Cus­tomiz­ing tran­si­tional care for North Carolina Med­i­caid pa­tients

Modern Healthcare - - BEST PRACTICES - By Ja­clyn Schiff

Health­care or­ga­ni­za­tions are in­creas­ingly try­ing to crunch data to find pa­tients who are at risk of be­ing hos­pi­tal­ized and re­turn­ing to the hospi­tal soon af­ter go­ing home. But find­ing them doesn’t mean they’ll all re­spond to the same kinds of in­ter­ven­tions.

A not-for-profit group that works closely with the North Carolina Med­i­caid agency has de­vel­oped a data-driven tran­si­tional-care pro­gram in­tended to con­nect the right pa­tients with the re­sources that are most likely to work.

The physi­cian-led Com­mu­nity Care of North Carolina, which co­or­di­nates care for 1.4 mil­lion Med­i­caid ben­e­fi­cia­ries, cre­ated an al­go­rithm two years ago based on tran­si­tional care de­liv­ered to more than 100,000 pa­tients. The process pro­duces an “im­pactabil­ity score.”

“Tra­di­tional mod­els look at risk,” said Dr. Tom Wroth, CEO and chief med­i­cal of­fi­cer of North Carolina Com­mu­nity Care Net­works, the Med­i­caid arm of CCNC. The im­pactabil­ity score, Wroth said, “pre­dicts prospec­tively which pa­tients are go­ing to ben­e­fit from which tran­si­tional-care in­ter­ven­tions.”

With this ap­proach, CCNC has sig­nif­i­cantly re­duced hos­pi­tal­iza­tions for some of the state’s sick­est pa­tients. In March it was se­lected as the win­ner of the in­au­gu­ral Hearst Health Prize, a $100,000 award rec­og­niz­ing out­stand­ing achieve­ment in man­ag­ing or im­prov­ing health.

Since the pro­gram be­gan in 2008, hospi­tal ad­mis­sion rates for Med­i­caid re­cip­i­ents with mul­ti­ple chronic med­i­cal con­di­tions have de­clined by 10%, ac­cord­ing to the or­ga­ni­za­tion. Read­mis­sions for the same group have dropped by 16%.

For ex­am­ple, a 6-year-old boy had more than 30 emer­gency de­part­ment and hospi­tal vis­its in a year be­cause of seizures. One episode re­sulted in a 16-day hospi­tal stay. Un­der the tran­si­tional-care pro­gram, a care man­ager helped the boy’s mother find a new pe­di­a­tri­cian and get a re­fer­ral to a neu­rol­o­gist who ini­ti­ated a new treat­ment plan. A few weeks later, the boy was sta­bi­lized with the help of med­i­ca­tion and went seizure-free for al­most a year.

The suc­cess of the model re­lies on a broad menu of in­ter­ven­tions. The in­di­vid­ual com­po­nents of the pro­gram— which sup­ports about 2,600 Med­i­caid pa­tients each month—aren’t rev­o­lu­tion­ary. They in­clude co­or­di­nat­ing com­mu­ni­ca­tions and link­ing pa­tients back to pri­mary-care providers.

One key el­e­ment is rig­or­ous med­i­ca­tion man­age­ment. A team that might in­clude a case man­ager, phar­ma­cist and pri­mary-care physi­cian gath­ers med­i­ca­tion lists from all of the providers a pa­tient has seen. The team then gen­er­ates a con­sol­i­dated, cost­ef­fec­tive med­i­ca­tion reg­i­men.

The phar­ma­cist is a cru­cial part of the tran­si­tional-care team. CCNC has em­pow­ered about 300 phar­ma­cies to take an ac­tive role in pa­tients’ care. The phar­ma­cies have ac­cess to the or­ga­ni­za­tion’s in­for­mat­ics plat­form. Since pa­tients tend to visit the phar­macy more of­ten than they see their pri­mary-care physi­cian, it of­fers op­por­tu­ni­ties for ad­di­tional touch points and fol­low-up.

The role of the care man­ager—typ­i­cally ei­ther a reg­is­tered nurse or a so­cial worker—is also crit­i­cal. CCNC trains care man­agers to be the “quar­ter­back” of the care team and use mo­ti­va­tional in­ter­view­ing and other tech­niques to strengthen the like­li­hood of chang­ing be­hav­ior, Wroth said.

Lo­cal hires also make a dif­fer­ence. “They have the same ac­cent, they know the pa­tients,” said Paul Ma­honey, CCNC’s vice pres­i­dent for com­mu­ni­ca­tions. While other com­pa­nies use out-of-state call cen­ters to help di­rect pa­tients to ser­vices, “our folks know what they have here. They know the lo­cal play­ers and where the small sup­port oper­a­tions are.”

CCNC staff are also placed at hos­pi­tals that dis­charge large num­bers of Med­i­caid pa­tients to ed­u­cate pa­tients and fam­ily mem­bers on “red flags,” in­di­cat­ing when a doc­tor or care man­ager should be called. Care man­agers fol­low up soon af­ter dis­charge.

The tran­si­tional pe­riod typ­i­cally lasts about 30 days. Dur­ing that time, the pa­tient might be re­ferred to other pro­grams for on­go­ing sup­port. “We’re de­frag­ment­ing the health­care sys­tem for pa­tients,” Wroth said.

The model, mean­while, could be up­ended by the state’s plans to move to a Med­i­caid man­aged-care model in which ben­e­fits would be ad­min­is­tered by pri­vate health plans and providerled groups.

While state lead­ers pur­sue the nec­es­sary fed­eral waiver, CCNC lead­ers in­tend to stream­line oper­a­tions so they can con­tinue work­ing as part­ners with what­ever en­ti­ties as­sume re­spon­si­bil­ity for the state’s Med­i­caid pop­u­la­tion. The tran­si­tional-care ap­proach, Ma­honey said, “makes us valu­able to any riskbear­ing en­tity seek­ing to op­er­ate un­der the new man­aged-care sys­tem.”

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.