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Right Intervention, Right Time: Managing Medically Complex Members Expert Presenters

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Right Intervention, Right Time: Managing Medically Complex Members Expert Presenters Right Intervention, Right Time: Managing Medically Complex Members Expert presenters Dr. Gary Dana, Medical Director, CarePlus, Optum Dr. Scott Howell, MD, Sr. National Medical Director, Optum edical labeling tends to oversimplify patient resulting in chronic kidney disease, and a history of colon cancer that health status, particularly in the case must be monitored. John lives alone, takes 13 medications, utilizes of medically complex members. The 12 providers, and will have 30 to 40 outpatient visits next year. disproportionate impact of the high-risk, Multiple hospital admissions and readmissions also are likely. high-cost population underscores the M John is part of a small portion of the total insured population — importance of using strategic, specialized typically 5 to 10 percent — who account for 30 to 50 percent care management to control the unsustainable costs attached to of a health plan’s medical costs1. He represents the segment of treating chronic diseases — and their debilitating impact on high-risk and highly complex members whose predictable future quality of life. care costs justify implementing provider-led in-home care to As an example, congestive heart failure is the major disease category improve outcomes, enhance quality of life and contain for “John” in Figure 1. His medical record, however, also indicates medical costs. atrial fibrillation, cardiac ischemia, implanted devices, diabetes Figure 1 Medical information for a high-risk and highly complex member John, 83-Year-Old Male • Congestive heart failure • No active complaints COPD Urinary Tract Palliative • Avoid ER visits, inpatient admissions. Heart Failure • When questioned, admits to worsening cough Exacerbation Infection Care/Hospice • Reduce medications, unnecessary procedures. • Improve disease state understanding and self care. MEDICAL HISTORY MEDICATIONS DAILY LIVING, SOCIAL Patients History and physical History and physical History and physical Advance directives in • Systolic CHF from CAD/ischemia AND FAMILY HISTORY • Create closer relationships with providers. focusing on weight focusing on vital signs, place within 90 days of • Coreg • Levimere Insulin Laboratory and • Atrial fibrillation — chronic • Address advanced illness care goals including advance (directives). gain, fluid status and oxygenation status program enrollment • Warfarin • Metformin • Lives alone. cardiopulmonary (pulse ox) and evaluation including • 3V CABG urinalysis and urine Review and adjust, or • Proscar • Norvasc 2.5mg examination cardiopulmonary • Three stents/PTCA • Uses walker. • Improve patient understanding and outcomes. examination culture prescribe palliative care • Aortic stenosis • Lisinopril • Flomax Evaluation of current medications • IACD implanted • Bathes independently. • Deliver timely, high-quality information. Prescribing of oral or • Furosemide • Crestor medications, adjustment Evaluation and • Diabetes mellitus with multiple Providers • Assistance in managing dicult, complex patients. as needed and adjustment of current parenteral antibiotics Initiate hospice referral • Timoptic Opth ii • Drives. manifestations • KCL • Deliver preventive maintenance care, including disease education and intervention provision of parenteral medications; possible • Stage 4 renal disease • Colace • Doesn’t cook, eats cold meals. diuretics initiation of steroids PCP notification, nurse Coordinate with PCP, • Hypertension Neighbors bring 25% meals cooked, for clinical, functional, environmental, psychosocial and cultural triggers. care manager follow-up nurse care manager Laboratory or imaging Laboratory studies such calls • Hyperlipidemia and assist with laundry. In-depth discussion • Gout PROVIDERS studies such as portable as portable CXR • Divorced. Widowed to second wife. Chest X-ray (CXR) or PVP follow-up visit if with hospice team to • Osteoarthritis • Primary Care • Gastroenterologist blood tests Coordination and indicated determine next steps • DJD with knee/hip replacement One child, son, lives more than Health • Improve quality. • Dermatologist follow-up with PCP, and responsible parties • H/O old MI • Cardiologist 1,000 miles away. Last visit seven • Lower costs for members. Coordination and nurse case manager for ongoing management • Oncologist Plans • H/O colon cancer • Ophthalmologist years ago; calls weekly. follow-up with Primary • H/O SCCA and BCCA skin • General Surgeon Care Provider (PCP), PVP follow-up visit • Quit