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Funded by the John A. Hartford foundation Initial development at Intermountain Healthcare. Addressing Problems in Care Coordination: Experience of Care Management Plus. Presented by: David A. Dorr, for the Care Management Plus team. Date: Sept 27 th , 2007. OHSU David Dorr, MD, MS
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John A. Hartford foundation
Initial development at
Presented by: David A. Dorr, for the Care Management Plus team
Date: Sept 27th, 2007
a 75-year-old woman
mild congestive heart failure,
recently diagnosed dementia.
And Out in the hall:
How can Dr. Smith and the primary care team handle these issues?
In 15 primary care clinics at Intermountain Healthcare
Larger infrastructure: Electronic Health Record, quality focus
Adapted from Closing the Quality Gap: Volume 7 Care Coordination
Care Managers act as a guide, coordinator, and helper to facilitate patients receiving coordinated, sensitive care.
CMP: Tracking database creates reports
Clinic: works with payers to change reimbursement
CMP: embeds certain disease protocols
Clinic: consensus about approach and maintenance
Collaborative care planning
CMP:Care manager works with patient, family, and catalyzes plan
Clinic: Refers appropriate patients for intervention.
Health Information technology
CMP: Provides pop. management and flexible reminders
Clinic: Creates patient summary
CMP: assessment and structure part of training, protocols
Clinic: has technique for less intensive structured visits.
CMP: team approach part of assessment, CM training
Clinic: must commit to measurement and change
Preventive care summary
Wilcox, Proc of AMIA Symp, 2005
Organized by illness
Dorr, HSR, 2005
Dorr, AcademyHealth, 2006
Dorr, AJMC, 2007; Dorr, AcademyHealth, 2007
Care Management Plus has similar issues across populations: specific benefits are tied to specific populations.
From the Medicare Coordination of Care Demos, 2 year Summary Report, March 21st, 2007; available from cms.gov
By program description
By what a patient actually receives (‘dosage’)
Dorr, JGIM, 2007
David Dorr (PI)
Kelli Radican (Project manager)
or visit www.caremanagementplus.org
< 1% of population
Care Management Plus
3-5% of population
50% of pop.
Different drugs = breadth
Different services = breadth
One pill po q6hrs x 7 days
Education 1 hr
Every 3 weeks x 6 mos
Dorr, JGIM, 2007; Adapted from work by Huber et al
8% more productive
Dorr, AJMC, 2007
(email, phone call,
(In person visit or
(fill out as much as possible)
-Evaluation (success of
Program, barriers to
-Hire a Care Manager
-Sign a contract
-Register for training