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Application of Predictive Modeling to Identify, Stratify, and Triage Members in Care Management Programs: A Health Plan Case Study. Soyal Momin, MS, MBA Sylvia Sherrill, RN, MS Lelis Welch, RNC, CCM Judy Slagle, RN, MPA Terence Shea, PharmD Steven Coulter, MD. Outline.

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slide1

Application of Predictive Modeling to Identify, Stratify, and Triage Members in Care Management Programs: A Health Plan Case Study

Soyal Momin, MS, MBA

Sylvia Sherrill, RN, MS

Lelis Welch, RNC, CCM

Judy Slagle, RN, MPA

Terence Shea, PharmD

Steven Coulter, MD

slide2

Outline

  • Historical View: Case Management at BCBST
  • Concept: Next Generation Care Management (NGCM)
  • Implementation and Evaluation of NGCM
  • Enhancements/Improving Process Efficiency
slide3

History

  • Identifying Members for Case Management
    • Referrals from
      • Internal Sources
      • External Sources
      • An internally developed ICD9 Trigger list
        • The ICD9 Trigger list included Asthma, Diabetes, High Risk OB, AIDs, Cancer, CHF, COPD etc
  • Case managers workload
    • 103/CM/Month
  • DCG implementation validation revealed missed opportunities for case management
slide4

Base Year and Year-2 Risk Profile of Members Referred to Case Management

Commercial Line of Business

7,000

6,170

6,000

Current methodology of identifying members for case

management (Trigger List) seems to be working

5,000

4,543

4,244

4,124

4,117

4,000

3,000

2,683

2,120

2,087

1,926

2,000

840

1,000

0

Risk Level 1 ($0-1K)

Risk Level 2 ($1K-$5K)

Risk Level 3 ($5K-$10K)

Risk Level 4 ($10K-$25K)

Risk Level 5 (>25K)

Base Year (04/01-03/02)

Year-2 (04/02-03/03)

slide5

Year-2 Detailed Risk Profile of Members NOT Referred to Case

Management

Commercial Line of Business

1000

872

907

900

800

700

600

500

Light Touch

400

303

300

200

88

100

27

24

0

$25,000-$30,000

$30,000-$40,000

$40,000-$50,000

$50,000-$60,000

$60,000-$70,000

$70,000-$9,999,999

Year-2 (04/02-03/03)

slide6

Year-2 Case Mix Index of Members NOT Referred to Case Management

Commercial Line of Business

24

22

20

17.04

18

16

14

12

10

6.87

8

6

3.23

4

1.13

2

0.24

0

Risk Level 1 ($0-1K)

Risk Level 2 ($1K-$5K)

Risk Level 3 ($5K-$10K)

Risk Level 4 ($10K-$25K)

Risk Level 5 (>25K)

Year-2 (04/02-03/03)

slide9

Lifestyle/Health Counseling for Healthy and Worried Well:

  • Information on disease/condition
    • Web resources
    • Pamphlets
    • Telephonic health library
  • Encouragement to take more active role/accountability
slide10

Care Coordinationfor Chronically Ill

  • Telephonic coordination with members and their providers
  • Ensures appropriate treatments and pharmaceuticals
  • Six different programs included in this model
slide11

Care Coordination Programs

  • Pharmacy Care Management
  • Emergency Room (ER) Visits Management
  • Centers of Excellence (COE)
  • Transition of Care
  • Condition Specific Care Coordination
  • Disease Management
slide12

Care Coordination Program # 1

  • Pharmacy Care Management for Specialty Populations
    • Pharmacy Case Management Programs:
      • Hepatitis C
      • AMI-Beta Blocker
      • Migraine
      • Polypharmacy
slide13

Care Coordination Program # 2

  • Emergency Room (ER) Visits Management Program
    • Monthly report identify ER “frequent flyers”
    • Contacted by a nurse with psychiatric

training

    • Clinical counseling and guidance
    • Discuss options of care with goal to reduce

ER Visits

slide14

Care Coordination Program # 3

  • Centers of Excellence (COE) Program
    • Identify providers based on utilization and quality of care indicators (CQI using ETGs) and input from regional staff
      • Asthma
      • Diabetes
      • CHF
      • COPD
      • CAD
    • Can be used to refer/steer members to providers considered COE
slide15

Care Coordination Program # 4

  • Transition of Care Program
    • Formerly known as discharge planning, make sure members are in appropriate setting for treatment
    • Assist facility, physician, and member with transition
      • Lower ALOS for per diem admissions
      • Better outcome for DRG admissions
      • Reduce re-admissions
      • Smooth transition of care
slide16

Care Coordination Program # 5

  • Condition Specific Care Coordination
    • Assess and advise program with one time follow-up
      • CAD
      • CHF
      • COPD
      • Asthma
      • Diabetes
      • Hypertension
      • GI disorders
slide17

Care Coordination Program # 6

  • Disease Management programs
    • Carved out to LifeMasters Supported SelfCare, Inc.
      • CAD
      • CHF
      • COPD
      • Asthma
      • Diabetes
slide18

Next Generation Care Management:Catastrophic Case Management

  • Directed to members with
    • Terminal illness
    • Major trauma
    • Cognitive/physical disability
    • High-risk condition
    • Complicated care needs
  • Systematic process of assessing, planning, coordinating, implementing, and evaluation of care
slide19

Next Generation Care Management:Implementation

  • MCSource
  • Predictive Modeling Using
    • DCG
    • ETG
  • Rolling 12 Months DCG Explanation Prospective Model
  • ETG Cost to Supplement DCG Prediction
slide20

Better Understanding of Predictive Modeling

  • Do Predictive models work like a crystal ball?
  • Models do not predict a disease (ICD-9)
  • Helps quantify a disease
  • Provides early warning for certain diseases with high future resource requirements
slide21

Example of Predictive Modeling

  • Clinical Profile of Member XYZ
      • Diagnosed with CHF (Date: 10/01/2002)
      • Diagnosed with Diabetes (Date: 10/30/2002)
  • Our traditional methods might refer this member for Case Management (CM) some time in 2003
  • DCG/ETG approach will identify this member for CM in 11/2002 or 12/2002
slide22

Next Generation Care Management:Program Evaluation

  • Medication cost avoidance and members’ compliance
      • Hepatitis C ($1.5M/Year)
      • Beta Blockers post AMI ($1.3M/Year)
      • Migraine care management
  • Member and provider satisfaction
  • CM staff turnover
  • Triaging efficiencies
slide23

Next Generation Care Management:Program Evaluation

Total Number of Members

(04/03 - 03/04)

  • Lifestyle/Health Counseling - 1,555
  • Care Coordination - 7,229
  • Catastrophic Case Mgmt. - 13,622
  • Number of Cases/CM/Month=76/CM/Month
slide24

Next Generation Care Management:Program Enhancements

  • Developed SQL database containing DCG and ETG information
    • Improved processes/workflow
    • Easy and continuous access
    • Better documentation
slide27

Conclusions

  • More scientific/standardized approach
  • Able to touch more lives efficiently
  • Well accepted by our case managers
  • NGCM has helped
    • streamline our processes
    • better manage case managers case load
  • Provide “Peace of Mind” to our members and clients