1. CTC-RI NCM High Risk Reporting Process for UHC Members
January 2016

2. NCM Caseload Reconciliation
Excerpt from CTC Nurse Care Management (NCM) Measure Specifications:
It is anticipated that NCMs will outreach to patients on the high risk lists provided by the payers and successfully engage (inclusive of care plan) with 40% of the high risk patient list.
Practices are responsible for providing each health plan with a list of identified complex/high cost patients with the identified fields completed on a monthly basis (or as agreed upon with each payer).
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3. Distribution of Risk Reports
United Medicaid:
A prioritized list of high risk patients is produced on a quarterly basis (January, April, July and October) and posted on UHC Online.
Additionally, practices are notified via phone when a Top 5% member who is on their practice panel is admitted to the hospital.
Practice NCMs are to use the quarterly high risk list to report NCM activities for patients that are in the highest, higher and high priority categories.
United Commercial:
A list of all UHC Commercial practice patients is produced on a quarterly basis (January, April, July and October) with current and prospective risk scores that reflect expected future costs. The Patient List is posted on UHC Online.
Practice NCMs are to use the high risk patient list to report NCM activities for patients that are in the top 5%.*
*More details on UHC Commercial Process later in deck
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4. UHC Medicaid NCM High Risk Activity Reporting Process
UHC Medicaid Top 5% Report generated quarterly on the 2nd or 3rd Tuesday of each quarter
Includes patient demographics, PCP name and last PCP visit, Primary Risk Factor, Future Risk – Costs, Prior Costs annualized
Priority assigned – highest, higher, high and, other opportunities
Columns with Drop Down Boxes for NCM activity reporting will be added to the report before posted on UHC Online
Additionally, a field to identify member is “new to report” will be added
NCM pulls UHC Top 5% Report from UHC Online
NCM works report
By 20th of month, NCM will completed report to UHC Medicaid Secure Box
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5. UHC Medicaid High Risk Patient List Details
Contains:
Member Demographics (Subscriber ID, Member Last and First Name, DOB, Address, Phone, Gender)
PCP Name and Months Enrolled with UHC
Primary Risk Factor, Future Risks and Costs
Priority (categories listed below)
Priority
 Category 1
Highest
Future Risk Cost > 10 AND 3+ ER visit and/or 2+ Admits AND no PCP visit 2
Higher
Future Risk Cost > 10 AND no PCP visit OR 3+ ER visits OR 2+ Admits 3
High
Future Risk Cost > 10 with a PCP visit AND < 3 ER visits AND < 2 admits 4
Other Opportunities
Future Risk Cost < 10
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6. UHC Medicaid Drop Down Boxes
Engaged with NCM?
Yes
Patient is engaged with NCM/care plan in place No
Member is not currently engaged in care management activity
In process
Attempting to engage patient in care management activity
Date of Last NCM Encounter
Add date
Patient Intervention
High Intensity/Complex
NCM activity more than once a week over day time period
Moderate intensity
NCM activity once a week for day time period
Low intensity/Short Term
NCM activity for less than a 30-day time period
Reason for Closure
Closed-D/C from Practice
Closed-Goals Met
Closed-Patient Refused
Closed-Patient Stopped Engaging
Closed-Unable to Reach
Closed-LTC Placement
Closed-Expired
Closed - Patient followed for CCM due to pregnancy
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7. UHC Commercial NCM High Risk Activity Reporting Process
UHC Clinical Practice Consultant will modify the Commercial ‘Patient Risk’ reports*:
Reduce the full list to top 5% of patients with highest prospective risk scores (>5)
Add drop-down boxes for NCM reporting
This modified risk report will be sent via secure (with password protection) to the appropriate NCM contact at each practice.
NCM uses drop-downs to complete report.
By 20th of month beginning in February NCM will completed report to UHC Commercial Secure Box
*Reporting process will be different for practices that are part of a UHC ACO – Lifespan, Coastal and RIPCPC
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8. UHC Commercial Patient Risk Report Details
Contains:
Member Demographics (Member ID, Member Last and First Name, DOB, Gender)
Physician Name and Practice
Retrospective and Prospective Risk Scores
LAST NAME
FIRST NAME
PATIENT ID
GENDER
DATE OF BIRTH
RETROSPECTIVE RISK SCORE
PROSPECTIVE RISK SCORE
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9. UHC Commercial Drop Down Boxes
Engaged with NCM?
Yes
Patient is engaged with NCM/care plan in place No
Member is not currently engaged in care management activity
In process
Attempting to engage patient in care management activity
Date of Last NCM Encounter
Add date
Patient Intervention
High Intensity/Complex
NCM activity more than once a week over day time period
Moderate intensity
NCM activity once a week for day time period
Low intensity/Short Term
NCM activity for less than a 30-day time period
Reason for Closure
Closed-D/C from Practice
Closed-Goals Met
Closed-Patient Refused
Closed-Patient Stopped Engaging
Closed-Unable to Reach
Closed-LTC Placement
Closed-Expired
Closed - Patient followed for CCM due to pregnancy
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10. Next Steps Reduction of Administrative Burden on Nurse Case Managers:
Working with conveners to determine solutions
Embed MDE fields in EMR
Use of ‘Deep Domain’ for reporting
Establish Communication between Community Health Team and Payers (Medicaid)
CHTs request direct communication with health plan:
How to find members- new contact info, etc.
Pharmacy issues
Benefit/plan details
Reporting and member updates
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