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Care Management for Children with Chronic Conditions:. Health Plan vs. Primary Care June 24, 2004. Project Partners. Maternal Child Health Bureau Study period: July 1, 2002 – June 30, 2006 Children’s Hospital & Regional Medical Center (CHRMC) – Center for Children with Special Needs

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Care management for children with chronic conditions

Care Management for Children with Chronic Conditions:

Health Plan vs. Primary Care

June 24, 2004


Project partners
Project Partners

  • Maternal Child Health Bureau

    • Study period: July 1, 2002 – June 30, 2006

  • Children’s Hospital & Regional Medical Center (CHRMC) – Center for Children with Special Needs

    • John Neff, MD

    • Virginia Sharp, MA

    • Jean Popalisky, RN, MN

  • Regence BlueShield

    • Tracy Fitzgibbon, RN

    • Kristin Myers


Project goal objectives
Project Goal & Objectives

  • Develop, implement and evaluate a cost effective quality care management program for children with chronic conditions (CCC)

    • Identify and classify CCC for case management using Clinical Risk Groups (CRG) software (health plan).

    • Develop a range of reimbursement strategies case management in other settings (primary care).


Health plan case management
Health Plan Case Management

  • Implementation Elements:

    • Identifying CCC using Clinical Risk Groups software

    • Developing tools

    • Contacting members

    • Project management

      • Difficulty defining meaningful outcome measures


Health plan case management identification summary
Health Plan: Case Management Identification Summary

  • 315 CCC identified for CM screening

    • CRGs + utilization filters

    • 72 eliminated

    • 120 unable to contact

  • 123 CCC contacted

    • 87 members screened using the 22-item CM screening tool

      • 46 members (53%) opened case management



Health plan cost savings
Health Plan Cost Savings

  • $291,295

    • 1.5 FTE Nurse Case Managers

    • 19 month timeline

    • Regence cost-savings methodology


Health plan cm screening tool analysis
Health Plan: CM Screening Tool Analysis

  • Five CM screening tool questions used to identify need for case management:

    • Areas of concern:

      • Access/Organization of services (3 questions)

      • Out-of-pocket expenses (1 question)

      • Family stress (1 question)

    • 22-items could be reduced to 5 items


Health plan case management summary
Health Plan: Case Management Summary

  • Predictive Modeling:

    • CRGs + utilization filters + screening = “actionable” children with chronic conditions

  • Engagement rate = 37% of members contacted

  • Interventions:

    • member education

    • needs assessment

    • community resource coordination

    • benefit management

  • Value:

    • Cost savings of $291,295 over 19 months

    • Members report case management impact


Primary care case management
Primary Care Case Management

  • Implementation Elements:

    • Identify CCC for case management

    • Develop tools

    • Define outcome measures meaningful to the health plan


Primary care tracking activities
Primary Care: Tracking Activities

  • All clinic staff involved in tracking

  • Information collected:

    • Type of intervention (existing CPT codes)

    • Duration of intervention

    • Provider type performing intervention

    • Direct outcome of intervention

    • Avoided outcome as result of intervention

  • Tracking forms faxed to health plan at regular intervals for entry into database


Primary care tracking results
Primary Care: Tracking Results

  • Clinic #1

    • 454 tracking forms on 83 CCC

    • Engagement rate = 83%

  • Clinic #2

    • 813 tracking forms on 84 CCC

    • Engagement rate = 84%


Primary care care planning activities
Primary Care: Care Planning Activities

  • MD’s to do WRITTEN care plan

    • Short-term goals: 3 – 6 months

    • Include strategies for reaching goals

    • Include input from families

    • Revise when indicated

    • Document progress toward goals

  • Care plans faxed to health plan when completed


Primary care written care planning results
Primary Care: Written Care Planning Results

  • Clinic #1

    • Submitted 38 care plans

      • Family input included on 16 care plans

  • Clinic #2

    • Submitted 5 care plans

      • Family input included on 3 care plans



Primary care cost savings
Primary Care Cost Savings

  • $44,434 Avoided Out-patient services

    • 241 avoided ER visits @ $146/visit

    • 136 avoided Pediatric clinic visits @ $68/visit

  • 32 Avoided In-patient episodes


Primary care case management summary
Primary Care: Case Management Summary

  • Predictive Modeling:

    • CRGs + utilization filter + staff selection

  • Engagement rate = 83.5%

  • Interventions:

    • family support activities

    • condition management activities

  • Cost savings:

    • avoided services



Key learning points
Key Learning Points

  • Health plan case management activities and primary care case management activities are unique

  • Primary care providers identify, contact, and engage patients more efficiently and effectively than health plan

  • Both settings produce short-term cost savings from different sources


Recommendations
Recommendations

  • Comprehensive care coordination for the families of CCC should integrate the unique case management activities from the health plan and primary care into a single, cooperative effort


Contact information

John Neff, M.D. Jean Popalisky, MN

1100 Olive Way, Suite 500 1100 Olive Way, Suite 500

Seattle, WA 98101 Seattle, WA 98101

Phone: 206-987-5275 Phone: 206-987-5326

Fax: 206-987-5741 Fax: 206-987-5741

Email: [email protected] Email: [email protected]

Tracy Fitzgibbon, RN

333 Gilkey Road, MS: BU270

Burlington, WA 98233

Phone: 360-755-2755

Fax: 360-755-4576

Email: [email protected]

Contact Information:


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