Care Management in Value-Based Care: Overview of Clinical Programs

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Introduction

This document outlines the concept of care management within a value-based care system, presented by Angela Nunnery, M.D. and Tracy Maddox, J.D., M.S.N., R.N. The discussion emphasizes the transition from the traditional fee-for-service model to value-based care, a shift necessitated by escalating healthcare costs and the imperative to enhance patient outcomes. Value-based care prioritizes the long-term health of patients, particularly those with complex chronic conditions, and incentivizes providers for delivering high-quality care and efficient resource utilization.

The Clinically Integrated Network (CIN) and Its Role in Care Management

A central theme of the presentation is the pivotal role of the Clinically Integrated Network (CIN) in facilitating effective care management. The CIN provides a dedicated care management team composed of experts who support physicians and Advanced Practice Professionals (APPs) in managing their patient populations, especially those under value-based care contracts. The CIN's primary objective is to assist providers in improving patient outcomes and reducing avoidable healthcare utilization through a range of supportive services. These services include:

• Advanced Analytics: The CIN boasts an analytics team that integrates electronic health record (EHR) data with claims data. This enables the identification of high-risk and chronically ill patients who may have unmet needs that are not readily apparent through standard EHR data alone. This proactive identification allows for a shift from reactive to preventative care strategies.
• Multidisciplinary Care Management Team: The CIN's care management team consists of medical assistants and registered nurses who conduct telephonic outreach to patients. They reinforce the provider's treatment plans and strive to keep patients engaged in their care.
• Provider Liaisons: The CIN also has provider liaisons who assist with administrative and systemic issues that may impact patient care, such as credentialing and addressing high-cost concerns.

Key Objectives and Focus of CIN Care Management

The efforts of the CIN's care management team are guided by several key objectives aimed at improving the overall healthcare experience and outcomes:

• Reducing hospital readmissions.
• Minimizing avoidable hospitalizations.
• Decreasing unnecessary emergency department visits.
• Empowering physicians to concentrate on patient wellness, disease prevention, and the management of chronic illnesses.
• Improving the health of the broader patient population (population health).
• Alleviating provider burnout by offering crucial support.
• Enhancing the patient experience through better understanding of care plans and improved access to services.

The CIN's care management strategies focus on two primary areas:

• Longitudinal Care (Population Health): This involves a long-term perspective on patient care, proactively addressing health issues in the ambulatory setting and providing continuous support for individuals with chronic conditions.
• Episodic Care: This focuses on specific healthcare events, ensuring patients receive appropriate care during these times. This includes efforts to improve adherence to treatment plans and follow-up appointments, particularly for conditions like diabetes and hypertension.

Empowering Patients Through Self-Management and Transitional Care

A cornerstone of the CIN's approach is the promotion of proactive patient self-management. The care management team works to educate and empower patients to take ownership of their health through education and support, fostering a strong partnership with their healthcare providers.

The CIN places significant emphasis on transitional care management (TCM) to ensure seamless transitions between different healthcare settings, such as hospitals, emergency departments, and home. Tools like Bamboo Health are utilized to provide real-time notifications of patient admissions and ED visits, enabling timely follow-up calls. These calls aim to review discharge instructions, reconcile medications, coordinate necessary follow-up appointments, and identify potential complications, extending up to 60 days post-discharge.

Illustrative Patient Case Examples

Presenters offered several real-world case studies that demonstrate the impact of the CIN's care management team. These include:

• A patient with multiple chronic conditions (hypertension, new prostate health diagnosis, recent ER visits and hospitalizations, and pre-diabetes) who, through the intervention of a care management nurse over six months, experienced no further ER visits or hospitalizations and moved out of the pre-diabetes range due to coaching on diet and exercise.
• A patient identified as an ED high utilizer whose increased ED visits prompted a physician referral. The care management team identified a fall risk issue that the patient was concealing. The nurse facilitated a physician order for physical therapy and home health, leading to the initiation of these crucial services.

Additional examples highlighting the team's comprehensive support:

• A tow truck driver with poorly managed diabetes (A1C of 11) who faced challenges attending appointments due to his work schedule. After persistent outreach and nine months of support from the care management team focusing on appointment adherence, blood sugar monitoring, diet, and exercise, the patient's A1C significantly improved to 5.4.
• A patient with immobility issues requiring an electric scooter who faced a crisis when the scooter was left behind after an ER visit. The care management nurse assisted the patient in managing medical appointments and worked with the business to have the scooter returned. Notably, this patient had no family support, highlighting the crucial role of the care management team in providing not only clinical but also social support. This patient has had no readmissions since the incident and continues to work with the nurse.
• A case illustrating the impact of addressing social determinants of health. A patient with no money for rent or food, difficulty with daily living activities, and transportation problems received assistance from the CIN's community health worker. This included qualifying for Medicaid, food stamps, Texas rent relief, and accessing local food banks. The worker also facilitated the approval of an in-home caregiver, leading to improved health and well-being for the patient.

Tangible Benefits of Care Management: Data-Driven Outcomes

The effectiveness of the CIN's care management interventions is supported by compelling data analysis of their ACO population:

• Patients successfully contacted after emergency department discharge showed an 8-percentage point lower utilization rate at 60 days compared to those not reached. Additionally, the percentage of patients attending a primary care visit within 14 days post-ED discharge was 9 percentage points higher for those successfully contacted.
• For patients discharged from inpatient settings, those successfully engaged by the care management team experienced a readmission rate of 7%, significantly lower than the 24% readmission rate for patients who were not reached.

Provider Collaboration: A Key to Success

The presenters emphasized the crucial role of providers in maximizing the impact of the CIN's care management program. Providers can contribute by:

• Identifying and referring suitable patients who could benefit from care management services, including those with complex chronic conditions, frequent hospitalizations or ED visits, medication adherence challenges, or social determinants of health needs.
• Referring patients directly to the CIN team through various channels like email, fax, or the provided Google Form, detailing the specific needs of the patient.
• Encouraging patients to participate in the program and answer calls from the CIN team. The CIN team identifies themselves as calling from the clinically integrated network in conjunction with the patient's provider.
• Responding promptly to care management inquiries received through the EHR, which may include requests to order screenings or address specific patient needs identified during their outreach.

Identifying CIN Patients and Referral Criteria

Referrals should focus on patients attributed to the CIN's value-based care contracts, including those with insurance plans such as Blue Cross (Commercial and Employee Health Plan), Traditional Medicare, and various Medicare Advantage plans (United America Group, Devoted, Cigna, and Blue Cross Blue Shield). Specific referral criteria also include patients with metabolic syndrome, poorly controlled A1C or blood pressure, heart failure, chronic urinary tract infections, COPD with a history of smoking, difficulty with medication adherence, or new diagnoses of diabetes, hypertension, or heart failure, as well as pre-diabetic patients. Efforts are underway to make it easier to identify CIN-attributed patients within the EHR.

Connecting with the CIN Care Management Team

Providers have multiple avenues for connecting with the CIN care management team:

• Google Form: An online form for submitting detailed referral information.
• Email: A dedicated email address for direct communication.
• Fax: A designated fax number for sending referrals.
• EHR Messaging: Utilizing the staff messaging feature in Epic or the messaging system in ECW.

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