Value-Based Care

1. Value-Based Care Care Management Lecture a – Introduction to Care Management This material (Comp 23 Unit 4) was developed by Normandale Community College, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0003. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

2. Lecture aLearning Objectives • Define care management and explain why it is central to value-based care • Describe drivers of unnecessary or wasteful care • Discuss how Health IT can be used to support appropriate care and decrease waste/overutilization

3. Introduction to Care Management Care management is: • central to each of the triple aim’s three elements • a leading, practice-based strategy for managing the health of populations Sources: AHRQ, April 2015; Berwick, 2008 Source: CHFA, 2014 Triple Aim

4. Sources: CHCS, 2007; AHRQ, April 2015 Definition of Care Management Care management is a promising team-based, patient-centered approach “designed to assist patients and their support systems in managing medical conditions more effectively.” It also encompasses those care coordination activities needed to help manage chronic illness.

5. Source Iowa APCA, 2015 Care Manager Titles and Roles • Case managers • Care coordinators • Case navigators • Others

6. Eliminating Waste in U.S. Health Care Source: Berwick, D. M., & Hackbarth, A. D., 2012.

7. Source: Berwick, 2012 Reducing Waste in Health Care Spending • Failures of care delivery • Failures of care coordination • Overtreatment • Administrative complexity • Pricing failures • Fraud and abuse

8. Source: ABIM Foundation, 2015 Building Effective and Efficient Systems to Decrease Waste • Develop and implement evidence-based guidelines • Provide clinical decision support • Adopt team-based care models • Redesign systems and workflows • Integrate care management

9. Care Management Opportunities to Reduce Waste • Use primary care more effectively • Address both the supply and demand sides of the equation • Alternative payment models • Consumer-directed health plans • Apply care management practices Source: AHRQ, April 2015

10. Examples of Care Management • Complex care management • Transitional care management • High-risk and high-utilization management • Hospital care management • Patient Centered Medical Home Source: NCQA, 2015; Commonwealth Fund, 2014

11. The Value of Care Managers • Support the broad strategy of value-based care by helping: • Individuals use services at the right time • Care systems utilize resources more effectively • Improve health behaviors and outcomes based on modifiable risk Source: AHRQ, April 2015; CMS Fact sheet, 1.26.2015

12. Care Management Goals • Help patients regain optimum health, cost effectively in the right setting • Conduct a comprehensive assessment to: • Identify barriers to care • Determine benefits and resources • Develop patient goals • Establish monitoring mechanisms and follow up Source: CHCS, 2007; NCQA, 2015

13. Case Example: Barry Coulter Creative Stall., CC BY NC-SA 3.0. Source: Adapted from full case example at ICSI.com Care manager coordinated various specialists to address Barry’s chronic conditions Care manager coached Barry with education about his conditions and helped him take a greater role in self-managing his health Barry made progress toward his goals with the support of his care manager Overall cost of Barry’s care was reduced • Overweight • Depressed • Diabetes • Unable to carry out daily activities • Lost health insurance

14. Care Management Impact in VBC • Customizing plan of care • Helping the patient get the right level of service, in the right setting, and at the right time • Providing team-based care • Promoting self-management and behavior change for modifiable health risk • Achieving better health outcomes

15. Strategy 1: Identify Populations with Modifiable Risks • Use multiple metrics to identify patients with modifiable risks • Develop risk-based approaches to identify patients most in need of care management services Source: AHRQ, April 2015, NCQA, 2015

16. Strategy 2: Align Services to the Needs of the Population • Management of care • Referral tracking and follow up • Personalized care plans are tailored to individual patients’ preferences and goals • Self-management and patient engagement • Outreach to patients to provide education, support, and resources Source: AHRQ, April 2015

17. Strategy 3: Train Appropriate Personnel for Needed Services • Implement inter-professional team-based approaches to care • Determine who should provide care management services given the population needs and practice context • Identify needed skills, appropriate training, and licensure requirements Source: AHRQ, April 2015

18. Using Data to Select Patients • Quantitative risk-prediction • Acute-care-utilization • High-risk condition • Medication utilization and spending • Health risk assessment Source: Commonwealth, 2014

