Building a Medical Home

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Building a Medical Home The Case for Medical
Homes and Community Networks Pediatric Medical
Home Summit in Michigan February 13th,
2009 Denise Levis Hewson, RN, BSN, MSPH
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First - Background

• NC is mainly a rural state not well suited for
  traditional managed care
• NC is dominated by small practices and loosely
  organized medical systems
• The county system remains very strong
• Since early 1990s, NC has had in place across
  the state, Carolina Access, a medical home
  program for Medicaid recipients

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Primary Goals

• Improve the care of the Medicaid population while
  controlling costs
• Develop Community Networks capable of managing
  recipient care
• Develop the systems needed to improve chronic
  illness and support PCPs / Medical Home
• Fully develop the Medical Home

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Key Visions

• Managed not regulated
• CCNC is a clinical program not a financing
  mechanism
• Public-private partnership
• The medical home is key for success
• Community-based, physician led
• Quality and system oriented
• Economizing through raising quality rather than
  lowering fees

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Basic Operating Premise

• Regardless of who manages Medicaid, North
  Carolinas physicians, hospitals, health
  departments, and other safety net providers will
  be serving the patients
• Ownership of the improvement process must be
  vested in those who have to make it work
• Providers who care for patients must work
  together
• The State should partner with and support our
  community providers who are willing to build the
  care systems that are needed
• Focus on quality improvement
• Information and feedback are key

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Community Care of North Carolina

• Joins other community providers (hospitals,
  health departments and departments of social
  services) with primary care physicians
• Designated primary care medical home
• Creates community networks that assume
  responsibility for managing recipient care

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THEN
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Community Care of North Carolina Now in 2008

• Focuses on improved quality, utilization and cost
  effectiveness of chronic illness care
• 14 Networks with more than 4000 Primary Care
  Physicians (1300 medical homes)
• Over 825,000 enrollees
• Now mandated inclusion of Aged, Blind and
  Disabled
• and SCHIP by General Assembly

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NOW
February 2009 Enrollment 884,097
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Community Care Networks

• Non-profit organizations
• Includes all providers including safety net
  providers
• Medical management committee
• Receive 3.00 pm/pm from the State (5.00 for
  A,B,D)
• Hire care managers/medical management staff to
  work with PCPs
• PCP also get 2.50 pmpm to serve as medical home
  and to participate in Disease Management and
  Quality Improvement (5.00 for Aged, Blind and
  Disabled)
• NC Medicaid pays 95 of Medicare FFS

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Each Network Now Has

• Part-time paid Medical Director role is
  oversight of quality efforts, meets with
  practices and serves on Sate Clinical Directors
  Committee
• Clinical Coordinator oversees the overall
  network operations
• Care Managers small practices share/large
  practices may have their own assigned
• Now all networks have a PharmD to assist with
  medication management of high cost patients

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Key Attributes of Our Medicaid Medical Home

• Provide 24 hour access
• Provide or arrange for hospitalization
• Coordinated and facilitate care for patients
• Collaborate with other community providers
• Participate in disease management/prevention/quali
  ty projects
• Serve as single access point for patients

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Key Innovations

• Provider networks organized by local providers
  and are physician led
• Evidenced based guidelines are adopted by
  consensus rather than dictated by the state
• Medical Homes are given the resources for care
  coordination and get timely feedback on results
• Inclusion of other safety net providers and human
  service agencies
• We are about building local systems of
  care rather
• than changing how we pay for services

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Managing Clinical Care(Spreading Best Practice)
PRACTICE A
PRACTICE B
PRACTICE C
Care Managers and CCNC quality improvement staff
support clinical management activities
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Patient Identification

• Real time data / referrals
• Hospitals
• Primary Care Providers
• Specialist
• Members of the care team
• Identify high risk and high cost through claims
  analysis
• Provide audits State AHEC and/or local Network
  audits

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Case Management Process

• Comprehensive Assessment
• Develop Individualized Care Plan
• Care Coordination
• Re-Assessment / Monitoring
• Outcomes
• Evaluation

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Current State-wide Disease and Care Management
Initiatives

• Asthma
• Diabetes
• Pharmacy Management (PAL, Nursing Home
  Polypharmacy)
• Dental Screening and Fluoride Varnish
• Emergency Department Utilization Management
• Case Management of High Cost-High Risk
• Congestive Heart Failure (CHF) (2006)
• Chronic Care (Aged, Blind and Disabled)
• Rapid Cycle Quality Improvement

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Network Specific Quality Improvement Initiatives

• Assuring Better Child Development (ABCD)
• ADD/ADHD
• Childhood Obesity
• Stroke Prevention
• HealthNet/Coordinated care for the uninsured
• Projects with Public Health (Low Birth Weight,
  open access diabetes self management)
• Diabetes Disparities

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New Network Pilots

• Depression Screening and Treatment
• Mental Health Integration
• Mental Health Provider Co-Location
• E-Rx
• Partner with AHEC to support Improving
  Performance in Practice Initiative
• Medical Group Visits
• Dually Eligible Recipients

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Results
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Key Results

• Asthma
• 40 decrease in hospital admission rate
• 16 lower ED rate
• 93 received appropriate maintenance medications
• Diabetes
• 15 increase in quality measures
• Source 2007 Asthma Disease Management Program
  Summary

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Cost/Benefit Estimates
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Community Care of North CarolinaJuly 1, 2002
June 30, 2003

• Cost - 8.1 Million
• (Cost of Community Care Operations)
• Savings - 60,182,128 compared to FY02
• Savings - 203,423,814 compared to FFS
• (Mercer Cost Effectiveness Analysis AFDC only
  for Inpatient, Outpatient, ED, Physician
  Services, Pharmacy, Administrative Costs, Other)

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Community Care of North CarolinaCost Savings for
SFY 2004July 1, 2003 June 30, 2004

• Cost - 10.2 Million
• (Cost of Community Care Operations)
• Savings - 124 million compared to SFY03
• Savings - 225 million compared to FFS
• SFY 2005 and 2006 results 231 million saved

NC Medicaid Administrative costs only 6!
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Community Care of North Carolina in the
news

• October 3, 2007 Community Care of North
  Carolina wins the 2007 Annie E. Casey Innovations
  in American Government Award given by the Kennedy
  School of Government at Harvard University

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Next Steps

• Strengthen the ability of the medical home to
  manage chronic illness care
• Enhance the ability of practices/networks to
  support patient self-management
• Improve care planning/coordination across
  provider settings
• Integrate specialist expertise into care
  improvement process
• Strengthen communication and performance feedback
  to clinicians
• Investing in improved Clinical Information System

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Key Take Home Thoughts

• Key attributes of CCNC are replicable in other
  states despite the idiosyncrasies of NC
• Key principles may have role in non government
  programs
• Many states have rural areas and undeveloped
  markets that may benefit from local system
  development
• Operations vary by community CCNC principles
  allow local variability

The medical home and community system
development are the keys to success!
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Want to Know More?

• www.communitycarenc.com