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Cruising Health Policy &Its Impact on CaseManagementCheri Lattimer, R.N., BSNExecutive DirectorCase Management Society of America (CMSA)National Transitions of Care Coalition (NTOCC) and

TODAY’S HEALTHCAREENVIRONMENT“It's about better care: care that is safe, timely, effective,efficient, equitable and patient-centered.”¹“Applying integrated approaches to simultaneously improvecare, improve population health, and reduce costs per capita”²1. Source: 21.htm2. IHI Triple Aim Population ; ges/default.aspx

Health Care Needed ATransformationThe Current Process Is Not WorkingThe VisionCriticalBusinessIssues ?“To provide health care servicesFragmentation & Silo’s of Careand support to all consumersincluding health prevention, careGrowing Cost of Chronic Carecoordination, and appropriateAccess to Care Options (24x7)resource utilization. To promoteInconsistent Approachesquality of care to improve qualityof life for our citizens. ACollaborative Team Practicecommitment to processes thatWhole Person Care Approachfocus on education, consumerTransitions of Care Facilitationadvocacy, clinical optimization ofresources, patient safety, andTechnology Advancementstechnology to achieve superiorclinical and financial outcomesRegulatory/Gov’t Imperativeswith positive member and providersatisfaction”Premium Increases, MLRs andProvider PaymentNeedsOptimum HealthGaps

What Causes Poor Transitions ofCare & Often HospitalReadmissions?

Transition Issues Dramatically ImpactPatients & Their Family CaregiversPatient &CaregiverERICUOUTPATIENT: Home Home Care PCP Specialty Pharmacy Case Mgr. Caregiver HospiceIn-PatientSNFPatient &CaregiverALF

Transition Issues Dramatically ImpactPatients & Their Family Caregivers iliation HomeNODischargeCare PlanPatient & ICUHome CarePCPSpecialtyPharmacyCase Mgr.CaregiverHospiceNOCoordinatedCare PlanNO MedicationReconciliationNO PersonalMedicine ListIn-PatientSNFALFPatient &NOPersonalMedicine ListNOCare PlanCaregiverNOCare PlanNO MedicationReconciliationNO PersonalMedicine List

To Date We Have Not HadConsistent and Accepted TransitionTools Medication Reconciliation Elements, MedicationPatient List or Comprehensive Medication Review(CMR) Comprehensive Care Plan Health or Clinical Status Transition Summary Patient & Caregiver Tools & Resources Consistent Performance Measures That Apply to AllHealth Care Settings Accountability for Sending & Receiving Information

Our healthcare system operates in“silos” and information queues– incapable of reciprocal operation with other relatedmanagement systems & different departments of organizations Eric A. Coleman, MD, MPH

Continuum of Care & Spectrum ofServicesHow will you coordinate care beyond your service?EnrollmentHealth &WellnessSpecialistHome HealthSkilled & LTCAcute HospitalizationSub-acutePalliative CareRehabHealthHealthRespite CareDoctor's HospiceOP ngTreatmentManagementCareCenterLong TermAcuteHospital

Waves of Change Newmodels of health care delivery andreimbursement are quickly evolving Their success iscontingent on effectivecare coordination This in turn requiresinterprofessional andtransdisciplinarycollaboration

Health Care PolicyShaping Our Strategy17.6M Consumers GainedHealth Insurance129M Americans had preexisting conditionsincluding 19 M Children2.3M Americans gainedcoverage because theycould stay on theirparents health care plansuntil they were 26Out-of-pocket costseliminated for preventivecare 137M including 55MwomenCourtesy: years-later

Health Care Policy BringsInnovation, Creativity, &OpportunityNew Models of Health Care Delivery andReimbursement for SystemsPatient-Centered Medical Home (PCMH) Primary Care PracticesAccountable Care Organizations (ACOs)Integrated Health Delivery SystemsPopulation Health ManagementComprehensive Primary CareOutcomes-Based Reimbursement With Shared RiskValue Based Purchasing of Health Care Services

“We’ve medicalized so many things, but transitions are not medicalevents. It’s about the team working together. It’s a person event.”Jennifer Fels, RN, MS, Director, Southwestern Vermont MedicalCenter

To MakeIt All Work,We Must BuildCollaborativeTeams

A Different Level ofPhysician Engagement Todays Health System transformationcall for a different level of physicianengagement–organizing care around the patient–means working together in teams–Embracing the bigger mission of the organization“An engaged physician workforceis also linked to enhanced patientcare, greater efficiency and lowercost and improved quality andpatient ticle.dhtml?dcrPath /templatedata/HF fold-medsynergies

Creating the CollaborativeClinical TeamCollaboration amongphysicians, pharmacist,nurses, case managers,social workers, allied healthand supporting staff iscritical to achieving thegoals of the team, theorganization and changingthe way we deliverhealthcare todayhttp://www.crystalgraphics.com/

The Pharmacy Opportunity Leadership role in interdisciplinary efforts toestablish accurate and complete medication lists–Hospital admission and discharge–Any change in level of care Encourage community-based providers and healthcare systems to collaborate in medicationreconciliation efforts Educating patients and their caregivers on theirrole in retaining a current list of medications Assisting patients and caregivers through theprovision of a personal medication list Providing a Comprehensive Medication Review(CMR)ASHP. Medication Therapy and Patient Care: Organization and Delivery of Services–Positions.2009

