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Advanced Illness Care Coordination in a Medicare Advantage Setting
Richard Raskin, MD,FACPChief Medical Officer, East Division
Avon, CT
Danielle Butin, MPH,OTRDirector, Health Services, East Division
White Plains, NY
Angelina Yearick, JD, MSPHConsultant to Health Services
White Plains, NY
2
Setting the Stage
• Medicare Advantage
• Geography and Demographics
• Population Selection
* Health Risk Assessment
* HCC Scoring
* Claims Based/Predictive Modeling
* Diagnoses
3
Rationale for Development of Program Targeted at Medicare
Advantage Enrollees• Medicare enrollees have high incidence of chronic disease
and life-threatening illness• Clinical deterioration in these enrollees often occurs
suddenly • Patients facing end-of-life decisions often do not have the
requisite information to make informed choices about how they would like to spend their last days, and have not made these choices proactively.
• As a result, coordination of care for enrollees at end-of-life is inadequate, leading to suboptimal qualitative and financial outcomes.
4
Advanced Illness and Coordinated Care Program
The Advanced Illness Coordinated Care (AICC) Program, developed by Dr. Dan Tobin, is designed to:•Target enrollees with specific diagnoses for appropriate advanced care planning •Offer in home counseling to targeted enrollees.•Reduce the rate of patients dying in the hospital by providing patients the opportunity to spend the end-of-life in the setting of their choice;•Empower these enrollees to become more proactive in the delivery of their end-of-life healthcare services.
5
Program Description
The program consists of a 3-month intervention of up to 6 in-home counseling visits, focusing upon:
• Relief of death anxiety (counseling component). • Informed decision making about therapeutic
options and communication with surrogates, family members, caregivers and health care providers.
• Identification of opportunities for improved care coordination.
6
Staffing/Training • No health plan staff is allocated full-time to this
project.
• Contracted/Outsourced Models for Care Delivery: Model 1: Nurse Practitioners credentialed as Independent
Providers in AICC68 Trained providers in metro NY area to date
Model 2: Contracted Nurses and Social Workers through local Hospice Agency12 Trained Registered Nurses10 trained Social Workers
• All staff training is conducted by Dr Dan Tobin at a full day intensive seminar.
7
AICC Visits (Targeted in Borough of Queens, NY)
• Enrollee identified and mailed an introductory letter about the program.
• Follow-up call within 1 week to invite enrollee to participate
• Upon consent, AICC Provider assigned to conduct home visits
8
AICC Visits-What Happens at Home?
• Meeting 1 Introduce goals of AICCP How AICCP interacts with the primary care physician and the
acute care team, and What to expect.
• Meeting 2 Evaluate capacity of caregiver Discuss psychological, social, financial and practical concerns
• Meeting 3 Forging the partnership of member and caregiver in AICCP
care plan
9
AICC Visits – What happens at home?
• Meeting 4 Care management of functional impairment DNR orders
• Meeting 5 Obtaining feedback from providers on care plan Working with family members on care plan
• Meeting 6 Discuss accomplishments Address remaining concerns
10
AICC Providers-Need Back-Up• Coordination of services provided by Education &
Outreach Department• Additional service requests were made by practitioners
for: Home health care Nutrition consultations Prescription assistance Meals on wheels Transportation services DME Custodial care
11
AICC Visit Tracking
• CUP Profile (1-5) Curative, Uncertain,
Palliative
• Pain Assessment (1-5)• Coping with diagnosis (1)• Psychological Status (2)• Advance Directives (2)• Quality of Life (2)• Practical Issues (3)• Family Concerns (3)
• Palliative Care (4)• Spiritual/Religious Issues
(4)• Life-sustaining treatment
(5)• Psychological and other
concerns (5)• Bereavement needs (5)• Life closure (5)
Utilize 5 forms for data collection
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Demographics of PopulationPlace of Residence
Home
(93%)
With Relative
(2%)
Caregiver Living Arrangements
Alone
(23%)
Spouse/Other CG
(69%)
Gender Male
(55%)
Female
(45%)
Ethnicity Caucasian
(67%)
African American
(20%)
Hispanic
(4%)
Asian
(2%)
13
Diagnoses of Population
• Main Diagnoses for Selection on hospitalization and predictive modeling: CHF COPD Metastatic Cancer
• Some additional diagnosis were added in predictive modeling: Alzheimer’s disease Stroke
14
Enrollment in Program By Number of Visits
45
15
23
8
38
0
5
10
15
20
25
30
35
40
45
1 visit 2 visits 3 visits 4 visits 5 visits
Number ofParticipantsCompleting Visits
15
Adherence with Advance Directives
• National prevalence of advance directives: 15-20%• Compliance with Advance Directives in Program
Advanced Directives
2 visits 3 visits 4 visits 5 visits
Yes 60% 61% 75% 84%
16
Selection of Health Care Proxy
Healthcare Proxy
Selected
3 visits 4 visits 5 visits
YES 71% 63% 78%
17
Financial Results of Program 6 months Post PMPM
No AICC
(N=128)
AICC Visits
(N=38)
Inpatient $2,186 $999
ER $34 $11
Outpatient $779 $365
SNF $110 $21
Homecare $132 $283
Total $3,942 $1,926
18
Current Status of AICC Participants
Receiving Services %
Homecare 50%
Hospice 3%
SNF 5%
No Services 42%
19
Mortality Data
• Nationally, about 80% die in hospital or facility
• 9.3 % of enrollees died within 18 months 41% died in the hospital 58% died at home, in a snf or with hospice
• Of those who died, the average lifespan was 6 months after start date
20
Interpretation of Data
• Impact of Number of Visits on Outcome
• Impact of AICC Provider-2 Models
• Utilization of Palliative Care/Hospice Services
• Medical Utilization Impact
21
Conclusions
• AICC can be an effective strategy to improve end of life care within a Medicare Advantage population.
• Program success requires careful enrollee selection. • Nurses and nurse practitioners are effective AICC
providers • AICC Providers with case management expertise are more
successful at sustaining member enrollment and achieving positive outcomes.
• Collaboration between hospice organizations and Medicare Advantage health plans has the potential for improving hospice utilization and clinical outcomes.