smoking 15 years ago. nurse care manager • Hearing deficit • Urologist • Vascular Surgeon • CVA with vascular dementia • Two glasses of bourbon daily. Primary Visiting • Left leg weakness • Endocrinologist • Cardiothoracic • Mother and father with CHF, CAD, Provider (PVP) - • Glaucoma Surgeon • Orthopedist DM, dementia last 10 years of life. follow-up visits • H/O left fem artery stent • Multiple ER visits, admissions and Father deceased at 88; mother at 84. outpatient visits annually 2 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 One of the greatest drivers in avoidable admissions systems — tailored to disease processes that place members in and unnecessary care is the lack of clarity regarding categories like chronically high-risk, catastrophic and terminal. a patient’s disease progression and personal values regarding quality of life. Health plans use advanced analytics, predictive modeling and referrals from primary care physicians, case managers or discharge — Dr. Gary Dana Medical Director, CarePlus, Optum 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. Among members correctly identified for inclusion in a medically Typical targeted disease processes include: complex care delivery and management program, approximately • COPD/chronic respiratory 35 percent will expire, while 50 percent slowly progress and worsen, and 15 percent regress to the mean and can be discharged from • CHF/high-cost cardiac the program. • Frailty (end of life, MS, ALS) Accordingly, a complex medical delivery and management initiative • Social risk: homebound, socially isolated, transportation issues, financial risk seeks to achieve outcomes that reflect the goals specific to complex patients, their providers and health plans. • Comorbid conditions causing overutilization (anxiety, depression, dementia) Figure 2 John, 83-Year-Old Male Medical information for a high-risk and highly complex member • Congestive heart failure • No active complaints COPD Urinary Tract Palliative • Avoid ER visits, inpatient admissions. Heart Failure • When questioned, admits to worsening cough Exacerbation Infection Care/Hospice • Reduce medications, unnecessary procedures. • Improve disease state understanding and self care. MEDICAL HISTORY MEDICATIONS DAILY LIVING, SOCIAL Patients History and physical History and physical History and physical Advance directives in • Systolic CHF from CAD/ischemia AND FAMILY HISTORY • Create closer relationships with providers. focusing on weight focusing on vital signs, place within 90 days of • Coreg • Levimere Insulin Laboratory and • Atrial fibrillation — chronic • Address advanced illness care goals including advance (directives). gain, fluid status and oxygenation status program enrollment • Warfarin • Metformin • Lives alone. cardiopulmonary (pulse ox) and evaluation including • 3V CABG urinalysis and urine Review and adjust, or • Proscar • Norvasc 2.5mg examination cardiopulmonary • Three stents/PTCA • Uses walker. • Improve patient understanding and outcomes. examination culture prescribe palliative care • Aortic stenosis • Lisinopril • Flomax Evaluation of current medications • IACD implanted • Bathes independently. • Deliver timely, high-quality information. Prescribing of oral or • Furosemide • Crestor medications, adjustment Evaluation and • Diabetes mellitus with multiple Providers • Assistance in managing dicult, complex patients. as needed and adjustment of current parenteral antibiotics Initiate hospice referral • Timoptic Opth ii • Drives. manifestations • KCL • Deliver preventive maintenance care, including disease education and intervention provision of parenteral medications; possible • Stage 4 renal disease • Colace • Doesn’t cook, eats cold meals. diuretics initiation of steroids PCP notification, nurse Coordinate with PCP, • Hypertension Neighbors bring 25% meals cooked, for clinical, functional, environmental, psychosocial and cultural triggers. care manager follow-up nurse care manager Laboratory or imaging Laboratory studies such calls • Hyperlipidemia and assist with laundry. In-depth discussion • Gout PROVIDERS studies such as portable as portable CXR • Divorced. Widowed to second wife. Chest X-ray (CXR) or PVP follow-up visit if with hospice team to • Osteoarthritis • Primary Care • Gastroenterologist blood tests Coordination and indicated determine next steps • DJD with knee/hip replacement One child, son, lives more than Health • Improve quality. • Dermatologist follow-up with PCP, and responsible parties • H/O old MI • Cardiologist 1,000 miles away. Last visit seven • Lower costs for members. Coordination and nurse case manager for ongoing management • Oncologist Plans • H/O colon
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