Title: Organizational Infrastructure
1Organizational Infrastructure
- LTC Quality Summit
- February 20, 2006
John R. Mach, Jr. M.D.
2Multiple Chronic ConditionsDrive Cost and
Opportunity
2 chronic conditions drive 96 Medicare costs
Our data confirm predictability of utilization
Preventable admissions rise steeply with number
of chronic conditions
Quality matters and is measurable
3Multiple Chronic Conditionsand Miscellaneous
Costs
Other medical expenses
61
0.3 Other psychoses
Patients Chronic Diseases, in Four Body
Systems 1 Mental Disorders 2 Nervous System 3
Musculoskeletal System 4 Endocrine,
Nutritional, and Metabolic diseases
1.5 Spondylosis, intervertebral disc
2.0 Epilepsy, convulsions
Expenses related to chronic conditions
4.1 Other connective tissue disease
5.3 Hereditary degenerative nervous system
conditions
25
Diabetes
Early Retiree, Patient A
Source Uniprise Data
Individualized and comprehensive care plans are
necessary
4 Special Needs Individuals
Special Needs Individuals
- 50 of people die in hospital outside of Hospice
- Poor palliation services
- 5 chronic conditions 2/3 of all Medicare costs
- Greatest suffering ineffective resource
utilization
- Single condition but very high impact, e.g.
quadriplegia, advanced Alzheimers Disease
- Maybe functioning well, but no reserve secondary
to age - Sudden event is catastrophic
5Special Needs People
Care Management Model
For Special Needs People
6Clinical Model EffectivenessWhat is Attainable
Today
- Enrollee satisfaction 97
- Physician satisfaction 90
- ER and hospital utilization for dual eligible
community-based population reduced 30 - Arizona saved 111 million compared to FFS LTC
Medicaid - Texas saved 70 million in one county
- Florida saved 10K-15K per nursing home
eligible enrollee per year
Unmatched clinical results
7Clinical Model Evolution
Frail, Elderly in Nursing Homes
- Hospice/palliative care
- Retirement Community
- ESRD
- AARP Medicare Supplement
Community-Based Long-Term Care Medicaid
Care One Clinical Platform
Medicare Advantage
Ovations Data Mart
Galaxy
Community-Based Medicare via Special Needs
Plans (dual eligibles)
Reaching people regardless of living setting or
payer
8Necessary Infrastructure
- 1. Nurse Care Coordinators
- NPs/RNs
- Extended Team
- Geriatrics Training
- Management Support
- 2. Engaged LTC Staff
- Training support
- 3. Engaged MDs
- Enabling reimbursement
- Outcomes data Transparency feedback
- Geriatrics support
- Accountability
- 4. Evidence-based Care Process
9Necessary Infrastructure (contd)
- 5. Clinical Infrastructure System
- Early Access
- Portability
- Bridge sites of care
- ePrescribing
- 6. Enabling Financing Environment
- Special Needs Plans
- CMS Demos
- 7. Data Infrastructure, Analytics Reporting
- Appropriate measures
- Transparency
- 8. Effective Outreach Leadership
- Role of Special Needs Plans
- AAHSA, etc.
- Care Provider Leadership Gap