Case/Care Manager Skills AreRequired For Success in TheseNew Models!Knowledge and experience withcare coordinationFocus on patient-centeredprocessesAssessment, planning,facilitation across carecontinuumKnowledge of population-basedcare management strategiesMeaningful communication withpatient, family, care teamCourtesy: www.CMSA.org – CMSA Standards of Practice 2010

Connecting the Case/Care Management CommunityContinuumThrough Team-Based “Hand-Overs”Case/CareMgrPatientNavigators &CommunityHealth WorkersPatient IENT: Home PCP Specialty Pharmacy Case Mgr. CaregiverIn-PatientSNFPatient &CaregiverManagedCare/CaseMgrALF

Integrated Behavioral & MedicalCollaborative Care Initial agreed upon clinical and functional goals First line evidence-based intervention through primary careclinician Psychiatrist-supervised systematic diagnostic assessmentwith baseline symptom documentation Comprehensive medication review, management andcoordination with the pharmacist and care team Treatment to target--care escalation based on follow-upfindings (psychiatrist involvement and treatment change) Symptom stabilization and return to primary care follow-up Integrated case management professionals Psychiatric consultation teamCase Management Society of America & Cartesian Solutions, Inc.

Innovative HealthInformation Technology Technology Enabled Transitions Using data analytics and the EHR to shift from event basedtreatment to continuity of care Approach to a preventive medicine comprehensive wellnessfocus Integrated and interactive transfer of information in a timely andeffective manner to providers, patients and family caregivers Make it more than a financial business move but a focus ofimproving the patient-experience and becoming the changeagent for a failing healthcare system

Don’t Forget The Patient & Their FamilyCaregiver – You are Their Care Team

Facilitating A Safe TransitionMedication reconciliation at dischargeTransitionalplanningComprehensive dischargeplanningPost-discharge support (e.g. Pharmacist call,home care.) in specific conditions is essential!

NTOCC’s Seven EssentialInterventions Categories12345Medications Management67Information TransferTransition PlanningPatient and Family Engagement / EducationHealth Care Providers EngagementFollow-Up CareShared Accountability across Providers e/

But we need to go further in recognizing that care coordination is acollaborative process supported by a multidisciplinary teams who mustcoordinate , communicate and transfer information with each other andtheir patients and family terventionsCommunity HealthCenterAssessmentCare PlanMotivational AdvocacyPatient &CaregiverHealthPromotionHealth PlanPharmacy HospiceEmployerHospitalSpecialist

Continued Support for CareCoordination & Transitions ofCare

Development of CareCoordination Measures AHRQ – Care Coordination Measurers Atlas NQF – Performance Measures for Care Coordination CMS – SOW for QIOs focus on Care Transitions & CareCoordination TJC – Core Performance Measures & Patient Safety Standard#8 Medication Reconciliation URAC – Incorporated Transition of Care in revised CMStandards – Case Management Measures NCQA – Complex Case Management Standards AMA – PCPI Transitions of Care ANA – Framework for Measuring Nurse’s Contribution to CareCoordination

Transitional Care CodesImplemented January 2013National Average 142.96National Average 231.11 99495: Transitional CareManagement Services withthe following requiredelements: 99496: Transitional CareManagement Services withthe following requiredelements: Communication (directcontact, telephone,electronic) with the patientand/or caregiver within 2business days of discharge Communication (directcontact, telephone,electronic) with the patientand/or caregiver within 2business days of discharge Medical decision making ofat least moderatecomplexity during theservice period Medical decision making ofat least high complexityduring the service period Face-to-face visit, within 7calendar days of discharge. Face-to-face visit, within 14calendar days of discharge

FY2015 Medicare Physician FeeSchedule (PFS) –Effective January 2015 – CPT Code 99490 Chronic Care Management Codes (CCM) Focus on paying for team based care Patients with two or more chronic conditions Separate fee for managing multiple conditions 20 minutes of clinical labor time & may be provided outside ofnormal business hours Billed no more frequently than once a month Care management services may be provided by social workers,nurses, case managers, pharmacist Services must be available 24X7 to patients and their familycaregivers Providers using the CCM code must have an electronic healthrecord or other health ml

Policy & Advocacy:Opportunities in 2016 Senate Innovation for Healthier AmericansOpportunity to include language around interoperability andinformation transfer with electronic health records SenateChronic Care Working Group Opportunity to highlight the importance of transitional care inchronic care management Emphasis on Collaborative Teams and integration with BehavioralHealth CMS Physician Payment RuleImproving the current chronic care management code and additionof more care coordination tools CMS’s MACRA implementationIncluding transitional care in the calculation of the MACRA score CMS’sIMPACT Act implementation CMS’sRevised Discharge Planning

What Can We Do? Focus on patient-centered care Continuous quality improvement Effective Team practice with financialand performance measure alignmentincluding patient measures Team leadership and communication Cultural sensitivity and community focus Integrating behavioral health care withprimary care

Case Manager’s Must“Advertise”Their RoleDescribe requisite clinical expertiseDefine provision of whole patient support and advocacySupport towards behavior change & adherenceValidate outcomes of case managementRepresent the clinical valueBelieve in the value of what you do32

Don Berwick on Partnershipsfor Patients“No Single entity can improve carefor millions of hospital patients alone.Through strong partnerships atnational, regional, state and locallevels – including the public sectorand some of the nation’s largestcompanies – we are supporting thehospital community to significantlyreduce harm to patients” April, 2011