Clinical Care Management

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Clinical Care Management Bruce Niebylski, MD
February 17, 2005
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Senior PlusChronic Disease Management
Total 15,951
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Senior PlusChronic Disease Management
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Senior PlusChronic Disease Management
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Senior PlusChronic Disease Management
Disease Population
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Senior PlusChronic Disease Management

• Top 10 Diagnoses for ER visits
• October 1, 2003- September 30, 2004
• Number of Emergency Room Visits
• Chest Pain NOS 353
• Dizziness and Giddiness 176
• Urinary Tract Infection NOS 174
• Respiratory Abnormal Nec 155
• Syncope and Collapse 151
• Hypertension NOS 122
• Pneumonia, Organism NOS 118
• COPD 104
• Congestive Heart Failure 103

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Senior PlusChronic Disease Management

• Top 10 Diagnoses for Inpatient Admissions
• October 1, 2003- September 30, 2004
• Number of Inpatient Admissions
• Congestive Heart Failure 328
• Pneumonia, Organism NOS 263
• COPD 213
• Rehabilitation Proc Nec 176
• Subendo Infrc-Initial Episode 166
• Athrscl Cor Art 164
• Atrial Fibrillation 109
• Acute Renal Failure NOS 102
• Urinary Tract Infection NOS 98
• Syncope and Collapse 81

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Senior PlusChronic Disease Management

• Members with Fractures
• October 1, 2003- September 30, 2004
• (759 members) 4.87
• Members with Hip Fractures
• October 1, 2003- September 30, 2004
• (80 members) 0.51

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Senior Plus Cost Analysis
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Senior PlusChronic Disease Management
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HAP Disease Management Automated Model
NURSE TELEPHONIC INTERVENTIONS HOME MONITORING
(HEALTH BUDDY ) CLINICAL PHARMACIST
CONSULTATIONS CLINIC/CENTER OF EXCELLENCE
REFERRALS
Predictive Modeling Risk Stratification
Data Warehouse
HIGH RISK
MedicalClaims
HealthRiskIndicators
ChronicDiseaseRegistry
LOW MEDRISK
PharmacyClaims
Risk AssessmentBased onDxCG UtilizationPharm
acyLab Scores
Member-CentricChronic Disease Registry
Systematic Evaluation ofGaps-In-Care basedon
latest CPGs
LabData
MAILINGS PATIENT EDUCATION
All Patient Data Stored onSame Platform (Oracle
)
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Medical Equipment
End of Life
Community Services Needs
Appropriateness and Monitoring
Interventions
Lifestyle Changes
Compliance with Care
Education Counseling
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Appropriateness and Monitoring
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Appropriateness and Monitoring, (cont.)
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Appropriateness and Monitoring, (cont.)
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Compliance with Care
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Education Counseling
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Lifestyle Changes
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Lifestyle Changes, (cont.)
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Lifestyle Changes, (cont.)
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Community Services Needs
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Medical Equipment
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Medical Equipment
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End of Life
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Outcomes Measurement

• Case Manager Productivity
• Increased 175- 200
• Utilization and HEDIS Measures
• IP Days/1000, ER/1000
• PMPM (inpatient, outpatient, pharmacy)
• of members with LDL at or below target
• of members with HbA1C les than target
• Program ROI
• Overall Medical Cost Savings
• Operating Costs of CCM Programs/Interventions

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Next Steps

• Presently have CHF, DM, automated- automate HTN,
  Depression, CAD, LBP, Obesity, Osteoporosis
• Evaluate and automate HRA
• Website capability
• Benefit Expansion, esp. w/pharmacy
• Evaluation of staffing roles eg. pharmacy
• Physician Certification Programs
• NCQA Disease Management Accreditation

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Education Counseling