Good afternoon My name is Felicia Cojocnean, I am a Nurse practitioner from OC CA.. I have been working with CM for over the last 6yrs treating patients with chronic diseases in our Chronic Disease Management Clinics, Thank you for the opportunity to share with you our model of care that utilizes non-physician practitioners like myself in conjunction with Telehealth Services to deliver care to our chronically ill and frail patients.
CareMore started in California as a Medical group with Enrolled Medicare Benificiaries in 1995 It became Caremore Health Plan in 2001 when it obtain a CMS contract and It started offering a Chronic Care Special Needs Plan in 2006
From the beginning CareMore recognized that chronically ill and frail seniors received uncoordinated, often inadequate, and unnecessarily costly care from the existing “system.” Over the last 13 years, CareMore has built, and continues to refine, an alternative system designed to maintain health, improve outcomes, and reduce cost for chronically ill and frail seniors
Kaiser Permanente – 15% of the population spend 70% of the dollars Agency for Healthcare Research and Quality) 70% of all healthcare dollars are spent on chronic diseases
Dr Peter B. Bach, a physician at Memorial Sloan-Kettering Cancer Center in New York City, published a study of Medicare in the New England Journal of Medicine, showing that“40% of patients with chronic conditions…saw on average 11 doctors in seven practices; the upper quartile of this group saw 16 or more different doctors in nine or more practices…from a clinical perspective, 16 or 11 or even 7 different doctors treating a patient is no way to deliver high quality Care Commonwealth: Patients with “medical homes” better manage chronic diseases and maintain basic preventive care. In addition, “medical homes” eliminate racial and ethnic health care disparities Elizabet -The Quality of Health Care Delivered to Adults in the United States
Other studies have shown that …… In this population, noncompliance compounds the complications of chronic disease. A self-perpetuating downward spiral exists whereby patients not only fail to show up for as many as one-third of their doctor appointments due to their disabilities and also due to depletion in their financial resources and support systems therefore only seeking medical attention once complications have developed to a point of crisis. At that point, these patients seek medical attention from the ER and hospital- the most costly levels of care.
As the Baby Boomer generation ages, the number of frail patients who use up a disproportionately high amount of healthcare resources will only increase…unless a disruptive change in how we manage chronic and advanced disease is introduced.
Our goal is to
Our Special Needs Plan accounts for More than
At CareMore, we specialize in improving senior health care and advancing a truly unique philosophy of care designed to keep patients healthy. Our model produces comprehensive coordinated care that prevents or delays the progression of most serious illnesses. We address healthcare across the full spectrum of medical, psychosocial, pharmaceutical and economic needs. The CareMore model is proven and evolves to adjust to the health care needs of individual patients. Patients spend less time navigating the healthcare system and more time focusing on the important things in life.
CareMore’s success has drawn nationwide interest reflected in a rapidly growing membership that now numbers >70,000 in California, Arizona and Nevada. From 2005 to 2010, CareMore’s membership grew by 15% each year. Because of CareMore’s ability to replicate its success in geographically and demographically disparate communities, WellPoint acquired CareMore in August 2011 with the strategic vision of replicating CareMore’s model to its 70 million members in 14 states. In Jan of this year we have expanded to the E Coast and opened 4 CM centers in Richmond area and 2 Centers in NY.
Our Clinical model is patient centered and adds value to partner PCPs by extending their scope of practice with an assortment of CareMore services to include: wellness and social activities, chronic disease management programs (DMP), and "Extensivist"care. CareMore's "Extensivists“ are internal medicine physicians who tend to our highest acuity patients as their Intensivist/Hospitalists with routine communication to PCP, and continue to follow our patients while they are recovering at Skilled Nursing Facilities and in post-discharge clinic. Palliative care, Hospice and End-of-life care are strongly emphasized
The Purpose of Our Neighborhood Clinical Model is to -Identify and manage ‘frail’ patients from the ‘neighborhood’, -Coordinate use of all available resources to provide comprehensive care -Ensure effectiveness of our programs -Develop PCP relationships Comprehensive care is implemented by Nurse Practitioners (also known as Advanced Practice Registered Nurses) such as myself who provide high quality, evidenced based, and more cost-effective care than a physician based ambulatory care setting .
Some of the Benefits available for the patients enrolled in the Special needs programs…. We employ the services of Ideal Life with great success to monitor BP for hypertensive patients, to monitor Weights for pts with CHF and Blood Glucose for diabetics especially those as risk for hypoglycemic episodes.
Increased regularity and consistency of medical care even when provided by time and labor intensive home visits, translates into better care, better health and greater downstream savings by decreasing chronic disease complications and avoidance of ER/hospital use.
As a result of routine as well as aggressive wound care delivered by our Certified Wound Care Nurse Practitioners
The decrease in BP obtained by utilizing the Ideal Life Electronic BP cuffs, monitoring BP and adjusting treatment to goal had shown to reduce the instances of stroke over the long term by 40%.
