Practice-Based Care Management: Many Paths to Chronic Disease Care

1. Practice-Based Care Management: Many Paths to Chronic Disease Care Jodi Summers Holtrop, PhD, MCHES, Michigan State University Department of Family Medicine

2. Care Management Delivery Models

3. Provider-Delivered Care Management Pilot (PDCM Pilot) • Collaborative project between Blue Cross Blue Shield of Michigan (BCBSM) and 5 state Physician Organizations (POs) • Focus on Chronic Disease Care Management • $2M over 2 year Pilot • Goals: • To support chronic care management within primary care physician practices • Increase the percentage of BCBSM disease management cases managed by primary care physician practices

4. Provider-Delivered Care Management Grant (PDCM AHRQ Study) • Assess the PDCM pilot • 3 year $1.8 grant from AHRQ Goals: Compare patient outcomes among those offered PDCM versus health plan delivered care management Describe the implementation of PDCM Describe practice environments and contexts of chronic care delivery, and identify implementation, PO, and practice features associated with improved outcomes

5. PDCM AHRQ Study: Convergent Mixed Methods Model CER: Compare PDCM to HPDCM Does CM participation → improve clinical outcomes? → reduce utilization/cost? • Patient Outcomes: • Engagement • Clinical results • Utilization Does a higher quality CM program and more integration lead to better outcomes? Which outcomes? • Within PDCM: • CM Program Quality • CM Integration in practice • Normalization of CM • Practice Environment Are practice environment and normalization of CM mediators?

6. PDCM Pilot Monthly data flow process BCBSM PO • Confirm member is patient of pilot PCP • Confirm patient has chronic condition • Confirm ability to provide CM if needed • Decide to accept / not accept • Create member list • Member ID • Name • Date of birth • Gender • Risk score • High cost flags • Chronic disease flags • 12-month IP, ED counts • BCBSM CM/DM case status • New member flag • Lost eligibility flag (drop) • Previous month PO responses • Member list return file • Member ID • Acceptance status • Accept date • Reason for no accept • Chronic disease(s) • Acceptance end date • Acceptance end reason • Activity files • Encounters • Goals

7. Compare PDCM to Health Plan Delivered Care Management (HPDCM) HPDCM PDCM Number of patients having CM outreach attempt 100% 62 – 82% Targeted = Number of patients accepted Number of patients having CM encounter Engaged = 17-18% 35-100% Number of patients having CM outreach attempt Point: PDCM engagement rates appear to be higher than HPDCM Note – still completing PDCM individual PO CM only rates; HPDCM rates are for the overall, not matched, populations

8. Care Management Features • Program Quality • Patient access • CMgr qualifications and personal attributes • Staff CM training • Resources for staff and patients • Program duration, dosage, features and length of visit • Integration in Practice • Practice staff participation in CM • CM team use • Location of CMgr visits with patients • CMgr visit documentation • Incentives and barriers for CM use

9. Analysis of PO and Practice Care Management Features, Integration and Context Immersion crystalization analysis Emergent themes ACROSS practices/PO’s Quotations pulled by quotes Reconciliation meeting for all practices within PO model – team and coders Coders review summary documents, add comments/quotes All transcripts for each practice assigned and coded by one of three coders Reconciliation meeting across PO’s – team and coders Audio files sent for transcription • Practice visit – 2 team members • Interviews • Observations • Complete summary documents (both) • Quality • Integration • NPT/implementation • Lead RA: • Practice summary (internal) • Practice report and task diagram • Resources • Observation guide 2 team members reconcile scores and notes • Completed summary documents • Quality • Integration • NPT • Practice summary Revised summary documents v.1 Revised summary documents v.2 Revised summary documents v.3 – Key features WITHIN practices/PO Practice report sent to practice for member checking; modifications made

10. Care Management Models: Practice Integration or Centralization at PO

11. Care Management Models: Within PDCM Point: Within PDCM there is variation in practice integration • In 5 PO’s, 8 “models” of delivery – 2 distinct types • Integration: centralized → practice-based • One PO very centralized; more like health plan • Three PO’s two different models happening • Two PO’s highly integrated • Within practice-based models • Full-time C Mgr as practice team member only doing CM • Full-time nurse doing CM 1 day per week as part of job (included in job description of all practice nurses) • Travel model with panel manager and C Mgr (panel manager in practice; C Mgr 1-3 days per week at practice)

12. How people talk about Integration Point: Integration feels different than centralized to the participants Interviewer: If you would do anything to improve the CM program, what would it be? • Centralized models • C Mgr: Increase referrals of patients to the CM, like pulling teeth to get referrals • Provider: C Mgr is a resource we can refer to • Integrated models • C Mgr: Hire more C Mgr’s. We have so many patients with needs and can’t keep up with the existing number of C Mgr’s • Provider: Hire more C Mgrs. The CM is part of our team and how we practice care

13. Implementation vs. Program Quality and Integration

14. Program Quality Point: Most PDCM programs were of high quality with a few exceptions Examples: • MA delivered programs without much training • Not delivering motivational interviewing, rather telling patient what to do in one or a few brief calls • When restricted to only BCBSM patients on “lists” tended to work differently (out of patient flow, lacking provider selection of patient) rather than as team concept with this being just part of your care • Co-pays were reported to result in patient refusal of CM as compared to programs charging no patient co-pay or billing • Issues were the patient not knowing what the co-pay will be or wanting to pay it once they knew. Patients did not want to answer the phone for CM calls fearing they would get a bill

15. Program Quality and Integration Point: Lack of either quality or integration limits program use and likely effectiveness • Even if highly integrated, can it overcome problems of poor quality? PROBABLY NOT • Poorly trained or not properly credentialed C Mgr lacks cultural credibility and trust from team • Lack of time and support to do CM means it doesn’t happen • Even if your program is of high quality, can it overcome barriers of lack of integration? PROBABLY NOT • Hard to reach patients only by phone out of scope of normal care • C Mgr not known as practice team member • Lack of day to day huddles and ad hoc communication about patients (providers often don’t read EMR notes) • Providers and practice members forget to refer; an extra step

16. Summary • Patients appear to participate in PDCM at higher rates than health plan care management • Typical community, non-research directed primary care practices can implement CM • PDCM program quality is generally high • PDCM integration in practice is highly variable • More CM integration appears to equal more team use of CM and we think CM participation

18. To be continued… • Results are PRELIMINARY • Ongoing work includes • Verifying target population and specific practice and PO CM engagement rates • Gathering data on clinical values, claims • Analyzing emergent themes across practices • Further analysis • “Recipe” for successful care management – qualitative comparative analysis

19. Research Team • Michigan State University • Jodi Holtrop, Zhehui Luo, Qiaoling Chen, Laurie Fitzpatrick • University of Michigan • Gretchen Piatt, Lee Green (now U Alberta), Georges Potworowski (now SUNY Albany), Mike Fetters, Jean Malouin, Trudy Adler, Amy Kowalk • Altarum Institute • Rachelle May-Gentile, Anya Day, Brad Hinks, Lauren Wendel, Kristen Werner • Blue Cross Blue Shield of Michigan • Margaret Mason, Lisa Rajt, Min Tao, Ann Emeott, Guipeng Liu, Hsiu-Ching Chang, Darline El Reda • Physician Organizations • Ruth Clark, Mary Ellen Benzik, Cecilia Sauter, Jen Bailey, Cathy Heiman, Cara Seguin

20. THANK YOU!