Identifying and Providing Care Management for Vulnerable Populations:

A View From the Bronx, New York

Presentation to the Third ACO SummitJune 7, 2012

Stephen Rosenthal, MSc., MBAPresident, Chief Operating Officer

CMO, The Care Management Company of Montefiore

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Agenda

• Overview of the Bronx population

• Montefiore’s integrated delivery system

• Montefiore’s care coordination program

• Identifying and serving vulnerable and high risk populations

• The Montefiore Pioneer ACO

Overview of the Bronx Population and Montefiore’s Integrated Delivery System

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The Bronx, NY: 1.4 M People• 31% poor (vs. 21% across all of NYC);

• 90% Hispanic and/or Black

• Heavy disease burdenHigher prevalence of diabetes, obesity, asthma and other chronic conditions than NYC or NYS

• 20% higher per capita medical expense than US

• 8% of population accounts for 50% of medical expense

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Government Payers in the Bronx: Population and Healthcare Spend

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Montefiore’s Integrated Delivery System• Inpatient Care- Over 90,000 admissions

Three general hospitals and one children’s hospital1,500 beds

• Ambulatory Care- 2.5 million visits/year21 community primary care centers (>1 million visits)16 school health centers (52,000 visits)7 mobile healthcare units (11,000 visits)4 emergency departments (301,000 emergency visits)3 major specialty care centers (>1 million visits)

• Post-acute careHome care agency (500,000 visits)Rehabilitation

• University Hospital for Albert Einstein College of Medicine

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Montefiore IPA and CMO

• Formed in 1995• MD/ Hospital Partnership• Contracts with managed

care organizations to accept and manage risk

• Over 2,300 physician members (1,740 employed)

430 PCPs1,870 Specialists

• Established in 1996• Wholly-owned subsidiary of

Montefiore Medical Center• Performs care management

delegated by health plans as well as other administrative functions, e.g. claims payment, credentialing

• Licensed UR agent and certified claims adjustors

Montefiore IPACMO

Montefiore Care Management

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Source 2012 Population

2012 Est. 

Revenue

2013 Population

2013 Est. 

Revenue

Risk Contracts 140,000 $850 m 185,000 $1,085 m

Shared Risk 78,000 $490 m 80,000 $685 m

Medicaid health 

Home (Care 

Coordination)

10,000 $10 m 10,000 $18 m

228,000 $1,350 m 270,000 $1,788 m

Montefiore’s Risk and/or Value- Based Population and Revenue

The organization is moving from a transaction-oriented business to performance/value-based system.

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Montefiore’s Care Coordination Program

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Population Health Management Strategy

Self-ID DataMining

Sentinel Events, e.g. Post

DischargeProvider Referral

POPULATION

WELL &

WORRIEDWELL

FUNCTIONALCHRONICALLY

ILLFRAIL ILL/

HIGH UTILIZERS

INTERVENTION

INTENSITY

INTERVENTIONS ARE TARGETED TO MEMBERS HEALTH INFORMATION ACCESSED BY CAREGIVERS, AS NEEDED

* Intensive/complex case management* Palliative care* Transitional care management

MEMBERS ACCESS INFORMATION, AS NEEDED

* My Montefiore* General Health Information* PHR

MEMBERS ACCESS INFORMATION, AS NEEDEDHEALTH EDUCATION & INTERVENTIONS ARE TARGETED TO MEMBERS

* Self-management/empowerment tools* Customized assessments

WELL & WORRIED WELL

FUNCTIONAL CHRONICALLY ILL

FRAIL ILL/HIGH UTILIZERS

LOW

HIGH

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“Vulnerable” People: Need close monitoring

• Those with select chronic conditions currently in control

• Those being discharged from the hospital

• Those being discharged from home care services

• Duals• Nursing home residents

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High Risk People: Need Immediate Attention• Those with high costs• Those with select chronic conditions that are not

in control (diabetes, heart failure, asthma, COPD and a combination of depression and one of the above chronic conditions)

• Those with multiple co-morbidities/ polypharmacy• Homeless and those with unstable housing• Frail elderly and cognitively impaired

• Those with serious psychosocial/economic problems

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Care Guidance Program

Care Guidance Principles• Comprehensive baseline assessment done on

candidates for intensive case management

• Assessment covers medical, behavioral and social “risk” factors

• Care management system that links identified problems to possible interventions

• Individualized care plan produced

• Accountable Care Manager discusses care plan with patient and/or caregiver and modifies as needed

• Care plans shared with PCP

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Care Guidance Principles• Care management teams linked to specific PCMHs

• Use telemonitoring devices and telephone calls to monitor progress and reassess as needed

• Patients not identified as needing intensive case management can receive:

Chronic care management (diabetes, CHF, asthma/COPD, depression)Referral to House Calls, Palliative Care, HospiceInterventions during episodes of care: Post-discharge calls, ED Navigators, inpatient case managersPharmacy reviews

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• Enhance staffing and systems to address patients’ mix of medical and psychosocial issues:

Broaden use of team-based care by adding nurses and social workers to increase patient education opportunitiesExpand care coordination for patients seen by multiple providers (patient tracking, registries)Hub and Spoke Model (coordination with CMO)Increase patient-provider communication opportunities with secure email messagingIncrease responsiveness to patient feedback on their experience

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Using PCMHs to better support high risk/ vulnerable populations

