Planning a New Care Management Program NASHP Pre-Conference Sponsored by AHRQ Cheryl J. Roberts, J.D. Deputy of Programs a...
Presentation Overview <ul><li>Virginia Program Overview </li></ul><ul><li>Weddings and Care Management? </li></ul><ul><li>...
Virginia Medicaid   <ul><li>Currently cover 700,000 recipients. </li></ul><ul><li>Expend about $6 Billion per year. </li><...
Disease Management (2006) <ul><li>Program operational since 2006 under DRA provision.  </li></ul><ul><li>Voluntary enrollm...
Chronic Care Management ( projected implementation date 1/2009) <ul><li>More holistic program for FFS recipients who have ...
Planning a Wedding and Developing a Care Management Program What could they have in common?
A Lot!
Planning Tips for Weddings and Care Management Programs
Wedding Tip No. 1:    The Groundwork <ul><li>A good wedding starts with a great plan and a great man. </li></ul><ul><li>By...
Care Management Tip No. 1:  The Groundwork <ul><li>Vision –   </li></ul><ul><ul><li>Select the type of program you want: l...
Wedding   Tip No. 2: <ul><li>There is no need to send out formal invitations anymore.  </li></ul><ul><li>Use Evites, texts...
Care Management Tip No. 2:     Communication Strategy   <ul><ul><li>Develop a strong communication strategy with external ...
Wedding Tip No. 3:  I nvite both of your ENTIRE families <ul><li>Use this opportunity to invite the entire family:  immedi...
Care Management Tip No. 3:     Invite all stakeholders to the table   <ul><ul><li>Federal and State Authority – Get buy in...
Wedding Tip No. 4:  Is a real cake absolutely necessary? <ul><li>A real cake or fake one? </li></ul><ul><li>You only need ...
Care Management Tip No. 4:     Don’t create a program just for show. <ul><ul><li>Your program needs to be more than show. ...
Focus on Quality:   Diabetes Management <ul><li>www.dmas.virginia.gov/dsm.htm  </li></ul>
<ul><li>Best cost saver : </li></ul><ul><li>Have wedding and reception at sunrise.  </li></ul><ul><li>You get same orange ...
  Care Management Tip No. 5:     Build in flexibility and be open to new ideas <ul><ul><li>Project will evolve and need th...
Wedding Tip No. 6:    Times are tight, but don’t skimp on  everything! <ul><li>Don’t skimp on everything….especially not o...
Care Management Tip No. 6:     Times are tight, but don’t skimp on everything! <ul><ul><li>Don’t skimp on evaluation proce...
Focus on Outcomes:   What gets measured gets done <ul><li>Asthma HEDIS Outcomes </li></ul><ul><li>  2004  2005  2006 </li>...
Wedding Tip No. 7:    Beware of too good to be true <ul><li>Watch out for bargains that seem too good. </li></ul><ul><li>B...
Care Management Tip No. 7:     Don’t just select the lowest bidder <ul><ul><li>Care management has become a multi-million ...
Happily Ever After <ul><ul><li>Like a wedding, care management programs entail a lot of work and expense: </li></ul></ul><...
Yes
The End…. Thank you!
