Soyal Momin, MS, MBA Sylvia Sherrill, RN, MS Lelis Welch, RNC, CCM Judy Slagle, RN, MPA
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Transcript of Soyal Momin, MS, MBA Sylvia Sherrill, RN, MS Lelis Welch, RNC, CCM Judy Slagle, RN, MPA
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
• Historical View: Case Management at BCBST
• Concept: Next Generation Care Management (NGCM)
• Implementation and Evaluation of NGCM
• Enhancements/Improving Process Efficiency
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
Base Year and Year-2 Risk Profile of Members Referred to Case ManagementCommercial Line of Business
2,1201,926
2,087
4,124
6,170
4,2444,117
2,683
4,543
840
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
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)
Current methodology of identifying members for case management (Trigger List) seems to be working
Year-2 Detailed Risk Profile of Members NOT Referred to Case Management Commercial Line of Business
907
303
88
27 24
872
0
100
200
300
400
500
600
700
800
900
1000
$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)
Light Touch
Year-2 Case Mix Index of Members NOT Referred to Case ManagementCommercial Line of Business
0.24
1.13
17.04
6.87
3.23
0
2
4
6
8
10
12
14
16
18
20
22
24
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)
Next Generation Care Management: One size does not fit all
Segmentation % Members % Cost
Healthy Group 40% 0%
Worried Well 52% 45%
Chronically Ill 7% 30%
Catastrophic 1% 25%
Next Generation Care Management:Triage Guidelines
Segmentation DxCG Risk Level
Management Type
Healthy Group; Worried Well
1 – 2
Lifestyle/Health
Counseling
Chronically Ill 3 – 4 Refer to Care Coordination Unit
Catastrophic
5
Refer to Catastrophic Case Management
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
Care Coordinationfor Chronically Ill
• Telephonic coordination with members and their providers
• Ensures appropriate treatments and pharmaceuticals
• Six different programs included in this model
Care Coordination Programs
• Pharmacy Care Management
• Emergency Room (ER) Visits Management
• Centers of Excellence (COE)
• Transition of Care
• Condition Specific Care Coordination
• Disease Management
Care Coordination Program # 1
• Pharmacy Care Management for Specialty Populations
– Pharmacy Case Management Programs:• Hepatitis C• AMI-Beta Blocker• Migraine• Polypharmacy
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
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
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
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
Care Coordination Program # 6
• Disease Management programs– Carved out to LifeMasters Supported
SelfCare, Inc.• CAD• CHF• COPD• Asthma• Diabetes
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
Next Generation Care Management:Implementation
• MCSource
• Predictive Modeling Using– DCG– ETG
• Rolling 12 Months DCG Explanation Prospective Model
• ETG Cost to Supplement DCG Prediction
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
• 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
Example of Predictive Modeling
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
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
Next Generation Care Management:Program Enhancements
• Developed SQL database containing DCG and ETG information
– Improved processes/workflow– Easy and continuous access– Better documentation
Next Generation Care Management:Program Enhancements
Next Generation Care Management:Program Enhancements
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