1. Advanced Illness Care Coordination in a Medicare Advantage Setting Richard Raskin, MD,FACP Chief Medical Officer, East Division Avon, CT Danielle Butin, MPH,OTR Director, Health Services, East Division White Plains, NY Angelina Yearick, JD, MSPH Consultant to Health Services White Plains, NY

2. 2 Setting the Stage Medicare Advantage Geography and Demographics Population Selection * Health Risk Assessment * HCC Scoring * Claims Based/Predictive Modeling * Diagnoses

3. 3 Rationale for Development of Program Targeted at Medicare Advantage Enrollees Medicare enrollees have high incidence of chronic disease and life-threatening illness Clinical deterioration in these enrollees often occurs suddenly Patients facing end-of-life decisions often do not have the requisite information to make informed choices about how they would like to spend their last days, and have not made these choices proactively. As a result, coordination of care for enrollees at end-of-life is inadequate, leading to suboptimal qualitative and financial outcomes.

4. 4 Advanced Illness and Coordinated Care Program The Advanced Illness Coordinated Care (AICC) Program, developed by Dr. Dan Tobin, is designed to: Target enrollees with specific diagnoses for appropriate advanced care planning Offer in home counseling to targeted enrollees. Reduce the rate of patients dying in the hospital by providing patients the opportunity to spend the end-of-life in the setting of their choice; Empower these enrollees to become more proactive in the delivery of their end-of-life healthcare services.

5. 5 Program Description The program consists of a 3-month intervention of up to 6 in-home counseling visits, focusing upon: Relief of death anxiety (counseling component). Informed decision making about therapeutic options and communication with surrogates, family members, caregivers and health care providers. Identification of opportunities for improved care coordination.

6. 6 Staffing/Training No health plan staff is allocated full-time to this project. Contracted/Outsourced Models for Care Delivery:  Model 1: Nurse Practitioners credentialed as Independent Providers in AICC  68 Trained providers in metro NY area to date  Model 2: Contracted Nurses and Social Workers through local Hospice Agency  12 Trained Registered Nurses  10 trained Social Workers All staff training is conducted by Dr Dan Tobin at a full day intensive seminar.

7. 7 AICC Visits (Targeted in Borough of Queens, NY) Enrollee identified and mailed an introductory letter about the program. Follow-up call within 1 week to invite enrollee to participate Upon consent, AICC Provider assigned to conduct home visits

8. 8 AICC Visits- What Happens at Home? Meeting 1  Introduce goals of AICCP  How AICCP interacts with the primary care physician and the acute care team, and  What to expect. Meeting 2  Evaluate capacity of caregiver  Discuss psychological, social, financial and practical concerns Meeting 3  Forging the partnership of member and caregiver in AICCP care plan

9. 9 AICC Visits – What happens at home? Meeting 4  Care management of functional impairment  DNR orders Meeting 5  Obtaining feedback from providers on care plan  Working with family members on care plan Meeting 6  Discuss accomplishments  Address remaining concerns

10. 10 AICC Providers-Need Back-Up Coordination of services provided by Education & Outreach Department Additional service requests were made by practitioners for:  Home health care  Nutrition consultations  Prescription assistance  Meals on wheels  Transportation services  DME  Custodial care

11. 11 AICC Visit Tracking CUP Profile (1-5)  Curative, Uncertain, Palliative Pain Assessment (1-5) Coping with diagnosis (1) Psychological Status (2) Advance Directives (2) Quality of Life (2) Practical Issues (3) Family Concerns (3) Palliative Care (4) Spiritual/Religious Issues (4) Life-sustaining treatment (5) Psychological and other concerns (5) Bereavement needs (5) Life closure (5) Utilize 5 forms for data collection

12. 12 Demographics of Population Place of Residence Home (93%) With Relative (2%) Caregiver Living Arrangements Alone (23%) Spouse/Other CG (69%) GenderMale (55%) Female (45%) EthnicityCaucasian (67%) African American (20%) Hispanic (4%) Asian (2%)

13. 13 Diagnoses of Population Main Diagnoses for Selection on hospitalization and predictive modeling:  CHF  COPD  Metastatic Cancer Some additional diagnosis were added in predictive modeling:  Alzheimer’s disease  Stroke

14. 14 Enrollment in Program By Number of Visits

15. 15 Adherence with Advance Directives National prevalence of advance directives: 15-20% Compliance with Advance Directives in Program Advanced Directives 2 visits3 visits4 visits5 visits Yes60%61%75%84%

16. 16 Selection of Health Care Proxy Healthcare Proxy Selected 3 visits4 visits5 visits YES71%63%78%

17. 17 Financial Results of Program 6 months Post PMPM No AICC (N=128) AICC Visits (N=38) Inpatient$2,186$999 ER$34$11 Outpatient$779$365 SNF$110$21 Homecare$132$283 Total$3,942$1,926

18. 18 Current Status of AICC Participants Receiving Services% Homecare50% Hospice3% SNF5% No Services42%

19. 19 Mortality Data Nationally, about 80% die in hospital or facility 9.3 % of enrollees died within 18 months  41% died in the hospital  58% died at home, in a snf or with hospice Of those who died, the average lifespan was 6 months after start date

20. 20 Interpretation of Data Impact of Number of Visits on Outcome Impact of AICC Provider-2 Models Utilization of Palliative Care/Hospice Services Medical Utilization Impact

21. 21 Conclusions AICC can be an effective strategy to improve end of life care within a Medicare Advantage population. Program success requires careful enrollee selection. Nurses and nurse practitioners are effective AICC providers AICC Providers with case management expertise are more successful at sustaining member enrollment and achieving positive outcomes. Collaboration between hospice organizations and Medicare Advantage health plans has the potential for improving hospice utilization and clinical outcomes.