Significant Improvement in Severe Diabetic Medicare Patients

Cum

ulat

ive

Perc

ent

Hgb

A1c

<8

Groups with baseline A1c ≥

9. CMO patients have a significantly higher rate of achieving target A1c <=8

P < .01

Note: Sample Size includes 386 Medicare patients managed by CMO vs. 1,052 Not CMO Medicare Patients with a median age of 71 for CMO Patients vs. 67 for Non-CMO Patients

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Decline of 30% for Diabetic Patient Admissions

Source: CMO Paid Claims; Author: H. Shao

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Note: Rx costs not available

Note: Projected Costs Estimated using healthcare inflation trend of 16%

Source: CMO Medical Expense Report; Author: H. Shao19

Effective Management of Diabetes has resulted in a 12% Drop in Total Costs

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Identifying and Serving High Risk/ Vulnerable Populations

Identifying high-risk/ vulnerable patients • Data mine in clinical, billing and claims systems

• Use predictive tool to identify those at risk of readmission (at point of admission)

• Collect data related to sentinel eventsPost-discharge calls ED patient navigators and inpatient case managers

• Referrals from medical, behavioral care, social service, and housing providers

• Patient/ caregiver self-referrals21

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Care Coordination for High Risk/ Vulnerable Populations• Individual Level

Assessment tools focus on medical and psychosocial issues Expand capability to work with participants face-to-faceIncorporate tools to support individual behavior change

• Provider LevelImprove access and availabilityExpand PCMH infrastructureIncorporate behavioral health expertise into care management teams

• System LevelSupport organizational behaviors that reduce preventable utilizationPartner with other providers/agencies to identify vulnerable patients and create integrated comprehensive care plans Develop IT infrastructure to support cross-organizational communication and data exchange

High risk example: Housing-at-Risk• “Real Time” flagging of individuals who present in

the ED or are admitted to the hospital who haveAddress that says ‘homeless’, ‘undomiciled’ or ‘shelter’“Home” address that is one of our hospital or clinic sites or a shelter address PCP who specializes in care for this populationBeen identified by housing/social service provider as at-risk

• When a Housing-at-Risk person presentsED Social worker is “beeped” and email alert is sent to ED Patient Navigator or Inpatient Social Work Manager (as appropriate) Email alert includes list of previous ED visits and reason for visit (e.g. visit to get prescriptions refilled)

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High risk example: Housing-at-Risk• Social worker meets with patient and ED providers to

assist in discharge plan, assure care is accessed and unnecessary admission avoided

Housing organization may come to pick up patient and drive to another care setting if necessarySome housing providers support patients in following treatment plans

• Regular case rounds on most challenging patients

• Have secured 2 “respite” beds to facilitate hospital discharge of the homeless and allow extended recovery time outside the acute care setting

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High risk example: Programs for Frail Elderly• Identified through provider referrals and case manager

recommendations

• Provide primary care, at home, for those unable to access care on an ambulatory basis using teams of physicians, nurse practitioners and social workers

• Patients use telemonitoring devices to respond to standard set of questions on daily basis and care managers call patients to follow up depending on responses

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Vulnerable population example:Synergy Program• An evidence-based model for treatment of depression

and/or alcohol abuse with chronic medical conditions

• Use clinical/claims information to identify patients in need

• Administration of PHQ 9 and AUDIT-C by PCP• Interventions conducted in PCMH and telephonically

Collaborative Care for DepressionSBIRT protocol (screening, brief intervention, referral to treatment for at- risk alcohol use)Psychiatry Consultation and Short Term Therapy Intensive Case Management for Complex PatientsTelephonic Psychotherapy for Depression and At-Risk Alcohol Use

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Montefiore Pioneer ACO

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Montefiore Pioneer ACO Population• Initially attributed 23,250 fee-for-service

Medicare beneficiaries

• 9,076 (39%) Duals

• 1,153 (4.9%) opted out of data sharing

• 21,292 beneficiaries with claims data

• 503 deaths to date

• 12,887 (55%) managed by community physicians not employed by Montefiore

• 780 live in nursing homes

Major Categories of ACO Expense $334.6 million

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Pioneer ACO Charlson Conditions

Charlson

Comorbidities Non‐ICM % Total ICM % ICM

Total Beneficiaries (deaths excluded) 20,939 100%1,830 100%Diabetes without complications              3,590 17% 771 42%Chronic Pulmonary Disease                   2,311 11% 665 36%Cancer                                      1,824 9% 357 20%Congestive Heart Failure                    1,362 7% 758 41%Renal Disease                               1,331 6% 782 43%Diabetes with complications  (total)                1,239 6% 338 18%

* Known deaths excluded* Conditions with 10% or more in either cohort

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Pioneer ACO Candidates for Intensive Case Management • 1,906 individuals (2+ admissions or

expense >$50k in last 12 months)

9% of the population = 55% of the medical cost ($184m)96 have already died49% are DualsAt least 113 reside in SNFs55% have some psychiatric diagnosisAlmost 70% are with non-employed PCPs

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• New targeted interventions for select groups (e.g. Duals, ESRD)

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• Additional interventions for SNF residents

• Expand linkage with non-employed ACO providers

• Expand strategies for beneficiary engagement

• Focus on patient satisfaction (7 of 33 ACO quality measures)

• Expand current programs

Ongoing efforts for ACO population

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Expected Results of Accountable Care• Bronx is a healthier community

• Bronx residents are more satisfied with their health care services

• Medicare achieves short term savings and decreased spending in long term

• The Bronx accountable care model is SustainablePatient-CentricTransferableEfficient use of financial resources