Health Care Update 2017 - PowerPoint Presentation

Health Care Update 2017 Lending Clarity to Chaos Michigan State University November 1, 2017 Vivian Campagna, Chief Industry Relations Officer, CCMC 1

Health Care Reform and Case Management 2 A Little History Affordable Care Act and Care Coordination The Professional Case Manager Best Practices The Future The Future for Case Managers

A Little History Can be traced back to the 1860s 1863 Board of Charities 1900 Visiting Nurse Service 1901 Care Coordination 1950s Post World War II1960s coined term “case management”1970s Medicaid and Medicare established1980s Prospective Payment System established1990s Managed Care OrganizationsTahan, H., Case Management: A Heritage More Than a Century OldNursing Case Management, Vol. 3, No. 2, 55-60 3

The Aging Population - More than 10K Baby Boomers will turn 65 each day for 19 years Chronic health issues are increasing Populations of patients like our dual eligible spend a disproportionate amount of healthcare dollarsMinority of individuals are spending the majority of healthcare dollarsSuccessful Transitions of Care are criticalLong-term care needs are growing for the aging population Community care is cost-effective Health Care Outlook4

Affordable Care Act Primary Goals Access to Healthcare Improved quality and lowered cost Consumer protections5

Care coordination is integral to patient-centered care, to the newer and emerging models of care such as the medical home and accountable care organizations and across all practice settings More than ever, effective care coordination is needed to pursue clinical, financial, and patient-satisfaction and other outcomes Given the importance of care coordination/case management now and into the future, it behooves us to answer the question, “Who is providing these services?” Spotlight on Care Coordination 6

The Institute of Medicine’s “Crossing the Quality Chasm” identified these systemic issues: Lack of coordination within the delivery systemFragmentation that slows care and undermines personal accountability Poor communication and use of information technologyFailure of health professionals to work together to ensure that care is appropriate, timely and safe Care Coordination has always been important…7

The National Quality Forum “Care coordination helps ensure a patient’s needs and preferences for care are understood, and that those needs and preferences are shared between providers, patients and families as a patient moves from one healthcare setting to another.” Care Coordination has always been important… 8

Care Coordination has always been important… Proprietary & Confidential to CCMC Problems in care delivery Silos Fragmentation Increased cost of chronic careAccess to care options (24/7)Inconsistency of approachCare transitionsMultiple case managers9

Agency for Healthcare Research and Quality “The Agency for Healthcare Research and Quality (AHRQ) defined care coordination as “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care.” Care Coordination has always been important… 10

Care Coordination A Function of the Case Manager Identify the dimension of the health care teamDetermine the roles, functions, expectations of each team memberClinical and non-Clinical responsibilities Identify a patient on the continuum of careAcute Event versus Chronic ConditionWellness to End of Life Person-centered approachInitiate the case management process Screen, Assess, Stratify and RiskPlan, Implement, Follow-UpTransition, Evaluate11

Care Coordination Initiatives: The Goal Care Coordination Improved Quality Reduced Health CareCostsProprietary & Confidential to CCMC

New Models of Care Delivery Model Focus Role for Case Managers Medicare ACOs Coordinate care for Medicare fee-for-service beneficiariesParticipate as part of ACO to coordinate care servicesPatient-Centered Medical Homes (PCMH)Coordinate primary care for individuals with chronic conditionsParticipate as part of community-based health teamsCommunity-Based Care TransitionsImprove post-hospital care for at-risk Medicare beneficiariesAssist with interactions between patients and post-acute/outpatient providersIndependence-at-HomeImprove outcomes for chronically-ill Medicare beneficiariesParticipate as part of primary care teamsMedicare Payment BundlingCoordinate care around a hospitalization for Medicare beneficiariesProvide transitional and other services13

Integrated Behavioral and Medical Care The Problem People with mental illness die earlier than the general population and have more co-occurring health conditions 68% of adults with mental illness have one or more chronic physical conditions 1 in 5 adults with mental illness have a co-occurring substance use disorder The Solution Lies in integrated care – the coordination of mental health, substance abuse, and primary care services.Integrated care produces the best outcomes and is the most effective approach to caring for people with complex healthcare needs.SAMHSA – HRSA Center for Integrated Health Solutions14

High Cost, High Need Patients/Clients Successful models of care – Focus of Service Enhanced Primary Care Interdisciplinary primary care Care and case management Chronic disease self-managementTransitional CareIntegrated CareNational Academy of Medicine15

High Cost, High Need Patients/Clients Care Attributes of Successful Care Models Assessment Targeting Planning AlignmentTrainingCommunicationMonitoringLinking16

High Cost, High Need Patients/Clients Delivery Features of Successful Care Models Teamwork Coordination Responsiveness FeedbackMedication ManagementOutreachIntegrationFollow-up17

