Multi-tiered model helps manage chronic diseases
Multi-tiered model helps manage chronic diseases
Plan takes a holistic approach to care coordination
An intensive case management program that provides case management, disease management, and behavioral health coordination for high-risk, high-cost members has resulted in savings of $6.1 million in a 12-month period for Keystone Mercy Health Plan.
Members who are selected for the PerforMED program were based on their predictive risk score. The typical member:
- has three or more chronic illnesses plus one behavioral health diagnosis;
- is taking five or more prescription medications, not counting over-the-counter medications;
- receives care from three or more physicians;
- uses all health plan services at three to four times the rate of the average plan member;
- has a predictive risk score of 4.5, indicating that their risk is 4.5 times higher than the plan average.
The PerforMED intensive case management program is a product of AmeriHealth Mercy, the umbrella organization for Keystone Mercy Health Plan, which provides coverage for publicly insured members.
The savings calculated by an actuarial firm compare the members' baseline health care expenditures and the current expenditures, but the actual savings are likely to be significantly higher, says Karen Michael, RN, MBA, vice president for clinical services for the Philadelphia-based health plan.
"With this membership, if someone isn't helping them manage their care, their costs continue to rise. We know, based on people we have not been able to contact, that the health care costs of members in the program would be higher now than the baseline year if we had not intervened," she says.
Members are identified by predictive modeling, new member assessments, and referrals from providers and community partners.
Once the members are in the program, they are stratified based on past utilization of health care resources, diagnosis, laboratory results, medication profile, and medical history. Based on their stratification, members are placed into levels of care intensity.
Members who are eligible for the program work with one care coordinator, instead of talking to one RN for case management and another for disease management.
"Members with chronic conditions don't usually have a single disease. They typically have a complex medical history. Our goal is to address all of their issues and to coordinate with the member and his or her primary care provider to set priorities and goals," says Robin Griffin, RN, BSN, CCM, director of rapid response and outreach of the PerforMED program at Keystone Mercy Health Plan.
The health plan has a dedicated rapid response team, which works mainly to resolve any urgent issues that arise.
"If the member telephones in with a problem or we identify a need, it is triaged by the rapid response team, which works to resolve any immediate barriers," Michael says.
For instance, the team may help a member get his or her prescriptions filled, arrange transportation for a visit to a specialist, or refer the member to a behavioral health specialist.
"The rapid response team works beyond the medical sphere, helping with other stressors in the member's life. If a member's power is turned off or she doesn't have food for her children, she can't focus on her own health care needs," Michael says.
The rapid response team can connect members to community resources or government agencies who can help with their needs.
The rapid response team includes nurses, social workers, and case management technicians, nonclinical staff who have been trained in health care delivery, medical terms, and how to coordinate access to the health care system.
Case management technicians answer the rapid response team telephones the majority of the time, gathering information about the member's condition and purpose of the call. The case management technician works to resolve non-clinical issues and triages the member to the appropriate staff member for clinical or social work assistance.
Once the rapid response team has the member's immediate problems stabilized, the member is turned over to a case manager.
The health plan's case managers are registered nurses and master's-prepared social workers.
Case managers typically handle the care of between 150 and 200 members with the support of a case management technician.
"We assign cases based on acuity. We know that the new cases are more time - intensive," Michael says.
The case management technicians assist the case managers by arranging transportation, making reminder calls about physician appointments to members, and other tasks that free the case managers to concentrate primarily on health care issues.
When case managers connect to the members, they conduct a comprehensive assessment and work with the members and the provider to develop individual goals, then continue to work with the member over time to execute the treatment plan.
For instance, an immediate goal may be to work on getting the member's hemoglobin A1c down a point or sending the member to a physician's office for tests to measure his or her lipid level.
"Our intensive case managers provide constant education and reminders to help the members keep their chronic condition under control and assist in removing the barriers to compliance," Griffin says.
The case manager maintains an ongoing relationship with the member, working on issues in the care plan and assisting members with any problems that arise.
For example, the members may need assistance in getting an appointment with an endocrinologist or financial assistance for their medication copay.
The case managers call members at intervals that are determined by the members' individual needs.
"In the beginning, the case managers may make weekly or even daily contact with the members if they are working on a problem together. As the situation stabilizes, the contacts are less frequent. We never discharge anyone from the PerforMED program. The only time they are removed from the program is when they lose eligibility or die," Michael says.
In addition, Keystone Mercy Health Plan has a nurse advice line, accessible to the entire membership, 24 hours a day, seven days a week.
The rapid response team follows up with callers to the nurse line to make sure that their problems or concerns have been resolved. For instance, if someone needs help getting in to see a physician or has transportation needs, the nurse refers the call to the rapid response team.
Members may reach any component of the PerforMED program by calling the health plan's main number in addition to calling the direct line for their case manager.
"We have created an umbrella of services around our members. The key to that umbrella is to have a system in place to feed information from one part of the umbrella to the other," Michael says.
If a member who is working with a case manager calls the rapid response team, the call is transferred to the case manager if he or she is available. Otherwise, the rapid response team takes care of the issue.
All members of the PerforMED team have received training on the current national guidelines, best practices, and other health care resources. The health plan also calls on its pharmacy partners to conduct case reviews and consult on medication management issues.
The health plan's medical director has provided education on chronic conditions and assisted with the creation of computerized teaching tools, including talking points and questions to assist the care coordinators in working with members.
"Coordination of all elements of care is the critical differentiator for Keystone Mercy's Care Coordination unit. The support from the medical directors and pharmacy partners, combined with the focused efforts of the case management teams, assures that members receive the advocacy needed for enhanced self-care, improved health status, and achievement of personal quality-of-life goals," Michael says.
An intensive case management program that provides case management, disease management, and behavioral health coordination for high-risk, high-cost members has resulted in savings of $6.1 million in a 12-month period for Keystone Mercy Health Plan.Subscribe Now for Access
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