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Planning a New Care Management Program update

  1. 1. Planning a New Care Management Program NASHP Pre-Conference Sponsored by AHRQ Cheryl J. Roberts, J.D. Deputy of Programs and Operations Department of Medical Assistance Services Commonwealth of Virginia Sunday, October 2, 2008
  2. 2. Presentation Overview <ul><li>Virginia Program Overview </li></ul><ul><li>Weddings and Care Management? </li></ul><ul><li>Wedding and Care Management Planning Tips </li></ul><ul><li>Closing and Questions </li></ul>
  3. 3. Virginia Medicaid <ul><li>Currently cover 700,000 recipients. </li></ul><ul><li>Expend about $6 Billion per year. </li></ul><ul><li>55% of participants are in a Managed Care Organization; including the ABD population. </li></ul><ul><li>70% of funding goes toward long-term care and services for individuals with disabilities. </li></ul><ul><li>LTC is community focused: HCBS waivers, 7 PACE sites, Money Follows the Person, and VALTC pilot (the integration of LTC and managed care). </li></ul><ul><li>Virginia has operated a disease management (DSM) program since 2006. </li></ul><ul><li>Implementing a chronic care coordination program in 2008. </li></ul>
  4. 4. Disease Management (2006) <ul><li>Program operational since 2006 under DRA provision. </li></ul><ul><li>Voluntary enrollment, telephonic program. </li></ul><ul><li>No of enrollees: high intensity 2,000; low intensity 3700. </li></ul><ul><li>Five disease states: CAD, CHFD, COPD, asthma, and diabetes. </li></ul><ul><li>Developed as a quality initiative and uses HEDIS-like measures. </li></ul><ul><li>Health Management Corporation handles DSM contract for DMAS FFS, state employees, and largest Medicaid contracted MCO. </li></ul><ul><li>All VA Medicaid MCOs must </li></ul><ul><li>have DSM programs for same 5 </li></ul><ul><li>conditions. </li></ul>
  5. 5. Chronic Care Management ( projected implementation date 1/2009) <ul><li>More holistic program for FFS recipients who have high dollar claims and unmanaged care. </li></ul><ul><li>Will use predictive modeling tool, assessments and telephonic and face-to-face case management services. </li></ul><ul><li>Voluntary enrollment in two tiers: high and low. </li></ul><ul><li>Excludes the 5 DSM conditions. </li></ul><ul><li>Developed as a quality and cost savings measure. </li></ul><ul><li>Developed SPA under DRA provision. </li></ul><ul><li>RFP released July 2008, responses due at the end of September 2008. </li></ul>
  6. 6. Planning a Wedding and Developing a Care Management Program What could they have in common?
  7. 7. A Lot!
  8. 8. Planning Tips for Weddings and Care Management Programs
  9. 9. Wedding Tip No. 1: The Groundwork <ul><li>A good wedding starts with a great plan and a great man. </li></ul><ul><li>By sticking with the plan, hopefully you will end up with the great plan and man! </li></ul><ul><ul><ul><ul><ul><li>Vision </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Project planning </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Implementation </li></ul></ul></ul></ul></ul>
  10. 10. Care Management Tip No. 1: The Groundwork <ul><li>Vision – </li></ul><ul><ul><li>Select the type of program you want: look at other state models, private sector, industry trends, your own state structure and infrastructure. Document plans and concepts as a blue print. </li></ul></ul><ul><li>Planning : </li></ul><ul><ul><li>Determine what federal and state approval and budgetary support you will need and how to obtain it. </li></ul></ul><ul><ul><li>Find a someone to lead and champion program. </li></ul></ul><ul><ul><li>Join entities like ARHQ to assist you in network and program development. </li></ul></ul><ul><li>Implementation </li></ul><ul><ul><li>Develop a project plan. </li></ul></ul><ul><ul><li>Place contingencies in the plan. </li></ul></ul><ul><ul><li>Keep track of major items. </li></ul></ul><ul><ul><li>Get support for interfaces, research, and data analysis </li></ul></ul><ul><ul><li>Ensure implementation stays in line with vision. </li></ul></ul>
