Chronic Disease Management Programs - Wellpoint/CareMore

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Presentation by Felicia Cojocnean, FNP-MSN, BC, Family Nurse Practitioner, Chronic Disease Management, Wellpoint/CareMore

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  • 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.
  • Chronic Disease Management Programs - Wellpoint/CareMore

    1. 1. Felicia Cojocnean MSN, FNP, AANP-BC Chronic Disease Management Programs Wellpoint/CareMore Health Plan Orange Co/LA, California 1
    2. 2. CAREMORE • 1995 –Medical Group with enrolled Medicare beneficiaries • 2001-CareMore Health Plan • 2006- CareMore Special Needs Plan 2
    3. 3. CAREMORE 3
    4. 4. CAREMORE Health Spending & Chronic Disease Five chronic diseases make up the vast majority of this category* Diabetes Congestive Heart Failure Coronary Artery Disease Asthma Depression * Hypertension contributes to complications 4
    5. 5. 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 cooperate. Patients are best served when they have at most a few physicians who work together well 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 5
    6. 6. 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) 6
    7. 7. OUR MISSION Providing innovative and focused healthcare approaches to the complex process of aging. 7
    8. 8. 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 8
    9. 9. CAREMORE A Chronic Care Special Needs Plan •>70K members nationwide •Average age = 72 years •44% Diabetics •40% HTN and CHF •16% COPD and Renal Disease •20% Medicare – Medicaid •50% with annual income < $30,000 9
    10. 10. CAREMORE INTEGRATED PATIENT CARE DELIVERY SYSTEM COPD COPD CAD CAD CHF CHF Diabetes Diabetes Wound Clinic Wound Clinic Chronic Disease Chronic Disease Support Support ESRD ESRD Healthy Start Healthy Start Monitoring Monitoring Hospice Hospice End of Life Care End of Life Care PCP PCP Secondary Secondary Prevention Prevention Extensivist Extensivist Nutritionist Nutritionist Palliative Palliative Care Care Foot care Foot care Social / Social / Behavioral Behavioral Support Support Social Social Workers Workers Clinical Clinical Care Centers Care Centers (CCC) (CCC) Case Manager/ Case Manager/ NP NP Risk Event Risk Event Prevention Prevention Exercise Exercise Pre-Op Pre-Op Mental Health Mental Health Frailty Support Frailty Support Extensivist Extensivist Management Management Predictive modeling Integrated IT infrastructure Strength Strength Training Training Longitudinal patient record Coumadin Coumadin Fall Fall Evidence-based protocols Point-of-care decision support
    11. 11. 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. 11
    12. 12. CareMore CLINICAL MODEL Design: •Provide support system for PCPs •So, Chronically ill & Frail seniors receive all the services necessary to live an active & independent lifestyle • And, avoid hospitalizations & other unnecessary acute episodes 12
    13. 13. CAREMORE Neighborhood Clinical Model Care Center Community Focus •Located in the heart of the neighborhood Social Environment •Designed for seniors •Resource for family and caregivers •Frequent classes and activities Clinical • Disease Management • Foot Center • Healthy Start • Pre- Op • Fall Prevention • Wellness programs 13
    14. 14. 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  transportation  remote house monitoring through Telehealth services  home visits  social service support  Constant vigilance and use of predictive modeling to allow for early and rapid intervention  Healthy Start–complete evaluation within 30 days of enrollment  Predictive Modeling eg. CARS  Monitor risk indicators 14
    15. 15. CAREMORE 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) Blood Pressure Weight Blood Glucose Free Transportation to CareMore Care Centers 24 hour help line Caregiver support Home Care Respite Care Healthy Start (comprehensive assessment within 30 days of enrollment and individual plan) A Personal Care Plan for every member 15
    16. 16. RESULTS CareMore has consistently produced results that compare favorably to community norms 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 16
    17. 17. DIABETIC MANAGEMENT Observation 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. CAREMORE Redesign 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. Result Average HbA1c for those attending our diabetic clinic is 7.08, with 7.0 being considered good control. 1, 2 17
    18. 18. DIABETIC WOUND MANAGEMENT Observation 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 amputations. CAREMORE Redesign Nurse Practitioners became certified in wound care and took responsibility for high-touch wound intervention. Result 3 Amputation rates are 78% less than the national average. 18
    19. 19. REDUCTION IN STROKE RISK Observation 11 High blood pressure increases risk of stroke. Hypertension is not controlled in 12 70% of patients with this condition. Physicians have limited ability to get correct readings between patient visits which resulted in poor control of hypertension. CAREMORE Redesign 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. Result 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 13,14 the long term by 40% in patients. 19
    20. 20. CHF READMISSION Observation Congestive Heart Failure is a leading cause of hospital admissions and 15 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. CAREMORE Redesign 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. Result 56% reduction in hospital admission rate in 3 months. 20
    21. 21. 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 21
    22. 22. REFERENCES 1. 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 2. National Diabetes Information Clearinghouse. DCCT and EDIC: The Diabetes Control and Complications Trial and Follow-up Study. 3. 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 4. USRDS Annual Data Report (2008). ESRD: Overall Hospitalization- Morbidity and Mortality. www.usrds.org 5. Zinberg SS, Furman DS, Austin J. Older and Wiser (2007). Advance for Directors in Rehabilitation. p.39,40,48 6. Tinetti ME (2003). Preventing Falls in Elderly Persons. The New England Journal of Medicine. Volume 348:42-49 7. 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 8. 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 9. Medicare.gov Nursing Home Compare, Advancing Excellence Campaign in Nursing Facilities www.nhqualitycampaign.org 10. Anderson G, Herbert R. Johns Hopkins University Analysis of Medicare Standard Analytical Files (SAF) 5% Inpatient Data. The Commonwealth Fund www.commonwealthfund.org 22
    23. 23. REFERENCES 11. 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 12. 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 13. 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 14. Canadian Hypertension Education Program Recommendations (2007). Hypertension as a Public Health Risk www.hypertension.ca 15. HCUP Fact Book No. 1(2000). Hospitalization in the United States. AHRQ Publication No. 0031 www.ahrq.gov 16. Garnett C (2000). Don’t Accept the Blues: Depression in the Elderly is Treatable. National Institutes of Health (NIH) www.nih.gov 17. Depression in Late Life: Not a Natural Part of Aging (2009). Geriatric Mental Health Foundation www.gmhfonline.org 18. NIH Senior Health (2007). Depression Frequently Asked Questions. National Institute of Mental Health www.nihseniorhealth.gov 23

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