1. Transforming Perspectives
Effective use of Care Management services in a Value Based World

2. Disclosure
All presenters and planners of today’s activity do not have any financial relationships with any commercial interest related to the content of this activity
This activity has not received commercial support

3. Objectives
To understand the definition of Longitudinal Care Management
To understand the key strategies and goals of Care Management
To understand the importance of Care Management involvement with the transformation to Value Based Contracts

4. Michelle’s Story “You treat a disease: You win, you lose.
You treat a person, I guarantee you win, no matter the outcome.”
-Patch Adams
Pictured: Michelle Jonassen, BSN, RN Care Manager

5. What is Care Management?
Care management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes
(The Case Management Society of America, 2016:

6. Longitudinal Care Management
Supportive care of a patient and family over a period of time
Encompasses a holistic, dynamic, and integrated plan of care
Includes treatment goals and plans reflecting the patients values and preferences

7. Care Management Responsibilities
Engaging patients in their health
Patient education related to disease management and prevention
Self-management support through close follow-up as needed
Comprehensive care planning
Medication reconciliation
Transitions of care
Coordinating referrals and tests
Connecting patients to community resources
Advance care planning

8. Goals of Care Management
Help patients achieve self-management of chronic diseases
Improve coordination of care
Provide cost effective, non-duplicative services
Improve quality outcomes
Improve access to care
Increase patient satisfaction

9. Goals of Care Management Cont.
This Care Management work supports, but does not replace, the work and relationship of the care team

10. Trinity Health: People Centered 2020
The goals of People-Centered 2020 : attain high-quality, longer lives free of preventable disease, disability, injury and premature death. To achieve health equity, eliminate disparities and improve the health of all groups. To create social and physical environments that promote good health for all. To promote quality of life, healthy development and healthy behaviors across all life stages.

11. Population Health
As defined by the CDC, Population Health is “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” It is an approach to health that aims to improve the health of an entire human population.
Care Management is an essential component of successful population health management

12. The Population Health Journey
Highly
Care Managed
Future State
Fact: by the year 2050, nearly 20% of the population will be 65 and older, Medicare expenditures will continue to grow as the population ages, which is why population health is so important.
With the gradual shift from fee for service to the value based care models, care management is aligned perfectly to care for the rising risk populations that directly affect the cost of healthcare.
The transition from fee for service to value based reimbursement won’t happen overnight, it will take time. And is definitely a financial challenge for healthcare systems.
Traditional
Model
No or Little
Care Management
Fee-for-service
Full-Risk /
Value Based Contracts

13. Value Based Care Performance-based payment or reimbursement
Payment tied to health outcomes and metrics
A tool for aligning incentives among:
Health systems, suppliers, manufacturers, employers, payers
A shared performance or risk-sharing model
Value based care is tied to patient health outcomes, efficiency, and quality. The goals of the stakeholders are improved patient outcomes, experience, quality of care, enhanced population health, and operational efficiencies. We share the benefits or the penalties if the goals are not achieved.

14. Value Based Care

15. Value Based Contracts Priority Health
Commercial & Medicare Advantage plans
Blue Cross Blue Shield of Michigan
Select Commercial & Medicare Advantage plans
State Innovation Model (SIM) - Managed Medicaid Plans
Trinity Health ACO (TH-ACO) - Medicare
Bundled Payment for Care Improvement (BPCI) - Medicare
These are the current value based contracts Care Management participates with.
PH and BCBSM pay fee for service with incentive dollars tied to care management work.
SIM pays a per member per month for care management services with an additional incentive for meeting quality metrics.
The Trinity Health ACO is our Next Generation model accountable care organization (ACO) that serves as population health management for our Medicare community. Payment is based on keeping healthcare costs down and meeting quality benchmarks.
BPCI is our bundled payment care improvement program – the payment model provides a single bundled payment to providers based on the patient’s episode of care during a hospital stay, and follow up care, for a period of time.

16. Who Needs Care Management?
Those at risk for developing complications from poorly controlled chronic disease
Those with a new diagnosis or medication(s) and need education
Those at risk for readmission or exacerbation
Those with high and/or inappropriate service utilization
Those with multiple co-morbidities
Those with identified Social Determinants of Health needs

17. Pictured: Jill Maciejewski, RN Care Manager and her Family
Jill’s Story
Pictured: Jill Maciejewski, RN Care Manager and her Family

18. Benefits of Care Management
The shift from fee-for-service to Value Based Care has increased the need for Care Management in the primary care setting
Care Management follows the guide of the Triple Aim in caring for our at risk patient population
What are the Benefits of Care Management? Better Health, Better Care, Lower Costs.

19. Better Health Improving the health of populations overall
Improving quality metrics
Closing gaps in care
Addressing Social Determinants of Health
Utilizing clinical-community linkages
Care Management helps to improve patients health by:

20. Better Care Improving patient experience
Improving relationships and trust between patient and care team
Patients feel better as their health improves
Patients are able to set and meet health goals
Patients have direct access to their Care Manager for timely care
Care Management helps to provide better patient care, by:

21. Lower Costs Reducing hospital admissions
Reducing hospital readmissions
Reducing ED utilization
Reducing length of stay in Hospital and Skilled Nursing Facilities
Avoiding duplicative testing and services
Providing prompt care and treatment to reduce risk of complications
Care Management helps to lower healthcare costs by:

22. Trinity’s Mission and Core Values
Patient
Population Health
Value Based Contracts
Care Management
Trinity’s Mission and Core Values

23. “He who has Health has Hope;
and he who has Hope,
has Everything.”
-Unknown