The results obtained by utilizing the Ideal Life Electronic Scales in close monitoring pt’s weights daily as well as adjusting their treatment led to
Again thank you for giving me the opportunity to share with you a Model of Care that utilizes non-physician practitioners like myself in conjunction with Telehealth Services to deliver care to those frail patients who need it the most.
Health Spending & Chronic Disease
Five chronic diseases make up the vast majority of this category*
Congestive Heart Failure
Coronary Artery Disease
* Hypertension contributes to complications
THERE IS GREAT OPPORTUNITY
CHRONIC DISEASES CAN BE MANAGED… BUT USUALLY ARE NOT
Dr Peter B. Bach (6/21/07),study of Medicare in the New England Journal of Medicine
Patients with chronic conditions do not need more doctors, they need a few who
Patients are best served when they have at most a few physicians who work together
Commonwealth Fund Health Care Quality Survey,Report (July 2007)
Medical Homes result in better outcome
Elizabeth A. McGlynn et al (2003)
Patients receive appropriate care only half of the time
THERE IS GREAT OPPORTUNITY
CHRONIC DISEASES CAN BE MANAGED… BUT USUALLY ARE NOT
Diabetic complications could be cut 90% with best care and involved patients (Center for
Disease Control and Prevention), yet
Diabetes related admissions have risen from 3.5 to 6.5 million since 1993
Low income diabetics are 80% more likely to be hospitalized
Second heart attacks can be reduced 40% (J.R. Jowers)
More doctors involved in care decreases information exchange and leads to unnecessary
hospitalizations (Wennberg/ Dartmouth)
Providing innovative and focused
healthcare approaches to the
complex process of aging.
WHY OUR MISSION
We are here to:
serve our members by prolonging active and independent life
serve caregivers and family by providing support, education,
and access to services
protect precious financial resources of seniors and the
Medicare Program through innovative methods of managing
chronic disease, frailty, and end of life
A Chronic Care Special Needs Plan
•>70K members nationwide
•Average age = 72 years
•40% HTN and CHF
•16% COPD and Renal Disease
•20% Medicare – Medicaid
•50% with annual income < $30,000
CAREMORE INTEGRATED PATIENT
CARE DELIVERY SYSTEM
End of Life Care
End of Life Care
THE CAREMORE MODEL
Summary: Integrated care involves nurses, pharmacists and others on care
teams, all working together to achieve a common goal. WellPoint's recent
purchase of CareMore, which provides care for 15 percent of Medicare
Advantage beneficiaries who account for 75 percent of costs, is an example
of successfully integrated care.
CareMore CLINICAL MODEL
system for PCPs
•So, Chronically ill &
Frail seniors receive all
the services necessary
to live an active &
• And, avoid
hospitalizations & other
Neighborhood Clinical Model
•Located in the heart
of the neighborhood
•Designed for seniors
•Resource for family and caregivers
•Frequent classes and activities
• Disease Management
• Foot Center
• Healthy Start
• Pre- Op
• Fall Prevention
• Wellness programs
CAREMORE MODEL OF CARE
For the chronically ill:
The CareMore Care Center serves as a “home” for patients where questions are
answered, care is delivered and coordinated.
A variety of support services are provided , designed to “fool proof” patient noncompliance with care programs
remote house monitoring through Telehealth services
social service support
Constant vigilance and use of predictive modeling to allow for early and rapid
Healthy Start–complete evaluation within 30 days of enrollment
Predictive Modeling eg. CARS
Monitor risk indicators
A Chronic Care Special Needs Plan
Benefits that fit the need
Free insulin and diabetic supplies
Routine wound care
Free home-based electronic monitoring (Ideal Life)
Free Transportation to CareMore Care Centers
24 hour help line
Healthy Start (comprehensive assessment within 30 days of enrollment and individual plan)
A Personal Care Plan for every member
CareMore has consistently produced results that compare favorably to
In many cases these results have been dramatically superior
CareMore has not tried to change or work “through” the conventional
system but has built a new model that recognizes the increased demands
of the chronically ill
Many patients with out-of-control diabetes were not brought in control
through insulin use. Common wisdom was that inability to correctly self
administer or improper dosing were driving results. Further, insufficient
support in the areas of nutrition and exercise were observed.
Established insulin “starts” and insulin “camps”. At the “start” day,
patient is trained in all aspects of self-administration of insulin. At
“camps”, patients are brought to the center for a full day to observe
all of their behaviors and monitor glucose levels at all points of self
care. A personal nutrition counselor was assigned.
Average HbA1c for those attending our diabetic clinic is 7.08, with
7.0 being considered good control.
DIABETIC WOUND MANAGEMENT
Routine diabetic wound care was being primarily delivered by vascular and
orthopedic surgeons, who were not inclined to supply the highly-repetitive,
low intensity health care necessary to heal wounds. This resulted in frequent
Nurse Practitioners became certified in wound care and took
responsibility for high-touch wound intervention.
Amputation rates are 78% less than the national average.
