High-risk Medicare members targeted
High-risk Medicare members targeted
Integrated CM cuts hospitalization, ED visits
An integrated approach to managing the care of Medicare Advantage members with special needs has paid off for Baltimore-based XLHealth, resulting in increased primary care interventions and reduced rates of hospitalization and emergency department visits.
Members in the Medicare Advantage Chronic Condition Special Needs Plan experienced increased primary care interventions by 7%, decreased hospitalizations by 9%, cuts in hospital days by 19%, and reductions in readmissions by 28% when compared to a sample of members in fee-for-service Medicare, according to Kristy Duffey, MS, BNP-BC, vice president of clinical operations.
The program aims to reduce unnecessary and costly readmissions among the high-risk members of Care Improvement Plus, XLHealth's Medicare Advantage plan, Duffey says.
When members enroll, a nurse practitioner visits them at home, completes a comprehensive assessment, and enters it into the health plan's XLCare database. The health plan's predictive modeling system uses information gathered by the nurse practitioner during the home visit, historical and real-time claims data, and laboratory data to stratify members based on severity of illness, gaps in care, and psychosocial needs.
"We have the ability to look at the members' chronic conditions and acute conditions and predict future events. This enables us to get members into appropriate programs earlier and stop or slow the progress of the disease," she says. Members who are at high risk receive intensive case management services. Those with advanced illnesses are enrolled in Connected Care, which provides a palliative care team and telephonic case management to help prevent unnecessary hospitalizations. About 12% of members in the special needs program are in the high-risk case management program. About 3% of those in the high-risk program are enrolled in Connected Care.
The program includes telephonic nurse case management, pharmacy management, social services, access to a nurse hotline 24 hours a day, seven days a week, and a Transitions of Care program that bridges the gap as members move from one level of care to another.
A key component of the model is the health plan's HouseCalls program, which sends nurse practitioners and physicians to at-risk patients' homes to conduct assessments, provide education, and coordinate care with the patients' primary care physicians. Approximately 85% of special needs enrollees receive a HouseCalls visit.
A health plan pharmacist contacts members who are taking multiple medications, reviews the medications and follows up with each member's primary care provider.
Nurse care managers call high-risk members at regular intervals to make sure they are following their treatment plan. In 2011, the health plan's nurse care managers conducted more than 455,000 counseling sessions over the telephone.
When members are hospitalized, XLHealth care managers collaborate with the hospital case managers on the discharge plan. A health plan nurse works at one hospital where a large number of health plan members are admitted, visits the members while they are in the hospital and works with the discharge planning staff. When members are admitted to other hospitals, the health plan case manager contacts the hospital case manager by telephone.
"We know that when health plans and hospitals work together on discharge planning and transitions of care, we can reduce readmissions. Since we started the program, readmission rates have gone down in the hospital where we have an on-site nurse," Duffey says.
When members are hospitalized, a case manager calls them within 24 to 48 hours of discharge. In addition, a HouseCalls practitioner makes a post-discharge visit and a health plan pharmacist calls the member and conducts medication reconciliation and counseling. "We have a strong transitions-of-care program because we know that patients are most vulnerable when they transition from one level of care to another," she says.
Appropriate heart failure patients use telemonitoring equipment that measures their weight on a daily basis and feeds the information back to the case management team. The case manager is alerted if a member has weight gain or weight loss. He or she calls the member immediately and doesn't wait to get a call from the emergency department, she says.
When members are discharged from the hospital to a lower level of care, such as a skilled nursing facility, the case manager conducts telephonic concurrent review with the facility to ensure the member's progress. If the member has been stratified as high-risk, a HouseCalls clinician visits the member in the facility.
Care for members who qualify for a new program, Connected Care, is coordinated by a nurse practitioner who works with the member, the family, and the primary care physician. The program takes a holistic approach to care and provides social, psychosocial, and spiritual support and education on treatment options in order to help the patient avoid unnecessary hospitalization and get advance directives in place.
The program includes telephonic case management by nurse practitioners and social workers, in-home visits by HouseCalls practitioners, and palliative care services. "Members are in this program in their last 12 to 18 months of life. We help them with quality-of-life issues and work with physicians on managing the disease progress," she says. The team educates the family about what is likely to happen with the patient so their choices are documented and plans are in place when the patient takes a turn for the worse. "We don't want the family to wait until the patient's weight drops dramatically to decide if they want a feeding tube. We want to get everything in place before the decision is critical," she says.
An integrated approach to managing the care of Medicare Advantage members with special needs has paid off for Baltimore-based XLHealth, resulting in increased primary care interventions and reduced rates of hospitalization and emergency department visits.Subscribe Now for Access
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