Care Management for Children with Chronic Conditions:

1
Care Management for Children with Chronic
Conditions

• Health Plan vs. Primary Care
• June 24, 2004

2
Project Partners

• Maternal Child Health Bureau
• Study period July 1, 2002 June 30, 2006
• Childrens Hospital Regional Medical Center
  (CHRMC) Center for Children with Special Needs
• John Neff, MD
• Virginia Sharp, MA
• Jean Popalisky, RN, MN
• Regence BlueShield
• Tracy Fitzgibbon, RN
• Kristin Myers

3
Project Goal Objectives

• Develop, implement and evaluate a cost effective
  quality care management program for children with
  chronic conditions (CCC)
• Identify and classify CCC for case management
  using Clinical Risk Groups (CRG) software (health
  plan).
• Develop a range of reimbursement strategies case
  management in other settings (primary care).

4
Health Plan Case Management

• Implementation Elements
• Identifying CCC using Clinical Risk Groups
  software
• Developing tools
• Contacting members
• Project management
• Difficulty defining meaningful outcome measures

5
Health Plan Case Management Identification
Summary

• 315 CCC identified for CM screening
• CRGs utilization filters
• 72 eliminated
• 120 unable to contact
• 123 CCC contacted
• 87 members screened using the 22-item CM
  screening tool
• 46 members (53) opened case management

6
Health Plan Activities
7
Health Plan Cost Savings

• 291,295
• 1.5 FTE Nurse Case Managers
• 19 month timeline
• Regence cost-savings methodology

8
Health Plan CM Screening Tool Analysis

• Five CM screening tool questions used to identify
  need for case management
• Areas of concern
• Access/Organization of services (3 questions)
• Out-of-pocket expenses (1 question)
• Family stress (1 question)
• 22-items could be reduced to 5 items

9
Health Plan Case Management Summary

• Predictive Modeling
• CRGs utilization filters screening
  actionable children with chronic conditions
• Engagement rate 37 of members contacted
• Interventions
• member education
• needs assessment
• community resource coordination
• benefit management
• Value
• Cost savings of 291,295 over 19 months
• Members report case management impact

10
Primary Care Case Management

• Implementation Elements
• Identify CCC for case management
• Develop tools
• Define outcome measures meaningful to the health
  plan

11
Primary Care Tracking Activities

• All clinic staff involved in tracking
• Information collected
• Type of intervention (existing CPT codes)
• Duration of intervention
• Provider type performing intervention
• Direct outcome of intervention
• Avoided outcome as result of intervention
• Tracking forms faxed to health plan at regular
  intervals for entry into database

12
Primary Care Tracking Results

• Clinic 1
• 454 tracking forms on 83 CCC
• Engagement rate 83
• Clinic 2
• 813 tracking forms on 84 CCC
• Engagement rate 84

13
Primary Care Care Planning Activities

• MDs to do WRITTEN care plan
• Short-term goals 3 6 months
• Include strategies for reaching goals
• Include input from families
• Revise when indicated
• Document progress toward goals
• Care plans faxed to health plan when completed

14
Primary Care Written Care Planning Results

• Clinic 1
• Submitted 38 care plans
• Family input included on 16 care plans
• Clinic 2
• Submitted 5 care plans
• Family input included on 3 care plans

15
Primary Care Activities
16
Primary Care Cost Savings

• 44,434 Avoided Out-patient services
• 241 avoided ER visits _at_ 146/visit
• 136 avoided Pediatric clinic visits _at_ 68/visit
• 32 Avoided In-patient episodes

17
Primary Care Case Management Summary

• Predictive Modeling
• CRGs utilization filter staff selection
• Engagement rate 83.5
• Interventions
• family support activities
• condition management activities
• Cost savings
• avoided services

18
Side-by-Side Comparison
19
Key Learning Points

• Health plan case management activities and
  primary care case management activities are
  unique
• Primary care providers identify, contact, and
  engage patients more efficiently and effectively
  than health plan
• Both settings produce short-term cost savings
  from different sources

20
Recommendations

• Comprehensive care coordination for the families
  of CCC should integrate the unique case
  management activities from the health plan and
  primary care into a single, cooperative effort

21
Contact Information

• John Neff, M.D. Jean Popalisky, MN
• 1100 Olive Way, Suite 500 1100 Olive Way, Suite
  500
• Seattle, WA 98101 Seattle, WA 98101
• Phone [phone] Phone [phone]
• Fax [phone] Fax [phone]
• Email john.neff_at_seattlechildrens.org Email
  jean.popalisky_at_seattlechildrens.org
• Tracy Fitzgibbon, RN
• 333 Gilkey Road, MS BU270
• Burlington, WA 98233
• Phone [phone]
• Fax [phone]
• Email tfitzgib_at_regence.com