Hot Topics: Who Benefits

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Hot Topics Who Benefits

• Finding Common Ground on Care Coordination
• ASA-NCOA 2009 Annual Conference on Aging
• March 17, 2009

Patricia J. Volland, MSW, MBA SVP for Strategy
and Business Development Director, Social Work
Leadership Institute
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Care Coordination Who Benefits

• How can we characterize the target populations of
  care coordination?
• Identifying models of care coordination can help
  understand who is targeted and who benefits
• Different models target different populations,
  e.g. dual eligible, disease specific, transitions
  in care, etc.
• Medical, social and integrated models offer a
  clear distinction on ways populations may be
  targeted
• Must keep in mind which populations may be
  traditionally overlooked

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Models of Care Coordination

• Medical models target older adults with chronic
  conditions
• Primary care case management model (PCCM)
• Managed care models
• Targeted Disease Management programs, e.g.
  diabetes, cardiovascular disease, arthritis
• Social models target older adults with LTC needs
• Statewide programs that address long-term care
  needs primarily through HCBS (e.g. EISEP in NY
  Ohio Passport)
• Provided through state agencies, local area aging
  networks etc.
• Integrated Models whole person approach
• Bridge the gap between health and long-term care
  needs
• Degree of integration varies among programs

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Care Coordination and Dual Eligibles

• Many care coordination programs focus primarily
  on dual eligible population
• 8.8 million in number, two-thirds (5.6 million)
  age 65, and one third (3.2 million) younger
  persons with disabilities
• 18 of Medicaid enrollment compared to 46 of
  Medicaid spending
• High incidence of multiple chronic conditions,
  multiple providers, multiple medications
• Many require nursing home level of care and
  extensive care coordination

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The Dual Eligible Universe

• Dual eligible care coordination programs target
  high cost, high use, high risk populations with
  complex care needs
• However, among programs different target
  populations
• Some allow only nursing home level of care (e.g.
  PACE)
• Some allow any dual eligible with complex health
  and long term care needs (e.g. Texas Star )
• Population served is often defined by level of
  care coordination required and type of financing

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Waiver Programs and Population Served
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Models of Care and Intensity

• PACE and similar programs
• Interdisciplinary, highly structured, full
  integration of medical and social needs, nursing
  home level of care, soup to nuts, (Wisconsin
  Partnership Program)
• Managed care models
• Degree of integration varies, broader population
  of older adults (e.g. Georgia SOURCE), less
  intensive coordination of care
• Private Pay
• Care coordination needs tailored to individual
  can target any individual (who can pay) or level
  of care caregiver focus
• Single Point of Entry
• Information, screening and referral least
  intensive in terms of coordination (NJ EASE,
  Colorado POE)

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Dual Eligible Focus Limits Target Populations

• Managed care and waiver programs continue to
  serve relatively small portion of the older
  population
• Current care coordination efforts for older
  adults tend to focus on frail elderly at nursing
  home level of care
• Limited focus on prevention for at risk
  populations
• For many older adults gaining access requires
  spend down to Medicaid
• Lack of focus on caregiver population
• Medical models tend to overlook mental health,
  social support and caregiver needs

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Growing Focus on Medicare Beneficiaries

• About 20 percent of Medicare beneficiaries have
  five or more chronic conditions
• Accounts for over two-thirds of Medicare spending
• 325 billion for Medicare benefits in 2005
• See on average 14 different physicians in a year,
  and have almost 40 office visits
• Neither traditional fee-for-service Medicare nor
  Medicare Advantage (MA) is able to provide
  adequate care for these beneficiaries
• Renewed Focus from policy makers on these
  implications

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Emerging Models Medicare

• Medicare Modernization Act (MMA) provides for a
  new Chronic Care Improvement (CCI) program within
  the traditional Medicare program
• The CCI vendor-operated disease management
  program targets beneficiaries with chronic
  obstructive pulmonary disease, congestive heart
  failure, diabetes mellitus, and other diseases
• The CCI will be evaluated over three year period
  for financial outcomes, clinical quality and
  beneficiary satisfaction.

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Emerging Models Medicare

• Care Management Demonstration project (CMS)
• Six 3-year pilot programs implemented by six Care
  Management Organizations
• Care Level Management October 2005
• Health Buddy Early 2006
• Massachusetts General Care Management Early 2006
  
• Montefiore Care Guidance Early 2006
• RMS KEY to Better Health November 2005
• Texas Senior Trails Early 2006
• Beneficiaries will have to meet eligibility
  criteria outlined by each site, including having
  one or more chronic conditions

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Emerging Models Medicare

• Medicare Chronic Care Practice Research Network
  (MCCPRN)
• Develop, execute and evaluate evidence-based
  chronic care initiatives focused on high cost,
  co-morbid, fee for service beneficiaries
• Establish CMS practice-based research network
  focused on chronic care
• Serve as leading national resource to advance
  implementation of best practices
• Address limitations of demonstration programs
  with respect to replication and scalability

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Other Important Models

• Care Transitions model patients move from one
  setting to another targets patients aged 65 and
  older hospitalized with or for one or more
  chronic conditions (Coleman, Naylor)
• Chronic Care Model targets complex health
  conditions and takes holisitic approach for
  those with complex care needs
• Guided Care is a new model for chronic care in
  primary care practice settings with RN care
  coordinator where typical beneficiary has
  multiple chronic conditions and numerous
  providers
• Lorig Model offers chronic disease
  self-management to empower patients to take
  active role in their own care
• Many others (many of which you have heard about
  in more detail today)

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Overlooked Target Populations

• Mental Health
• IMPACT program targets older adults with
  depression
• Primary care physician works with a care manager
  to develop and implement a treatment plan
• This type of program not widely replicated,
  though successful
• Caregivers
• Recognition of importance and needs of caregivers
• Emerging trend towards care coordination support
  for caregiver
• Helping caregivers supports backbone of LTC
  system, can help improve their own health and
  reduce stress levels
• People with Dementia
• Special population with special needs
• Caregiver support crucial

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Benefits to Providers and Payors

• Providers and payers benefit primarily from gains
  in efficiency of care delivery through lack of
  redundancy, effective communication and
  technological solutions
• Healthcare professionals can redeploy resources
  and take on new roles within interdisciplinary
  team
• Providers and payers also have goal to achieve
  cost savings, often mandated by waiver programs
• Is there a balancing act between dual goals of
  improving quality of care and achieving cost
  savings or can it be win-win?

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Conclusions and Future Directions

• Across programs older adults with multiple
  chronic conditions, multiple providers and long
  term care needs provide a common denominator
• Currently the greatest challenge is making care
  coordination more widely available to those in
  need
• Major roadblock involves greater expansion from
  demonstration programs while promoting both
  quality and cost savings
• Need to avoid over medicalization of care
  coordination and promote integration of services
  to treat whole person
• Need to ensure that overlooked populations are
  integrated into care coordination equation
• Target the care coordination intervention to the
  specific population