Leading the Way: Complex Care Management Program Overviews

Publication Year: 2013
Patient Need Addressed: Chronic Conditions
Population Focus: Complex care
Intervention Type: Staff design and care management
Type of Literature: Grey

Aetna has developed a Medicare Case Management Program for selected participating medical groups. This program enhances the effectiveness of case managers by managing multiple chronic illnesses, overcoming psychosocial barriers, and managing advanced illness by providing such services in close collaboration with participating physicians and their staffs. In most cases, the case manager is embedded in the physician office.

The program focuses on Medicare Advantage patients and currently includes more than 75 collaborative relationships nationwide. In 2012, each case manager served an average of 1,000 patients, and the company served more than 100,000 patients total.

Insights Results

Overview of brief

  • This brief provides an overview of 19 innovative and successful approaches to managing care for patients with complex and chronic conditions. The below insights focus on successful programs specifically targeting Medicaid and dual-eligible beneficiaries

    Key takeaways/implications

    • Care Partners is a care coordination program targeting the frail, elderly population of Erie County. The majority of Care Partners patients have 2 or more chronic conditions. The most common diagnoses are congestive heart failure, chronic obstructive pulmonary disease (COPD), and dementia. The program’s goal is to help Medicare and dual-eligible patients remain independent in their homes. Nurses visit patient homes to perform the initial medical and social assessments. If social or behavioral health needs are identified as contributing to adverse medical outcomes, a social worker (SW) or a behavioral health social worker (BHSW) is assigned to the member. The nurse will also assess the patient’s medical history and current status in terms of cognition and psychosocial abilities. An individualized care plan is then developed with input from the member and/or family members. If the program is appropriate for the patient, then the care management nurse visits patients in their homes to provide general medical education, education on disease processes, and information about care choices and direction of care. The nurse also identifies red flags to help prevent readmissions and ED visits. The SW or BHSW works with the member to obtain and coordinate additional resources, initiate a Medicaid application if appropriate, and engage in advance planning discussions. The SW also assists in transitioning the member to a higher level of care if the interdisciplinary care team and the member determine the need. The nurses work in coordination with the PCPs, keeping PCPs informed and engaged through copies of care team notes and care plans, as well as by phone when indicated. Overall, the program achieved 98% positive patient satisfaction rate, 45% reduction in ED visits (compared to baseline), and 58% reduction in admissions. Independent Health designed the Care Partners program to be available at no cost to its members and with minimal limitations on the frequency of nurse or SW visits and phone support. The program has resulted in an 8.4% reduction in overall per member per month costs. Overall, these programs contribute to more than just financial savings; they generate goodwill within the community, which contributes to member satisfaction, retention, and enrollment
    • The Mount Sinai Visiting Doctors (MSVD) Program is a joint effort of Mount Sinai Medical Center’s Department of Medicine and Department of Geriatrics and Palliative Medicine. Started in 1995, MSVD is a multidisciplinary research, teaching, and clinical care initiative providing comprehensive primary and palliative care to homebound patients with complex chronic conditions in the Manhattan area. Program participants can be commercially insured, and dually eligible, under Medicare, Medicare Advantage, or Medicaid. An important aspect of the care provided by MSVD is the ability to offer resources beyond medical care. The MSVD team of social workers helps locate supportive services for patients and their loved ones that are available from New York City agencies, from securing medical benefits and setting up meal delivery to providing therapy and counseling. The primary program eligibility requirement is that the patient is unable to access regular medical care because of disease burden or functional or cognitive impairment. A triage nurse assesses all referred patients and, based on the data gathered, ranks patients on condition severity through a clinical severity score. The care team discusses goals of care with the patients on home visits — each care plan is tailored to each patient’s specific conditions, level of function, and goals of care. In addition to coordinating care, the MSVD team of social workers help locate supportive services for patients and their loved ones that are available from many New York City agencies — from securing medical benefits and setting up meal delivery to providing therapy and counseling. Patients work with program social workers to evaluate the need for help with finances, employment, health insurance, transportation, home care, assessing medical information, working with medical staff, emotional problems, family problems, spiritual or religious concerns, housing concerns, and help with daily chore. Prior to admission in the program, around 75% of patients reported at least one admission or ED visit. After one year in the program, only 25% of program patients had been hospitalized. The program also prospectively demonstrated reduced caregiver burden and a reduction in unmet needs for patient caregivers after enrolling in MSVD. Costs are hard to measure as the program reduces hospital admissions but also brings more services to the patient home. Costs are hard to measure as the program reduces hospital admissions but also brings more services to the patient home. Overall, although direct billing for academic HBPC programs does not generate enough revenue to meet operating costs, these programs can be significant revenue generators for the wider healthcare system and thus are fiscally worthy of subsidization
    • The HomeMeds Program evolved from the Visiting Nurses Association (VNA) of Los Angeles. The program was developed in response to home health nurses’ requests for additional support when dealing with the complex and ever changing medication regimens of some patients. Vanderbilt University researched the home health program and the potential for pharmacist integration. The HomeMeds Program cares for 2,500 patients nationally, of which most are Medicare or Medicare Advantage beneficiaries and dual eligibles (Medicaid plus Medicare). Based on the targeted nature of the HomeMeds intervention, it is estimated that the 4-year diffusion of the model has produced savings in excess of $1.2 million by preventing falls and other serious adverse drug events. This estimate is based on studies of the impact of medication therapy management services
    • Area Agencies on Aging (AAAs) are nonprofit corporations providing a variety of community based long term care programs for older adults. They were established in 1974 to provide local execution of the federal Older Americans Act of 1965. Title III of the Act authorizes funding for an array of community services, such as the meals programs, transportation, home healthcare, homemaking assistance, adult day care, home repair, and legal assistance. These services were designed to enable older adults to remain in their homes and to avoid unnecessary and costly institutional care. The scope of Ohio’s AAAs expanded in 1986 with the launch of the state’s Pre-Admission Screening and Services Providing Options and Resources Today (PASSPORT) program. This Medicaid-funded program seeks to prevent unnecessary nursing home placement of older adults through a managed care program that provides a specialized care plan designed around the specific needs of the Medicaid-eligible older adult client. A multitude of community-based services (e.g., homemakers, personal care aides, visiting nurses, home delivered meals, emergency alarm systems) are designed to enable a frail older adult to remain safely in their home. The cost to Medicaid for this program is approximately one-third of the cost of nursing home care
    • The TEAMcare intervention targets patients with either diabetes or heart disease, and comorbid depression. The program involves integrated medically supervised nurses assisting PCPs in the care of these patients. TEAMcare has implemented the program in other systems of care in the US and Canada. With a web-based tracking tool, TEAMcare is able to assess the performance of individual sites. With current funding from the Centers for Medicare and Medicaid Services (CMS), the goal is to bring an adaptation of TEAMcare to eight organizations, with each organization serving 1,000 patients, for a total of 8,000 patients. This effort may require five to eight nurses per site, with each nurse handling 100 patients per year. Some sites, however, will use medical assistants, pharmacists, and social workers to handle some of the key tasks in the intervention, reducing nurse time. Patients in this CMS project will be insured by Medicare and Medicaid. The intervention produced a total outpatient cost savings of approximately $600 per patient over a two-year period compared to usual care