State Coverage Initiatives Symposium

February 7, 2008

Nashville, Tennessee

Charles F. Willson MD

Medical Director

Community Care Plan of Eastern Carolina

State Coverage Initiatives Symposium

February 7, 2008

Nashville, Tennessee

Charles F. Willson MD

Medical Director

Community Care Plan of Eastern Carolina

Basic Operating PremiseBasic Operating Premise Regardless of who manages Medicaid, North Carolina’s

physicians, hospitals, health departments and other safety net providers will be serving the patients.

Through Community Care, DHHS is partnering with community and safety net providers to build the needed improvements in care for Medicaid and other low-income populations.

An enhanced primary care medical home is the best value in healthcare today.

Regardless of who manages Medicaid, North Carolina’s physicians, hospitals, health departments and other safety net providers will be serving the patients.

Through Community Care, DHHS is partnering with community and safety net providers to build the needed improvements in care for Medicaid and other low-income populations.

An enhanced primary care medical home is the best value in healthcare today.

Primary GoalsPrimary Goals Improve the care of the Medicaid population while controlling costs

Develop Community Networks capable of managing recipient care

Develop the systems needed to improve chronic illness

Improve the care of the Medicaid population while controlling costs

Develop Community Networks capable of managing recipient care

Develop the systems needed to improve chronic illness

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Goals Achieved By:Goals Achieved By:

Making sure people get care when they need it

Obtaining quality care

Implementing best practice guidelines

Managing Medicaid costs

Building local care systems

Making sure people get care when they need it

Obtaining quality care

Implementing best practice guidelines

Managing Medicaid costs

Building local care systems

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Community Care of North CarolinaCommunity Care of North Carolina

Joins other community providers (hospitals, health departments and departments of social services) with physicians

Creates community networks that assume responsibility for managing a population of patients

Networks serve as templates for innovation

Joins other community providers (hospitals, health departments and departments of social services) with physicians

Creates community networks that assume responsibility for managing a population of patients

Networks serve as templates for innovation

Builds on PCCM ProgramBuilds on PCCM Program

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Community Care of North Carolina Community Care of North Carolina

Focuses on improved quality, utilization and cost effectiveness of chronic illness care

14 Networks with more than 3500 physicians

762,814 enrollees

Each community has its medical assets and needs. CCNC tries to align these assets and needs

Focuses on improved quality, utilization and cost effectiveness of chronic illness care

14 Networks with more than 3500 physicians

762,814 enrollees

Each community has its medical assets and needs. CCNC tries to align these assets and needs

AccessCare Network SitesAccessCare Network CountiesAccess II Care of Western NCAccess III of Lower Cape Fear

Southern Piedmont Community Care Plan

Community Care Plan of Eastern NC

Community Health Partners Northern Piedmont Community Care

Partnership for Health Management

Sandhills Community Care Network

Community Care of Wake and Johnston Counties

Community Care of North Carolina Community Care of North Carolina

CCNC Networks as of October 2007 CCNC Networks as of October 2007

Carolina Collaborative Comm. CareCarolina Community Health Partnership

Comm. Care Partners of Gtr. MecklenburgCentral Piedmont Access II

Central Care Health Network

My Network: Community Care Plan of Eastern CarolinaMy Network: Community Care Plan of Eastern Carolina 27 counties, from the Atlantic to I-95 and from

the VA border to I-40 >160 primary care practices >100,000 patients Local clinical champions Local project coordinators

27 counties, from the Atlantic to I-95 and from the VA border to I-40

>160 primary care practices >100,000 patients Local clinical champions Local project coordinators

Community Care Networks: Community Care Networks: Non-profit organizations

Comprised of primary care practices and other safety net providers

Steering committees

Medical management committees

Receive $3.00 PM/PM from the State

Hire care managers/medical management staff

Non-profit organizations

Comprised of primary care practices and other safety net providers

Steering committees

Medical management committees

Receive $3.00 PM/PM from the State

Hire care managers/medical management staff

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What Networks DoWhat Networks Do

Assume responsibility for Medicaid recipients

Identify costly patients and costly services

Develop and implement plans to improve access, manage utilization and reduce cost

Create the systems to improve care

Assume responsibility for Medicaid recipients

Identify costly patients and costly services

Develop and implement plans to improve access, manage utilization and reduce cost

Create the systems to improve care

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Managing Clinical CareManaging Clinical Care

Clinical Directors Group • Select targeted diseases/care processes• Review evidenced-based practice guidelines• Define the program• Establish program measures

• Select targeted diseases/care processes• Review evidenced-based practice guidelines• Define the program• Establish program measures

I

ASTHMAASTHMA

DIABETESDIABETES

PHARMACYPHARMACY

HIGH-RISK & -COSTHIGH-RISK & -COST

EDED

Local Medical Mgmt. Comm.

