NC Department of Health

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• NC Department of Health Human Services
• Division of Medical Assistance
• Office of Research, Demonstrations Rural Health

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North Carolinas Strategy

• Statewide primary care case management
• Form community networks across the state
• Implement quality improvement initiatives
  through community networks
• Cost containment initiatives

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Statewide Primary Care Case Management

• Carolina ACCESS started in 1991
• gt 750,000 Medicaid patients enrolled
• gt 4,000 PCPs participating
• PCPs provide after hours and specialty referrals

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Community Care of North Carolina
Builds on Carolina ACCESS

• Started in 1998
• Joins other community providers (hospitals,
  health departments and departments of social
  services) with physicians
• Creates community networks that assume
  responsibility for managing Medicaid patients
  care

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Community Care of North Carolina

• Focuses on improved quality, utilization and cost
  effectiveness
• 13 Networks with more than 3000 physicians
• 510,000 enrollees

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Community Care of North Carolina
Access II and III Networks 1/04
Community Care Plan of Eastern NC
AccessCare Network Sites
Community Health Partners
AccessCare Network Counties
Durham Community Health Network
Access II Care of Western NC
Access III of Lower Cape Fear
Partnership for Health Management
Cabarrus Community Care Plan
Sandhills Community Care Network
Wake County Access II
Central Piedmont Access II
Carolina Community Health Partnership
Comm. Care Partners of Gtr. Mecklenburg
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Community Care Networks

• Non-profit organizations
• Comprised of safety net providers
• Steering committees
• Medical management committees
• Receive 2.50 PM/PM from the State
• Hire care managers/medical management staff

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What Networks Do

• Assume responsibility for Medicaid recipients
• Identify costly patients and costly services
• Develop and implement plans to manage utilization
  and cost
• Create the systems to improve care

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DISEASE MANAGEMENT
Implementing Disease Management

• Evidence-based guidelines
• Clinical directors set performance standards
• Local provider buy-in obtained
• Improve the care management process
• Local state level technical assistance
• Pilot initiatives

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Managing High Risk Patients
MANAGING HIGH-RISK PATIENTS

• Identify high cost through claims analysis
• Identify high risk through DxCG predictive
  modeling
• Targeted case management
• Coordinate resources

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Managing High-Cost Services
MANAGING HIGH-COST SERVICES

• Pharmacy
• Nursing home polypharmacy
• Prescription Advantage List (PAL)
• Emergency Department (ED)
• Other (pilot initiatives)

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Building Accountability
BUILDING ACCOUNTABILITY

• Chart audits
• Practice profiles
• Care management reports high-risk/high-cost
  patients
• PAL scorecard
• Progress toward goals benchmarks

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Current Initiatives

• Asthma
• Diabetes
• High cost services
• ED
• Pharmacy
• High cost / high risk enrollees

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Asthma Initiative

• First program initiative began Jan. 1999
• Adopted best practice guidelines (NIH)
• Implemented continuous quality improvement
  processes at each practice
• Physicians set performance measures
• Provide regular monitoring and feedback

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Asthma Initiative
Process Measures
Key
No. with asthma who had documentation of staging
No. staged II IV on inhaled corticosteriods
No. staged II IV who have an AAP
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Diabetes Initiative

• Second program-wide initiative began July 2000
• Adopted best practice guidelines (ADA)
• Implement continuous quality improvement
  processes at each practice
• Physicians set performance measures
• Provide regular monitoring and feedback

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Diabetes Initiative
ACCESS II-III Diabetes Chart Audit Results
Baseline (July Dec. 00)
July Dec. 01
July Dec. 02
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Community Care of NC creates an infrastructure
for

• Statewide Initiatives
• Collaboration w/other interested partners

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Lessons Learned

• Local buy-in a must
• All stakeholders must be at the table
• Incentives
• Legislative support
• Think outside of the box

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