  11. 11. Wedding Tip No. 2: <ul><li>There is no need to send out formal invitations anymore. </li></ul><ul><li>Use Evites, texts, You Tube, web sites and Facebook. </li></ul><ul><li>For the few people over age 90 for whom you have to use snail mail; download invitations from the web and generate them on your computer. </li></ul>No one RSVPs anyway! Communications Strategy
  12. 12. Care Management Tip No. 2: Communication Strategy <ul><ul><li>Develop a strong communication strategy with external parties. Make sure your message is simple, clear, and easy to understand. </li></ul></ul><ul><ul><li>Program must sound, logical, and doable. </li></ul></ul><ul><ul><li>Make communications relevant to the audience and use different mediums. </li></ul></ul><ul><ul><li>Clients may need several different venues: DVDs, letters, web, video, interactive materials. </li></ul></ul><ul><ul><li>For external groups, create materials that explain 1) How the program will operate; and 2) How it will affect them. Always include WIIFM in the commutation ( What’s in it for me?). </li></ul></ul><ul><ul><li>Allow interested parties opportunities to respond and provide input. </li></ul></ul><ul><ul><li>Provide annual reports and updates. </li></ul></ul>
  13. 13. Wedding Tip No. 3: I nvite both of your ENTIRE families <ul><li>Use this opportunity to invite the entire family: immediate, close, extended, distant, and complicated connections . </li></ul><ul><li>The pictures will be more valuable. </li></ul><ul><li>Excluding family members will hurt you more in the long run than the pain caused by a few hours of tolerance. </li></ul>
  14. 14. Care Management Tip No. 3: Invite all stakeholders to the table <ul><ul><li>Federal and State Authority – Get buy in from CMS and state budget/regulatory authority from the beginning. </li></ul></ul><ul><ul><ul><li>You need an authority GPS </li></ul></ul></ul><ul><ul><li>Advocates and Providers - Get their buy in – consider the affect on established care patterns. Spend time to educate and orientate them on your vision and plan. Place them in advisory partnerships. </li></ul></ul><ul><ul><li>Vendors – Use the opportunity to </li></ul></ul><ul><ul><li>talk to vendors. Invite them to </li></ul></ul><ul><ul><li>visit – hear what they have to </li></ul></ul><ul><ul><li>offer. Ensure they are </li></ul></ul><ul><ul><li>inclusionary and flexible. </li></ul></ul>
  15. 15. Wedding Tip No. 4: Is a real cake absolutely necessary? <ul><li>A real cake or fake one? </li></ul><ul><li>You only need a wedding cake for the pictures. </li></ul><ul><li>So, create one out of Styrofoam and decorate it with icing and flowers for the pictures. Then serve your guests a grocery store sheet cake. </li></ul><ul><ul><li>Extra savings $$$: Find a birthday cake that someone did not pick up. </li></ul></ul>
  16. 16. Care Management Tip No. 4: Don’t create a program just for show. <ul><ul><li>Your program needs to be more than show. </li></ul></ul><ul><ul><li>It must have definitive outcomes. </li></ul></ul><ul><ul><li>Health outcomes – Be able to document that enrollees are better off for participating in the program: managed care, change of treatment plans, change in venue, higher scores, medication management adherence. More than just reporting happy/satisfaction. </li></ul></ul><ul><ul><li>Co$t $avings - After determining a reasonable savings expectation, develop a mechanism in which this will be achieved and reported. You will need to isolate program intervention to determine savings. </li></ul></ul><ul><ul><li>Managed care + managed savings expectations = success </li></ul></ul>
  17. 17. Focus on Quality: Diabetes Management <ul><li>www.dmas.virginia.gov/dsm.htm </li></ul>
  18. 18. <ul><li>Best cost saver : </li></ul><ul><li>Have wedding and reception at sunrise. </li></ul><ul><li>You get same orange sun as you do at sunset PLUS much better symbolism. </li></ul><ul><li>You can invite everyone without fear of going over budget. A breakfast reception is much cheaper. </li></ul>Wedding Tip No. 5: Be flexible and open to new ideas
