Intensive program saves money, improves care
Intensive program saves money, improves care
Savings are more than $80 per member per month
Philadelphia-based Keystone Mercy Health Plan/AmeriHealth Mercy’s PerforMED, an intensive case management program for high-cost members receiving publicly funded health care, resulted in an adjusted savings of between $80 and $115 per member per month in the first six months.
The data represent the health care costs of 4,500 members who participated in the program, compared to a control group of members who were not selected, chose not to participate, or who could not be reached. Cost savings data were adjusted to account for selection bias and member participation, says Ian Duncan, a Hartford, CT-based actuary who analyzed the data.
The PerforMED program provides case management, disease management, and behavioral care coordination to high-risk and high-cost members.
There are about 300,000 members in Keystone’s Mercy Health Plan’s full-risk Medicaid HMO. About 70% of the members are mothers and children. The other 30%, those targeted by the PerforMED program, are in the aged, blind, and disabled category and receive Supplemental Social Security (SSI) benefits, reports Tom Lyman, senior vice president for market expansion.
Until 1997, when the state of Pennsylvania mandated that managed care organizations include the SSI population, Keystone Mercy primarily served mothers and children.
"We went from managing a primarily well population to having 30% of our members who were quite sick. This called for new approaches in care coordination," says Jane Israel, RN, executive director of clinical initiatives.
As the costs of inpatient and emergency department visits, pharmacy, and outpatient services soared, the administration at Keystone Mercy developed a predictive model to identify which members needed the most help and to stratify them.
They found that 10%-20% of the members were spending 80% of the overall expenditures. About 30% of them had comorbid behavioral health diagnoses, such as depression or bipolar disorder, that have an impact on medical management.
They were on an average of five or more prescription medicines, not including behavioral health medicines or over-the-counter drugs, such as medication for acid reflux.
In addition to receiving care from a primary care physician, these members typically were being treated by three or more specialists.
"The data told us that these members could not be managed through episodic case management alone because of the degree of their illness and their multiple comorbidities. Their care needed to be coordinated by a dedicated individual who understood the scope of their problems and who understood their benefit plan," Israel says.
Once a member has been identified through predictive modeling, he or she is referred to the rapid response center, staffed with case managers, RNs, and case management technicians who are trained, but unlicensed, medical health care professionals.
The staff at the rapid response center reach out to the members by telephone, through the mail, and go into the community to meet with the member whenever necessary. The health plan contracts with community agencies to help find the members.
During the outreach call, staff conduct an assessment that focuses on identifying the urgent needs that the members have, issues that if not resolved quickly could result in an emergency department visit or hospital admissions.
"We focus on when the member last saw the primary care physician, are they doing well in the home environment, did they fill their prescriptions for medication, and are they compliant with their medication," Israel says.
"The job of the rapid response team is to remove barriers to care and stabilize the member to get their immediate needs taken care of so they are ready for intensive case management," Israel says.
The rapid response team also serves as a nurse advice line for members during normal business hours. After hours, all members have access to a nurse triage and education service.
After the members’ immediate needs are taken care of by the rapid response team, they are turned over to a case manager who conducts a comprehensive assessment that includes whether they can care for themselves, financial barriers, understanding of their illness and medication, and support in the home.
The case managers work in teams with case management technicians who tackle tasks such as scheduling transportation that don’t require a licensed professional to handle them.
The caseload for case managers in the PerforMED program is higher than expected due to support from the interdisciplinary team and the role of the case management technician, Simmons says. Caseload depends on the severity of the members’ illnesses.
The case managers go beyond the typical duties of case management, arranging cab rides, arranging for pharmacy deliveries, calling food banks to get food delivered to homebound members, and assisting members in applying for community services.
The case managers work with the members and their providers to create individual plans of care. They focus on the things that make a difference in their quality of life, Israel says.
For instance, the case managers make sure the members see their physician on a regular basis, rather than just going when they are sick, a key factor in management of chronic illnesses. They check to make sure the members are on a treatment regime that follows nationally recognized clinical guidelines.
They call the members to remind them when they are due for an appointment, discuss things that the member should discuss with the physician, and follow up with the member immediately after the visit to review any changes in the treatment plan.
If necessary, the case manager will call the physician and review any changes in the plan of care to make sure that what the member understands is in fact what the doctor recommended.
The case managers call members on a routine basis, depending on the members’ needs.
They cover issues such as safety with medication, prevention of falls, nutrition, and exercise.
"For this population, many of whom are homebound, exercise may be as simple as sitting in a chair and doing leg lifts or moving their arms up and down. A goal may be to increase the number of aisles they go up and down at the grocery store," Israel says.
After a year, about 98% of members initially enrolled are still participating in the intensive case management program.
In addition to producing cost savings, the PerforMED program has resulted in high member satisfaction rates.
Philadelphia-based Keystone Mercy Health Plan/AmeriHealth Mercys PerforMED, an intensive case management program for high-cost members receiving publicly funded health care, resulted in an adjusted savings of between $80 and $115 per member per month in the first six months.Subscribe Now for Access
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