19. Health IT in Care Management • Using Health IT to access patient data • Facilitating electronic document exchange • Recording patient health data to enable information exchange • Facilitating teamwork Source: Anderson et. al 2012; Commonwealth, 2014

20. Health IT in Care Management 2 • Quality measurement • Electronic Health Record data • Claims data • Data reporting • Incentive payments • Disease registries Source: Anderson, et. al, 2012, Commonwealth, 2014

21. Health IT Supports Appropriate Utilization • Decision support and shared-decision making (SDM) tools • Registries for population health • Information exchange between care delivery sites and across continuum Source: Anderson, et. al, 2012

22. Care ManagementLecture a Summary • Defined care management and explored the goals of care management • Described drivers of waste in U.S. health care and the role of care management in saving resources and eliminating waste • Explored the role of care management in value-based care delivery • Discussed how Health IT can be leveraged to support care management

23. Care ManagementLecture a – References 1 References Anderson, K.M., Marsh, C.A., Flemming, A.C., et al. (July 2012). Quality Measurement Enabled by Health IT: Overview, Possibilities, and Challenges (Prepared by Booz Allen Hamilton, under Contract No. 290-09-00024I-4). [AHRQ Publication No. 12-0061-EF]. Retrieved from http://healthit.arq.gov/ Berwick, D. M., & Hackbarth, A. D. (2012). Eliminating waste in US health care. Jama, 307(14), 1513-1516. Berwick, D.M., Nolan, T.W. and Whittington, J. (2008). The Triple Aim: Care, Health, And Cost Health Affairs 27, no.3:759-769 doi: 10.1377/hlthaff.27.3.759 Better Care, Smarter Spending, Healthier People: Improving our Health Care Delivery System (January 26, 2015). CMS Fact sheet. Retrieved from https://www.cms.gov/ Care management definition and framework. (October, 2007). Center for Health Care Strategies, Inc. (CHCS). Retrieved from http://www.chcs.org/ Care Management, Case Management, Care Coordination and Navigation What’s the Difference? (n.d.). Iowa APCA. Retrieved from http:/www.iowapac.org Care Management: Implications for Medical Practice, Health Policy, and Health Services Research. (April 2015). Agency for Healthcare Research and Quality (AHRQ). Retrieved from http://www.ahrq.gov

24. Care ManagementLecture a – References 2 References Choosing Wisely in an Era of Limited Resources. (2012). ABIM Foundation Forum. Retrieved from http://abimfoundation.org/ Hong, C.S., Siegel, A.L., and Ferris, T.G., (August 2014). Caring for High-Need, High-Cost Patients: What Makes for a Successful Care Management Program? The Commonwealth Fund. Retrieved from http://www.comonwealthfund.org/ Kibbe, D.C. (Sep–Oct 2001). Physicians, are coordination, and the use of web-based information systems to manage chronic illness across the continuum. Case Manager. 12(5):56–61. Kodner, D.L. (Aug., 2002). The quest for integrated systems of care for frail older persons. Aging Clin Exp Res.14(4):307–13. Patient-Centered Medical Home Recognition. (2015). NCQA. Retrieved from http://www.ncqa.org/ Risk Stratification to Inform Care Management for Medicare-Medicaid Enrollees: State Strategies. (November 2014). CHCS. Retrieved from http://www.chcs.org/ Self-Management Support for People with Chronic Conditions. (March 2016). Institute for Healthcare Improvement (IHI). Retrieved from http://www.ihi.org/

25. Care ManagementLecture a – References 3 References Setting Achievable Goals Fuels Success. (n.d.). Institute for Clinical Systems Improvement (ICSI). Retrieved from http://www.icsi.org/ Images Slide 3: From Fragmentation to Integration: A Triple Aim Imperative [Online image]. (2014). CFHA 16th Annual Conference. Retrieved from: http:www/chfa.net Slide 6: Berwick, D. (2011). Eliminating Waste in US Health Care. Waste Wedges in U.S. Health Care [Image]. Slide 13: Elderly Man icon. CC BY-NC-SA 4.0

26. Care ManagementLecture a This material was developed by Normandale Community College, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0003.