Right Intervention, Right Time: Managing Medically Complex ...

Right Intervention, Right Time: Managing Medically Complex Members

2

Medical labeling tends to oversimplify patient

health status, particularly in the case

of medically complex members. The

disproportionate impact of the high-risk,

high-cost population underscores the

importance of using strategic, specialized

care management to control the unsustainable costs attached to

treating chronic diseases — and their debilitating impact on

quality of life.

As an example, congestive heart failure is the major disease category

for “John” in Figure 1. His medical record, however, also indicates

atrial fibrillation, cardiac ischemia, implanted devices, diabetes

resulting in chronic kidney disease, and a history of colon cancer that

must be monitored. John lives alone, takes 13 medications, utilizes

12 providers, and will have 30 to 40 outpatient visits next year.

Multiple hospital admissions and readmissions also are likely.

John is part of a small portion of the total insured population —

typically 5 to 10 percent — who account for 30 to 50 percent

of a health plan’s medical costs1. He represents the segment of

high-risk and highly complex members whose predictable future

care costs justify implementing provider-led in-home care to

improve outcomes, enhance quality of life and contain

medical costs.

Expert presenters

Dr. Gary Dana, Medical Director, CarePlus, Optum

Dr. Scott Howell, MD, Sr. National Medical Director, Optum

John, 83-Year-Old Male • Congestive heart failure

• No active complaints• When questioned, admits to worsening cough

MEDICAL HISTORY• Systolic CHF from CAD/ischemia • Atrial fibrillation — chronic• 3V CABG• Three stents/PTCA• Aortic stenosis• IACD implanted• Diabetes mellitus with multiple manifestations• Stage 4 renal disease• Hypertension• Hyperlipidemia • Gout • Osteoarthritis • DJD with knee/hip replacement• H/O old MI • H/O colon cancer • H/O SCCA and BCCA skin • Hearing deficit• CVA with vascular dementia • Left leg weakness• Glaucoma• H/O left fem artery stent• Multiple ER visits, admissions and outpatient visits annually

MEDICATIONS

• Coreg

• Warfarin

• Proscar

• Lisinopril

• Furosemide

• KCL

PROVIDERS

• Primary Care

• Cardiologist

• Ophthalmologist

• Urologist

• Endocrinologist

• Orthopedist

• Levimere Insulin

• Metformin

• Norvasc 2.5mg

• Flomax

• Crestor

• Timoptic Opth ii

• Colace

• Gastroenterologist

• Dermatologist

• Oncologist

• General Surgeon

• Vascular Surgeon

• Cardiothoracic Surgeon

DAILY LIVING, SOCIALAND FAMILY HISTORY

• Lives alone.

• Uses walker.

• Bathes independently.

• Drives.

• Doesn’t cook, eats cold meals. Neighbors bring 25% meals cooked, and assist with laundry.

• Divorced. Widowed to second wife. One child, son, lives more than 1,000 miles away. Last visit seven years ago; calls weekly.

• Quit smoking 15 years ago.

• Two glasses of bourbon daily.

• Mother and father with CHF, CAD, DM, dementia last 10 years of life. Father deceased at 88; mother at 84.

Patients

• Avoid ER visits, inpatient admissions.• Reduce medications, unnecessary procedures.• Improve disease state understanding and self care.• Create closer relationships with providers.• Address advanced illness care goals including advance (directives).

• Improve patient understanding and outcomes.• Deliver timely, high-quality information.• Assistance in managing di�cult, complex patients.• Deliver preventive maintenance care, including disease education and intervention for clinical, functional, environmental, psychosocial and cultural triggers.

• Improve quality.• Lower costs for members.

Providers

HealthPlans

Heart Failure PalliativeCare/Hospice

COPDExacerbation

Urinary TractInfection

History and physical focusing on weight gain, fluid status and cardiopulmonary examination

Evaluation of current medications, adjustment as needed and provision of parenteral diuretics

Laboratory or imaging studies such as portable Chest X-ray (CXR) or blood tests

Coordination and follow-up with Primary Care Provider (PCP), nurse care manager

Primary Visiting Provider (PVP) - follow-up visits

History and physical focusing on vital signs, oxygenation status (pulse ox) andcardiopulmonary examination

Evaluation and adjustment of current medications; possible initiation of steroids

Laboratory studies such as portable CXR

Coordination and follow-up with PCP, nurse case manager

PVP follow-up visit

History and physical

Laboratory and evaluation including urinalysis and urine culture

Prescribing of oral or parenteral antibiotics

PCP notification, nurse care manager follow-up calls

PVP follow-up visit if indicated

Advance directives in place within 90 days of program enrollment

Review and adjust, or prescribe palliative care medications

Initiate hospice referral

Coordinate with PCP, nurse care manager

In-depth discussion with hospice team to determine next steps and responsible parties for ongoing management

Figure 1Medical information for a high-risk and highly complex member

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The issue is not that a medically complex patient like John lacks

access to excellent doctors or committed caregivers. The needs of

this segment simply require heightened forms of care, collaboration

and coordination — along with specialized infrastructure and

systems — tailored to disease processes that place members in

categories like chronically high-risk, catastrophic and terminal.

Health plans use advanced analytics, predictive modeling and

referrals from primary care physicians, case managers or discharge

planners to identify and target members within their populations

who will benefit from a medically complex care delivery and

management strategy. One key selection parameter: more than

two acute admissions and two chronic conditions, or more than

eight chronic conditions.