The Professional Case Manager The CMSA’s philosophy of case management articulates that: The underlying premise of case management is based in the fact that, when an individual reaches the optimum level of wellness and functional capability, everyone benefits: the individual client being served, the client’s family or family caregiver, the health care delivery system, the reimbursement source or payer, and other involved parties such as the employer and consumer advocates. Professional case management serves as a means for achieving client wellness and autonomy through advocacy, ongoing communication, health education, identification of service resources, and service facilitation. Professional case management services are best offered in a climate that allows client’s engagement and direct communication among the case manager, the client, the client’s family or family caregiver, and appropriate service personnel, in order to optimize health outcomes for all concerned (CMSA, 2009). CMSA Standards of Practice for Case Management (Revised 2016)18

Patients: New Frontiers & Responsibility 19

The Role & Function: Changes in Practice 20

Industry: Outcomes and Accountability 21

The Critical Role of the Professional Case Manager Patients are already experiencing problems when care is not well coordinated across multiple sites or providers and studies are showing an increase in communication gaps between patients and providersThe Role and Function of the case manager is not consistently well defined, including the scope of work and employer and employee expectations The emphasis of care coordination in the industry as an essential component in the new models of care and delivery systems is without a clear and distinct definition of who is providing care coordination 22

The Role of the Professional Case Manager Complete assessment Identifying target care goals Patient and family advocacy Develop plan of care Facilitate communication, motivational support Addressing educational and knowledge deficitsCollaboration with team membersEnhancing care coordination and access to care, promoting self-advocacyAppropriate allocation, use and coordination of resources23

The Role of the Professional Case Manager Focus on patient-centered care Team leadership and communication Team participation Cultural sensitivity Integrate behavioral health with primary careKnow, and communicate, “value add” to patient/family and teamKnow the value you bring to the relationshipBest practice guidelines – Standards of Practice 24

Moral Distress and Ethics Moral distress The stress that occurs when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action Ethical dilemma A situation in which there is a choice to be made between two options, neither of which resolves the situation in an ethically acceptable fashion 25

Moral Distress and Ethics Because case management exists in an environment that may look to it to solve or resolve various problems in the health care delivery and payor systems, case managers may often confront ethical dilemmas. Case managers must abide by the Code as well as by the professional code of ethics for their specific professional discipline for guidance and support in the resolution of these conflicts.” CCMC Code of Professional Conduct 26

Moral Distress and Ethics Ethical Decision-Making Model Identify the problem. Gather information. Identify the ethical principles involved. Review codes of conducts and applicable laws/regulations.Consult Colleagues, supervisors, legal experts, professional organizations, Ethics Committees, professional literature.Generate courses of action.Select a course of action after a benefit/burden analysis is done.Implement the course of action.Evaluate the course of action selected.Document the decision-making process.27

Best Practices Technology Evidence-based medicine Clinical practice guidelines Collaborating to reduce readmissions Adopting telehealth to boost patient outcomesComputer assisted diagnosisImproving the discharge processTargeting the right patients for support28

Value Based Purchasing CMS National Quality Strategy National Quality Strategy Aims Patient Safety Person- and Family-Centered Care Effective Communication and Care CoordinationPrevention and Treatment of Leading Causes of Morbidity and MortalityHealth and Well-Being of CommunitiesMaking Quality Care More Affordable 29

Social Determinants of Health 30

The Triple Aim* Improving the experience of care Improving the health of populations Reducing per capita costs of health care * Institute for Healthcare Improvement31

Quadruple Aim 32

What does the future look like? Care coordination models are critical to reducing health care costs and improving quality.CMS has considerable flexibility to implement these models of care coordination established by the health care reform law.CMS can also institute reforms through the Center for Medicare and Medicaid Innovation. 33

21 st Century Cures ActEnacted December 2016CHRONIC Care Legislation Passed Senate September 28, 2017 Executive Order – Association Health Plans Other Legislation to Watch For34

Transitions of Care Reduced cost Improved qualityImproved patient satisfactionImproved adherence Improved management of chronic illnessIntegration of behavioral and medical care Reduced readmissions How Will We Define Our Success?35

Commission for Case Manager Certification The changing dynamics of the health care environment prompt all of us, especially those in case management, to always be prepared and ready to adapt … and to possess specific knowledge, skills and abilities 36

Outlook For ALL Case Managers Case managers play a pivotal role in new models of health care delivery. Physician and hospital-led provider organizations and other strategic partnerships will have new payment incentives to coordinate care by working with health care professionals, such as board-certified case managers, to improve quality and reduce health care spending.Qualified professionals such as board-certified case managers with demonstrated experience in care coordination will be in greater demand as these reforms are implemented. 37

Ultimately… Case managers must possess the education, skills, knowledge, competencies, and experiences needed effectively render appropriate, safe, and quality services to patients and their support systems and social networks TO 38

Career Implications for Case Management 39 “the need for qualified case managers is expected to grow in order to address the increasing elderly population, a growing number of patients suffering from chronic illness, and the impact of managed care and additional regulation.” Commission for Case Manager Certification, 2016

Case Managers exist in all settings across the continuum of health and human services Case Managers are the linchpin between clients/support systems and members of the health care team (both internal and external to the practice setting)Case Managers are effective in their roles - highly dependent on how well they are prepared: knowledge, skills and competencies “Insanity is doing the same thing over and over and expecting different results” -Albert Einstein Closing Thoughts…4040

1-856-380-6836 | vcampagna@ccmcertification.org www.ccmcertification.org 41