AMERIGROUP Community Care

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AMERIGROUP Community Care

• Entered Maryland market in 1999
• Largest MCO in Maryland
• Serving over 143,000 members in Baltimore City
  and 20 counties in Maryland
• Located in Maryland

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AMERIGROUP Community Care

• Care Management
• Utilization of overarching approaches and
  programs aimed at improving healthcare
• May include programs addressing provider
  availability, pharmacy, hospital admissions, case
  management, etc.
• Case Management
• A collaborative process of assessment, planning,
  facilitation and advocacy for options and
  services to meet an individuals health care
  needs through communication and available
  resources to promote quality cost-effective
  outcomes (Case Management Society of America)
• Case managers are usually nurses or social
  workers

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AMERIGROUP Community Care

• Care Management of Chronic Illness
• Management of lifelong illness or disease that
  requires high level of ongoing intense medical
  care by multiple providers
• Examples of Chronic Illness
• diabetes
• heart failure
• emhpysema
• sickle cell disease
• asthma

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AMERIGROUP Community Care Chronic Disease Risk
Groups

• Who Are They
• SSI members
• 15,000 SSI population individuals that qualify
  for Medicaid based on illness or disease
• 80 Adults
• Average length of membership 3.5 years
• 45 of SSI medical expenses spent on inpatient
  hospital care
• 2 (300 members) account for 50 of inpatient
  hospital care over 25 million inpatient
  hospital costs
• Behavioral health care 20 substance abuse 30
  mental health

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AMERIGROUP Community Care Care Management for
Chronic Illness

• Challenges Presented
• Severely ill with multiple chronic diseases
• Overwhelmed and exhausted
• Difficulty navigating the health care system
• Concurrent mental health or substance abuse
  issues

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AMERIGROUP Community Care Care Management for
Chronic Illness

• Approaches to Care
• Hospital Readmission Program
• Nurses and medical directors visit members and
  providers in the hospital
• Ensure members receive post discharge medication
  receipt of home health care access to PCP within
  2 weeks of hospital discharge transportation
• Risk Rank List
• Predictive tool for future admissions

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AMERIGROUP Community Care Care Management for
Chronic Illness

• Approaches to Care (Contd)
• Disease management specific optimal care
  guidelines, expectations, pathways and desired
  outcomes
• Disease specific pathways
• Graded approach, intervention proportional to
  need
• Telephonic management
• Case management
• Field case management

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AMERIGROUP Community Care Care Management for
Chronic Illness

• Network Development
• Specific highly skilled providers
• Use of community resources
• Centers of Excellence
• Community and home based providers

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AMERIGROUP Community CareCare Management for
Chronic Illness

• Key Elements for Success
• Proactive identification and engagement of member
• Develop an individualized care strategy
• Empower member
• Education
• Community based case management and outreach
• Incentives
• Encourage provision of care
• Partnership among providers and MCO
• Adherence to care plan

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AMERIGROUP Community Care Care Management for
Chronic Illness

• Outcomes
• Improved Quality of Life
• Decreased Morbidity and Mortality
• Reduced Costs
• Efficient Use of Resources