Typical targeted disease processes include:

• COPD/chronic respiratory

• CHF/high-cost cardiac

• Frailty (end of life, MS, ALS)

• Social risk: homebound, socially isolated, transportation issues,

financial risk

• Comorbid conditions causing overutilization (anxiety,

depression, dementia)

Among members correctly identified for inclusion in a medically

complex care delivery and management program, approximately

35 percent will expire, while 50 percent slowly progress and worsen,

and 15 percent regress to the mean and can be discharged from

the program.

Accordingly, a complex medical delivery and management initiative

seeks to achieve outcomes that reflect the goals specific to complex

patients, their providers and health plans.




MEDICATIONS

• Coreg

• Warfarin

• Proscar

• Lisinopril

• Furosemide

• KCL

PROVIDERS

• Primary Care

• Cardiologist

• Ophthalmologist

• Urologist

• Endocrinologist

• Orthopedist


• Metformin

• Norvasc 2.5mg

• Flomax

• Crestor


• Colace


• Dermatologist

• Oncologist

• General Surgeon




• Lives alone.

• Uses walker.


• Drives.






Patients




Providers

HealthPlans


COPDExacerbation











PVP follow-up visit











One of the greatest drivers in avoidable admissions

and unnecessary care is the lack of clarity regarding

a patient’s disease progression and personal

values regarding quality of life.

— Dr. Gary Dana Medical Director, CarePlus, Optum

Figure 2Medical information for a high-risk and highly complex member

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One of the greatest drivers in avoidable admissions and unnecessary

care is the lack of clarity regarding a patient’s disease progression and

personal values regarding quality of life. This underdeveloped “health

literacy” on the part of all stakeholders — patients, caregivers

and family — causes inappropriate utilization, increases cost and

reduces the member’s quality of life. As a result, the core principle in

improving care for the medically complex is delivering the right care,

to the right patients, at the right time and in the right setting, often

their personal residence.

Member-centric and provider-driven health care solutions designed

for complex, high-risk populations have reduced inpatient admissions

by 40 to 50 percent while providing an average savings of $1,468

per member per month in acute care admissions.2 Successful

programs emphasize several elements critical to improving medically

complex outcomes:

• Selection of evidence-based practice guidelines, plus services

designed to facilitate patient disease management and

adherence to treatment plans.

• Regular, in-home visits to treat members where they live and

reduce exacerbations.

• High intensity through a team approach to education, telephonic

monitoring, in-home provider oversight and direct primary care/

specialist involvement.

• Frequent patient encounters with treatment team members.

• 24/7/365 patient access to care.

• Advanced data collection, analytics and reporting, including

routine reporting and feedback to providers.

• Ongoing adjustment and alignment that responds to data,

measured outcomes and evidence-based care gaps.

• Graduatingmemberswhoregresstothemean.

As an example, under the Optum CarePlus program, clinicians visit

the medically complex patient where he or she lives whether that is

a skilled nursing facility, an assisted living complex or the member’s

private residence.

An initial comprehensive assessment drives care planning and

hierarchical condition coding (HCC). Next, the Optum provider,

care manager and primary care physician (PCP) develop the care

management plan. Scheduled visits by the Optum CarePlus in-home

providers reflect the member’s acuity. On average, care teams visit

members 1.0 to 1.2 scheduled times per month. Unscheduled visits

occur as needed to keep members out of the hospital. Telephonic

care management and coordination are also key to symptom

monitoring, trigger management and member/family education.

Member-centric and provider-driven health care solutions designed for complex,

high-risk populations have reduced inpatient admissions by 40 to 50 percent

— Dr. Gary Dana Medical Director, CarePlus, Optum

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MEDICATIONS

• Coreg

• Warfarin

• Proscar

• Lisinopril

• Furosemide

• KCL

PROVIDERS

• Primary Care

• Cardiologist

• Ophthalmologist

• Urologist

• Endocrinologist

• Orthopedist


• Metformin

• Norvasc 2.5mg

• Flomax

• Crestor


• Colace


• Dermatologist

• Oncologist

• General Surgeon




• Lives alone.

• Uses walker.


• Drives.






Patients




Providers

HealthPlans


COPDExacerbation











PVP follow-up visit











The above scenarios (see Figure 3) demonstrate how care team

in-home interventions support medically complex members who are

facing disease processes, dealing with illnesses, or making

end-of-life decisions.

Taking a holistic approach to care extends beyond managing

chronic conditions. The care plan also includes a focus on relevant

preventative services and guideline-driven treatment (e.g., flu shot,

pneumonia vaccination) to avoid unnecessary hospitalization.

Historically, the health care industry has taken a disease-by-disease

approach to chronic illness treatment — identifying and managing

clinical interventions tied to particular clinical situations. Population-

based health management of complex members — using a program

that modifies utilization and curtails unnecessary costs — can

improve outcomes and enable a better quality of life, while lowering

medical costs.

Figure 3In-home interventions supporting medically complex members

Want to learn more?

Visit optum.com

or call 1-800-765-6807.

How Optum can helpOptum partners with health plans to provide in-home, provider-led clinical care and

care management to improve quality while reducing unnecessary health care costs, for

the most expensive, medically complex population. Our solutions provide:

• Healthcaredesignedspecificallyforhigh-riskmembers

• Improvedqualityandlowerhealthcarecosts

• Preventedavoidablehospitalizations

1 Stanton MW. The High Concentration of U.S. Health Care Expenditures. Research in Action, Issue 19. AHRQ Publication No. 06-0060, June

2006. Agency for Healthcare Research and Quality, Rockville, MD. ahrq.gov/research/ria19/expendria.htm

2 Optum CarePlus Outcomes Study on Acute Admissions, based on claims savings for the large-patient pool programs in Five Markets. 2011. Data compiled by Optum Data Analytics.

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