REDUCTION IN STROKE RISK
High blood pressure increases risk of stroke. Hypertension is not controlled in
70% of patients with this condition. Physicians have limited ability to get
correct readings between patient visits which resulted in poor control of
Equip patients with blood pressure monitors with wireless cuffs for
recording three times a day. Readings taken at CareMore’s Care
Center. Make immediate, same day medication changes when
pressure levels change.
48% of the patients had > 10mm in Hg reduction in systolic
blood pressure. Patients with systolic blood pressures of 160 mm
Hg or > had an average drop of 23mm Hg. Those patients with
blood pressure of 150-160 mm Hg had an average drop of 19mm.
Those results had shown to reduce the instances of stroke over
the long term by 40% in patients.
Congestive Heart Failure is a leading cause of hospital admissions and
readmissions in the Medicare population. Primary care physicians were not
able/willing to collect accurate weight on a daily basis and intervene quickly.
Self-reported weights were inaccurate. Primary care physicians were not
adequately responsive to immediate care needs of patients who require
intervention within a few hours of onset of symptoms.
Equip each patient with a wireless scale that sets off alerts if weight
gain is 3 lbs overnight or 1 lb per day for more than 3 days. Sameday visit with clinician if alert is triggered. Proactive hospice planning
with changes in condition.
56% reduction in hospital admission rate in 3 months.
CAREMORE A DAY IN THE LIFE
CAREMORE SERVES 30,000 MEMBERS THROUGH 11 CARE CENTERS IN LOS
ANGELES AND ORANGE COUNTY CALIFORNIA
ON AN AVERAGE BUSINESS DAY, CAREMORE…
Provides more than 900 rides to patients to and from points of care
Makes or receives 3,385 phone calls arranging for care
Sees 40 new members to assess health and establish personal care plans.
Provides more than 950 hours of homemaker services for the frail
Visits 27 homes to provide care or social support
Engages 4 families in end-of-life/hospice planning
Makes 235 follow up calls to patients in care programs
Provides 191 strength training sessions
Makes 90 care visits to patients residing in nursing homes/assisted living
Reads 567 blood pressures from monitors in the homes of hypertensive patients
Reads 369 weights from monitors in the homes of chronic heart failure patients
Sees 413 patients in our Care Centers for follow up and chronic care management
Genuth S, Eastman R, Kahn R, Klein R, Lachin J, Lebovitz H, Nathan D, Vinico F (2002). Implications of the United
Kingdom Prospective Diabetes Study. Diabetes Care Volume 25, Supplement 1
National Diabetes Information Clearinghouse. DCCT and EDIC: The Diabetes Control and Complications Trial and
Krop JS, Bertoni AG, Anderson GF, Brancati FL (2002). Diabetes-Related Morbidity and Mortality in a National Sample
of U.S. Elder. Diabetes Care 25:471-475
USRDS Annual Data Report (2008). ESRD: Overall Hospitalization- Morbidity and Mortality. www.usrds.org
Zinberg SS, Furman DS, Austin J. Older and Wiser (2007). Advance for Directors in Rehabilitation. p.39,40,48
Tinetti ME (2003). Preventing Falls in Elderly Persons. The New England Journal of Medicine. Volume 348:42-49
Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C (2002). Prevention of Falls in the Elderly Trial
(PROFET): a Randomized Controlled Trial. National Center for Biotechnology Information (NCBI) www.ncbi.nih.gov
Ray WA, Thapa PB, Gideon P (2000). Benzodiazepines and the Risk of Falls in Nursing Home Residents. National
Center for Biotechnology Information (NCBI) www.ncbi.hih.gov
Medicare.gov Nursing Home Compare, Advancing Excellence Campaign in Nursing Facilities
Anderson G, Herbert R. Johns Hopkins University Analysis of Medicare Standard Analytical Files (SAF) 5% Inpatient
Data. The Commonwealth Fund www.commonwealthfund.org
Ostehega Y, Yoon SS, Hughes J, Louis T (2008). Hypertension Awareness, Treatment, and Control- Continued
Disparities in Adults: United States, 2005-2006. NCHS Data Brief: National Center for Health Statistics
Denny CH, Greenlund KJ, Ayala C, Keenan NL, Croft JB (2007). Prevalence of Actions to Control High Blood
Pressure---20 States 2005 www.cdc.gov/mmwr
Lewington S, Clarke R, Qizilbash N, Peto R, Collins R (2002). Age Specific Relevance of Usual Blood Pressure to
Vascular Mortality: A Meta-analysis of Individual Data for One Million Adults in 61 Prospective Studies The Lancet
v.360, i. 9349, p.1903-1913
Canadian Hypertension Education Program Recommendations (2007). Hypertension as a Public Health Risk
HCUP Fact Book No. 1(2000). Hospitalization in the United States. AHRQ Publication No. 0031 www.ahrq.gov
Garnett C (2000). Don’t Accept the Blues: Depression in the Elderly is Treatable. National Institutes of Health (NIH)
Depression in Late Life: Not a Natural Part of Aging (2009). Geriatric Mental Health Foundation www.gmhfonline.org
NIH Senior Health (2007). Depression Frequently Asked Questions. National Institute of Mental Health