1 Community Based Care Management Demonstration Project May 22 nd, 2008 Presenters: Geoff Green, Deputy Commissioner Deborah Nichols, Director Schaller Anderson in Maine Denise Levis Hewson, Consultant

2 Demonstration Project is Important Because We Can: Create a model that can be replicated statewide Build the capacity at the community level that is needed to sustain a care management program Meet the legislative mandate that provided a short time line for development and implementation of project

3 Contracting with Schaller Anderson to do the following: To create the pilot model in three different provider sites (FQHC, PHO, and Physician Practice) To develop selection criteria and choose the three pilots To contract and pay the pilot sites for community based targeted care management To administer the pilot program during the demonstration period

4 Purpose of this Meeting: To provide an overview of the project : Project Assumptions Primary Goals Participation Requirements Quality and Performance Metrics Time Line To take a brief look at the North Carolina model Questions and answer session at the end of the presentation

5 Community Care Plan of North Carolina -- Background NC is mainly a rural state and not well suited for traditional managed care NC is dominated by small practices and loosely organized medical systems The county system remains very strong Since the early 1990s, NC has had in place across the state, a medical home program for Medicaid recipients (PCCM – Carolina Access) NC Medicaid pays 95% of Medicare FFS

6 Community Care Plan of North Carolina Built upon a statewide PCCM program : Medical Homes Population Management Approach Quality Improvement Initiatives – Performance Metrics Targeted Care Management Focuses on improved quality, utilization and cost effectiveness of chronic illness care 14 networks with more than 3500 physicians and over 800,000 enrollees (taken 10 years to get statewide)

7 Community Care Plan of North Carolina Key Attributes of the Medical Home : Provide 24 hour access Provide or arrange for hospitalizations and specialty care Coordinate and facilitate care for patients Collaborate with other community providers Participate in disease management / prevention / quality initiatives Serve as single access point for patients Receives $2.50 PMPM from the State to manage population

8 Community Care Plan of North Carolina Community Care Networks : Non-profit organizations Includes safety net providers Steering and medical management committees Receives $3.00 PMPM from the State to hire care managers and implement quality improvement and disease management initiatives PCP also gets $2.50 PMPM to serve as medical home and to participate in the disease / care management and quality improvement initiatives Must partner with health department, department of social services and local hospital (s)

9 Community Care Plan of North Carolina Lessons Learned Started small and piloted in 9 networks with 100,000 enrollees Can’t do it alone – must partner Community ownership is important Must develop systems that change behavior Change takes time and reinforcement Need to be able to measure change Comprised of safety net providers Can be a win-win-win – for patients, providers and the State

10 Care Management Demonstration Project Assumptions Building upon Maine’s PCCM program – the State is paying the “medical homes” $2.50 PMPM Recognizing the community based infrastructure needed to support patient centered medical homes for the chronically ill Targeting “high risk” patients will both improve care and contain the costs of care Incrementally increasing the FFS payment rate to primary care providers Committing to build project upon in-state physicians, hospitals and ancillary providers

11 Patient Centered Medical Home Components Provides “continuous healing relationship” 24 hour access Use of care team Evidence-based treatment for chronic conditions Support for patient self-management Systematic follow-up and planned encounters Intensive management for high risk patients and for those not meeting goals

12 Patient Centered Medical Homes Components (cont.) Coordination across settings and professionals Patient tracking and alerts Care management Electronic tools, such as: EHRs, registries, etc. Clinical performance reporting and physician feedback

13 Care Management Demonstration Primary Goals: Transfer the care management of MaineCare members to community based practices Create a care management model that can be replicated in urban and rural areas Improve care while controlling costs Fully develop the medical home model Develop the systems needed to support chronic illness care Identify and stratify the population that will best respond to care mgt. interventions

14 Care Management Demonstration Sites There will be three pilots: 1) FQHC; 2) PHO and 3) physician practice Each pilot will target, at a minimum, 300 high risk MaineCare members with a maximum of 50 high risk patients per physician Pilots will need to meet the participation requirements

15 Care Management Demonstration Quality and Performance Metrics Collect specified HEDIS measures Participate in quality reporting program (e.g. pathways, bridges to excellence) Pharmacy review Number of enrollees on 10 or more drugs Percent on generic prescriptions Increase in medication adherence

16 Care Management Demonstration Quality and Performance Metrics Care Management/Coordination Number of adult members with completed PHQ-9 Number of members with completed HRA Number of members with completed SF-8 Improvement in PHQ-9 scores Improvement in SF-8 scores Increase in self management of chronic illnesses Number of members with a care plan in place Cost Metrics Average PMPM costs Total costs

17 Care Management Demonstration Quality and Performance Metrics Utilization management Emergency department rates per 1000 Hospitalization rates per 1000 Avoidable hospitalization rates per 1000 Readmission rates per 1000 Average length of stay Primary Care Provider Increase in primary care visits to medical home Provider satisfaction rate in coordination of care Number of members with provider consent on care plan

18 Care Management Demonstration Sites Selection Process Complete Application Process – must demonstrate ability to meet minimum requirements, such as: 24 hour access Large enough enrollment and physicians to yield 300 high risk members Ability to report performance metrics Processes to integrate behavioral health Experience and commitment in quality improvement and care and disease management Willingness to create patient-centered care plans and perform standardized health assessments and screenings Reconcile care management members on at least a monthly basis, e.g. new members and members no longer eligible Stratify members by levels of risk and implement outreach appropriate to risk level

19 Care Management Demonstration Sites Selection Process Must demonstrate ability to meet minimum requirements, continued: Proactively reach out to targeted members engaging them in their healthcare and performing health risk assessments (HRA), PHQ-9 and SF-8 Develop a process to receive referrals for high-risk members not in the targeted group but eligible for care management Develop a process to receive referral for members being discharged from an inpatient setting and following-up to ensure members are incorporated back into the practice and the community Targeted education to meet members specific needs Actively use SAMAI web-site tools Identify a physician champion for the project Implement disease management initiatives Assist with social, mental, economic and physical referrals Coordination of services with other health care providers Conduct home visits, as needed

20 Care Management Demonstration Sites Selection Process Complete sign in sheet and indicate interest to obtain an application form Expert review panel to review applications Panel will choose one site only for each provider group for this demonstration

21 Schaller Anderson Responsibilities for Demonstration Assume full responsibility for the development and implementation of the pilot Develop a care management project work group to monitor the project, share data and develop new disease and care management initiatives Utilize the “Predictive Pathways” risk stratification methodology to identify high risk enrollees for each site Provide each pilot site with a list of high risk patients and their utilization and cost data on a quarterly basis

22 Schaller Anderson Responsibilities for Demonstration In concert with work group and the State, identify the quality and cost metrics to use in monitoring and evaluating the project Educate sites on performance metrics Create quarterly reports for each site that tracks their impact on the performance measures Provide regular reports on the progress of the care management demonstration project Conduct a patient and provider satisfaction survey Be available to the projects sites for consultation, support and technical assistance

23 Summary of Key Dates May 23, 2008Application Released June 6, 2008Written Question Due June 11, 2008Responses to Questions June 18, 2008Applications Due June 26, 2008Award Three Contracts July 1, 2008Project Start Date

24 Care Management Demonstration Contact Information Deborah Nichols, Executive Director Schaller Anderson Medical Administrators 207 Larrabee Road, Suite 6 Westbrook, Maine Telephone: