2 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

3 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 individual’s 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

4 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

5 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

6 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

7 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

8 AMERIGROUP Community Care: Care Management for Chronic Illness Approaches to Care (Cont’d) 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

9 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

10 AMERIGROUP Community Care: Care 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

11 AMERIGROUP Community Care: Care Management for Chronic Illness Outcomes Improved Quality of Life Decreased Morbidity and Mortality Reduced Costs Efficient Use of Resources