• Implement state-level initiatives• Develop local improvement initiatives

• Implement state-level initiatives• Develop local improvement initiatives

PRACTICE A PRACTICE B PRACTICE C

Care Managers and CCNC quality improvement staff support clinical management activitiesCare Managers and CCNC quality improvement staff support clinical management activities

III

IIGASTRO-ENTERITISGASTRO-ENTERITIS

OTITIS MEDIAOTITIS MEDIA

CHILD DEVELOPMENTCHILD DEVELOPMENT

ADHDADHD

FEVER FEVER

DEPRESSIONDEPRESSION

CO-LOCATIONCO-LOCATION

CAP-CCAP-C

CHRONIC CARECHRONIC CARE

HEART FAILUREHEART FAILURE

MH INTEGRATIONMH INTEGRATION

DIABETES DISPARITIES DIABETES DISPARITIES DENTAL VARNISHINGDENTAL VARNISHING

OBESITYOBESITY COPDCOPD

Key Program Areas in Managing Clinical Care: Key Program Areas in

Managing Clinical Care:

Providing timely access to care

Implementing best practices/disease management

Managing high-risk patients

Managing high-cost services

Building accountability through monitoring & reporting

Providing timely access to care

Implementing best practices/disease management

Managing high-risk patients

Managing high-cost services

Building accountability through monitoring & reporting

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Evidence-based guidelines

Improvement specialists: IPIP

Practice “champions”

Establishing improvement processes within the practice

Benchmarking & goal setting

Evidence-based guidelines

Improvement specialists: IPIP

Practice “champions”

Establishing improvement processes within the practice

Benchmarking & goal setting

Implementing Best Practices:Implementing Best Practices:

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Implementing Disease Management Implementing Disease Management Evidence-based guidelines

Clinical directors set performance standards

Local provider buy-in obtained

Improve the care management process

Local & state level technical assistance Pilot initiatives

Evidence-based guidelines

Clinical directors set performance standards

Local provider buy-in obtained

Improve the care management process

Local & state level technical assistance Pilot initiatives

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Managing High Risk Patients Managing High Risk Patients

Identify high cost through claims analysis

Identify high risk through reporting and referrals

Targeted case management

Coordinate community resources

Set expectations

Identify high cost through claims analysis

Identify high risk through reporting and referrals

Targeted case management

Coordinate community resources

Set expectations

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Managing High-Cost Services: Managing High-Cost Services:

Pharmacy

- Nursing home polypharmacy

- Prescription Advantage List (PAL)

- Ambulatory, Polypharmacy & Multi-Prescriber Emergency Department (ED) Quadrant IV – High Physical and High Behavioral Health Care Needs

Pharmacy

- Nursing home polypharmacy

- Prescription Advantage List (PAL)

- Ambulatory, Polypharmacy & Multi-Prescriber Emergency Department (ED) Quadrant IV – High Physical and High Behavioral Health Care Needs

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Building AccountabilityBuilding Accountability

Chart audits Practice profiles Care management reports – high-risk/high-

cost patients PAL scorecard/ OTC meds Progress toward goals & benchmarks

Chart audits Practice profiles Care management reports – high-risk/high-

cost patients PAL scorecard/ OTC meds Progress toward goals & benchmarks

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Current Disease and Care Management InitiativesCurrent Disease and Care Management Initiatives

Asthma Diabetes CHF Chronic Care – (Aged, Blind and Disabled) High Cost – High Risk Pilots in Depression, ADHD, Special Needs Children,

COPD, Co-Location and Mental Health Integration

Asthma Diabetes CHF Chronic Care – (Aged, Blind and Disabled) High Cost – High Risk Pilots in Depression, ADHD, Special Needs Children,

COPD, Co-Location and Mental Health Integration

Asthma and Diabetes InitiativesAsthma and Diabetes Initiatives

Adopted nationally accepted best practice guidelines

Physicians set performance measures Provide regular monitoring and feedback Implement CQI at practice level

Adopted nationally accepted best practice guidelines

Physicians set performance measures Provide regular monitoring and feedback Implement CQI at practice level

Asthma InitiativeAsthma Initiative

KeyKey

Process MeasuresProcess Measures

47%

56%

64%64%

52%51%49%

93%95%92%93%93%

67%

78%75%73%

68%68%

0%

20%

40%

60%

80%

100%

'01 '02 '03 '04 '05 '06 '01 '02 '03 '04 '05 '06 '01 '02 '03 '04 '05 '06

47%

56%

64%64%

52%51%49%

93%95%92%93%93%

67%

78%75%73%

68%68%

0%

20%

40%

60%

80%

100%

'01 '02 '03 '04 '05 '06 '01 '02 '03 '04 '05 '06 '01 '02 '03 '04 '05 '06

1 2 3

1 % with asthmawho had documentation of staging

% with asthmawho had documentation of staging

2 % staged II – IV on inhaled corticosteroids

% staged II – IV on inhaled corticosteroids

3 % staged II – IV who have an AAP% staged II – IV who have an AAP

Diabetes InitiativeDiabetes Initiative

Second program-wide initiative – began July 2000

Adopted best practice guidelines (ADA) Implement continuous quality improvement

processes at each practice Physicians set performance measures Provide regular monitoring and feedback

