations to manage within our model."
Contact Ms. Hewson at (919) 745-2363 or [email protected].
Community Care of North Carolina, an enhanced Primary Care Case Management (PCCM) program, uses a "population management" approach to manage high-cost Medicaid clients.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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