  19. 19. Care Management Tip No. 5: Build in flexibility and be open to new ideas <ul><ul><li>Project will evolve and need the flexibility to change: </li></ul></ul><ul><ul><ul><li>New priorities; new trends and ideas; and </li></ul></ul></ul><ul><ul><ul><li>New internal and external pressures. </li></ul></ul></ul><ul><ul><li>Build in contract flexibility: </li></ul></ul><ul><ul><ul><li>Growth and shrinkage in program; </li></ul></ul></ul><ul><ul><ul><li>Ability to stop certain pieces and continue with others and operate some pieces internally. </li></ul></ul></ul><ul><ul><li>Continue to research and learn: </li></ul></ul><ul><ul><ul><li>Do not believe you have the golden goose- new ideas are born everyday. </li></ul></ul></ul><ul><ul><li>Compromise is not a bad word: </li></ul></ul><ul><ul><ul><li>Keep focused on the goal and plan as you make decisions. </li></ul></ul></ul>
  20. 20. Wedding Tip No. 6: Times are tight, but don’t skimp on everything! <ul><li>Don’t skimp on everything….especially not on the photographer! </li></ul><ul><li>When its all said and done, all you will have are pictures, memories, and credit card bills as a remembrance of the day. </li></ul>
  21. 21. Care Management Tip No. 6: Times are tight, but don’t skimp on everything! <ul><ul><li>Don’t skimp on evaluation process! </li></ul></ul><ul><ul><li>After a year of operation everyone will want </li></ul></ul><ul><ul><li>to know the program’s ROI. </li></ul></ul><ul><ul><li>Decide on the evaluation and reporting processes before you implement. </li></ul></ul><ul><ul><li>CHCS has a tool and a program for quality and ROI and there are a series of research models (e.g., control groups). </li></ul></ul><ul><ul><li>Look at HEDIS, URAC and QIO for ideas. </li></ul></ul><ul><ul><li>Find an independent source to evaluate program. </li></ul></ul><ul><ul><ul><li>The vendor’s annual report is not enough. </li></ul></ul></ul><ul><ul><ul><li>Think about using State Universities, EQRO, etc. </li></ul></ul></ul><ul><ul><li>Ensure that the evaluation terms are in the contract. </li></ul></ul>
  22. 22. Focus on Outcomes: What gets measured gets done <ul><li>Asthma HEDIS Outcomes </li></ul><ul><li> 2004 2005 2006 </li></ul><ul><li>Admits / 1000 50.0 52.7 42.3 </li></ul><ul><li>ED visits / 1000 269.8 265.1 250.5 </li></ul><ul><li>Appropriate Meds </li></ul><ul><li>Ages 5-56 67.7% 86.9% 88.3% </li></ul><ul><li>Actions: </li></ul><ul><ul><li>Outreach partnership with community organization. </li></ul></ul><ul><ul><li>Automatic telephone call reminder system. </li></ul></ul><ul><ul><li>Asthma & COPD provider guideline tools. </li></ul></ul>
  23. 23. Wedding Tip No. 7: Beware of too good to be true <ul><li>Watch out for bargains that seem too good. </li></ul><ul><li>Before you buy the honeymooners that $99.00 Caribbean cruise you saw on eBay- check for references. </li></ul>
  24. 24. Care Management Tip No. 7: Don’t just select the lowest bidder <ul><ul><li>Care management has become a multi-million dollar business. </li></ul></ul><ul><ul><li>And with the gold rush there are many vendors, purchasing ideas, and helpful friends. </li></ul></ul><ul><ul><li>There are no bargains – what appears to be too good to be true is. </li></ul></ul><ul><ul><li>Choose a vendor carefully. </li></ul></ul><ul><ul><li>Always include a prenuptial language – not just sanctions but a way out if both parties do not agree. </li></ul></ul><ul><ul><li>These program are not going to save the budget but they should control trends. </li></ul></ul><ul><ul><li>The biggest unknown is that you cannot control recipient behavior or participation – you just hope to influence it. </li></ul></ul>
  25. 25. Happily Ever After <ul><ul><li>Like a wedding, care management programs entail a lot of work and expense: </li></ul></ul><ul><ul><ul><li>Vision </li></ul></ul></ul><ul><ul><ul><li>Planning </li></ul></ul></ul><ul><ul><ul><li>Implementation </li></ul></ul></ul><ul><ul><li>All focused on achieving two outcomes: improving health outcomes and producing cost savings. </li></ul></ul><ul><li>Is it all worth it??? </li></ul>
  26. 26. Yes
  27. 27. The End…. Thank you!

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