Second program-wide initiative – began July 2000

Adopted best practice guidelines (ADA) Implement continuous quality improvement

processes at each practice Physicians set performance measures Provide regular monitoring and feedback

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Diabetes InitiativeProcess MeasuresDiabetes InitiativeProcess MeasuresCommunity Care of NC Diabetes Quality Initiative Summary (Established)Community Care of NC Diabetes Quality Initiative Summary (Established)

Baseline 2001Baseline 2001 R1 2002 R1 2002 R2 2002 R2 2002 R3 2003 R3 2003 R4 2004 R5 2005 R4 2004 R5 2005

0

10

20

30

40

50

60

70

80

90

100

Flow Sheet Cont. Care BP Eye Exam Foot Exam HbA1c Lipid Profile Flu Vaccine Pneu.Vaccine

Mono Exam

0

10

20

30

40

50

60

70

80

90

100

Flow Sheet Cont. Care BP Eye Exam Foot Exam HbA1c Lipid Profile Flu Vaccine Pneu.Vaccine

Mono Exam

CCNC - Cost SavingsCCNC - Cost Savings

Mercer Human Resource Consulting Group found, when compared what the access model would have cost in SFYs without any concerted efforts to control costs, the CCNC program saved: □ SFY 03 $ 60 million □ SFY 04 $ 124 million

□ SFY 05-06 $ 240 million

Mercer Human Resource Consulting Group found, when compared what the access model would have cost in SFYs without any concerted efforts to control costs, the CCNC program saved: □ SFY 03 $ 60 million □ SFY 04 $ 124 million

□ SFY 05-06 $ 240 million

Networks beginning to implement Improving Quality of Care

Guidelines and Toolkit Heart Failure Reports Performance Measures Links with local Heart Failure programs and Hospitals

Case Management Program Telephone Case Management Initiative Video telehealth visits

Networks beginning to implement Improving Quality of Care

Guidelines and Toolkit Heart Failure Reports Performance Measures Links with local Heart Failure programs and Hospitals

Case Management Program Telephone Case Management Initiative Video telehealth visits

Heart Failure Program Heart Failure Program

Modifiable Factors Leading to Hospital Readmissions for HF*: Modifiable Factors Leading to Hospital Readmissions for HF*:

Inadequate patient and caregiver education and counseling

Poor communication among health care providers Failure to organize follow up care Clinician failure to emphasize non-pharmacologic aspects

of HF care (dietary, activity, and symptom monitoring)

Inadequate patient and caregiver education and counseling

Poor communication among health care providers Failure to organize follow up care Clinician failure to emphasize non-pharmacologic aspects

of HF care (dietary, activity, and symptom monitoring)

*From 2006 HFSA Guideline on HF Disease Management

Lessons Learned Lessons Learned

Choose initiatives that can demonstrate quality improvement and impact cost

Use evidence-based best practice guidelines Local Physician buy-in and input during the

development is very important Build confidence at the provider level with your

data and reporting

Choose initiatives that can demonstrate quality improvement and impact cost

Use evidence-based best practice guidelines Local Physician buy-in and input during the

development is very important Build confidence at the provider level with your

data and reporting

Lessons Learned (continued) Lessons Learned (continued)

Build meaningful and provider friendly reports Choose performance measures that can be obtained

consistently and “painlessly” Sell your program to providers with “quality impact”

and sell your program to legislators with “cost impact and quality”

Physicians want to practice highest quality It will take you time to show results – stay under the

radar screen

Build meaningful and provider friendly reports Choose performance measures that can be obtained

consistently and “painlessly” Sell your program to providers with “quality impact”

and sell your program to legislators with “cost impact and quality”

Physicians want to practice highest quality It will take you time to show results – stay under the

radar screen

Lessons Learned (continued) Lessons Learned (continued)

Incentives must be aligned Must be able to measure change Modifiable measures – measures which can be

impacted Feedback should be educational not punitive Don’t lose site of the goal Continuous

Quality Improvement

Incentives must be aligned Must be able to measure change Modifiable measures – measures which can be

impacted Feedback should be educational not punitive Don’t lose site of the goal Continuous

Quality Improvement

Q U E S T I O N S

THANK YOU