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Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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APPENDIX A

CARE MODEL CASE STUDIES

The care models described here were presented or discussed as part of one of the workshop proceedings or came up during the deliberations of the planning committee or taxonomy workgroup.

ALIGNMENT HEALTHCARE
Target population
The 20 percent of a health system’s members who are frail, or have complex conditions or several chronic illnesses, and who account for 80 percent of health care spending. (Furman, 2015; Kao, 2016)
Matched Segment
Not used in matching exercise

Intervention Components

  • Alignment Healthcare’s program is built around a new type of clinician, the extensivist, a highly trained physician who cares for five or six patients in the hospital, instead of the 30 that a hospitalist would see, and who not only treats the patient but also speaks to the patient’s family and primary care physician every day. (Furman, 2015)
  • Any member of a participating health care system who was frail, whether posthospitalization or for any other reason, can be seen at a care center by a team that included the extensivist, nurse practitioners, social workers, and case workers functioning at the top of their licenses. These care centers also have teams of psychiatrists, psychologists, and psychiatric nurses who integrate mental health care and extend that care into nursing homes, skilled nursing facilities, and the patient’s home. (Furman, 2015)
  • Care centers incorporate nutritional counseling, podiatry services, and other key components for seniors. (Furman, 2015)
  • Technology and advanced analytics play a key role in supporting the care model, with the goal being to use analytical tools to develop earlier predictive patterns that inform preventive interventions before high-cost interventions are needed. (Furman, 2015)
Outcomes
Well-being Utilization
X
Cost
X
Notes
  • The program eliminates copayments for mental health care, which decreased costs and improved outcomes. (Furman, 2015)
SOURCES: Furman, 2015; Kao, 2016.
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
CARE MANAGEMENT PLUS
Target population
Generally adults 65 years and older, who have multiple comorbidities, diabetes, frailty, dementia, depression and other mental health needs; physician referral. (Care Management Plus, 2017; McCarthy, 2015)
Matched Segment
Advancing illness with social risk and behavioral health factors
Major complex chronic with social risk and behavioral health factors

Intervention Components

  • “Specially trained care managers (usually RNs or social workers) located in primary care clinics perform person-centered assessment and work with families and providers to formulate and implement a care plan.” (McCarthy, 2015)
  • “Care manager ensures continuity of care and regular follow-up in office, in the home, or by phone.” (McCarthy, 2015)
  • “Continuity of care enhanced by specialized information technology system.” (McCarthy, 2015)
  • “Care manager provides coaching and self-care education for patients and families.” (McCarthy, 2015)
Outcomes
Well-being
X
Utilization
X
Cost
Notes
  • Utilization results only significant among patients with diabetes. (Dorr, 2008)
SOURCES: Care Management Plus, 2017; Dorr, 2008; McCarthy, 2015
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
CAREFIRST’S PATIENT-CENTERED MEDICAL HOME PROGRAM
Target population
The 12 percent of CareFirst BlueCross Blue Shield members with advanced or critical illness and multiple chronic illnesses who account for 72 percent of the system’s hospital admissions and 63 percent of the total medical costs. (O’Brien, 2015)
Matched Segment
Not used in matching exercise

Intervention Components

  • An incentive-based program for primary care physicians that rewards them for managing patients and influencing the whole medical dollar, including the 94 percent of the plan’s expenditures on specialists, inpatient care, outpatient care, and prescription drugs. (O’Brien, 2015).
  • Credible data and analytic support provided through a dedicated informational portal and high-touch, superior technical support promote collaboration among physicians, local nurses, and other health professionals to manage members’ care. These analytics provide primary care physicians with information to help them spot potential hot-spot individuals within their panels and then provide links to additional services for those patients. (O’Brien, 2015)
  • Primary care physicians collaborate with the specialists and other medical professionals of their choice, informed by analytics that provide the primary care physician with cost and quality metrics for those other professionals, to more closely coordinate and track care for the sickest patients or those at highest risk for future illness. (CareFirst, 2017; O’Brien, 2015)
  • Care plans are supported by local community-based care teams headed by a registered nurse. (O’Brien, 2015)
Outcomes
Well-being Utilization
X
Cost
X
Notes
  • “Participating providers receive a 12 percentage point increase in their fee schedule, agreeing to higher compensation in exchange for increased effort and time devoted to improved coordination of care. They also receive additional new fees for developing care plans for select patients with certain chronic or multiple conditions and additional fees for keeping the care plans up to date.” (CareFirst, 2017)
  • Incentives (paid as fee increases) can be earned tied to better outcomes for the patients under the care of each panel of primary care physicians in the program. (O’Brien, 2015)
  • “Of the 291 PCMH panels participating in 2013, 69 percent earned an outcome incentive award averaging 36 percent, and of the panels participating in 2011-2013, 37 percent earned the award in all three years.” (O’Brien, 2015)
SOURCES: CareFirst, 2014; CareFirst, 2017; O’Brien, 2015
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
CAREOREGON’S HEALTH RESILIENCE PROGRAM
Target population
The 10 percent of CareOregon’s Medicaid members who incur 50 percent of the plan’s medical expenses. Members enrolled in the Health Resilience program were more likely to experience high disease burden and psychosocial challenges. The majority of those who enrolled have experienced significant trauma in their lives. (Ramsay, 2015)
Matched Segment
Not used in matching exercise

Intervention Components

  • Health Resilience Specialists are paired with primary health homes and specialty practices to provide individualized high touch and trauma-informed support to patients with exceptional utilization with the primary emphasis of mitigating social determinants of health. (CareOregon, 2014)
  • Staff are supported by clinically licensed supervisors who provide daily and weekly guidance, mentoring, and clinical supervision. (CareOregon, 2014)
  • The Health Resilience Specialists, who have mental health and addictions training, an in-depth understanding of trauma dynamics, and extensive outreach experience with the Medicaid population, are paid and administered by CareOregon but operate as part of a primary care team. (CareOregon, 2014)
  • The program also subcontracts with regional and culturally specific peer mentors to build longer-term sustainability into the program. (CareOregon, 2014)
Outcomes
Well-being
X
Utilization
X
Cost
X
Notes
  • CareOregon’s six programmatic principles of trauma-informed care include: reducing barriers; providing client-centered care; increasing transparency; taking time and building trust; avoiding judgment and labels; and providing care in a community-based setting. (CareOregon, 2014)
  • Measures of access and quality increased significantly, as did member access to help with food, housing, and transportation. (Ramsay, 2015)
  • Clinical staff rated the program highly on measures of care coordination, effectiveness at caring for high-need Medicaid patients, and care team satisfaction. (Ramsay, 2015)
SOURCES: CareOregon, 2014; Ramsay, 2015
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
CHENMED
Target population
Program serves 60,000 moderate- to low-income Medicare members in more than 40 locations in six states. More than 30 percent of the members are dual-eligibles. (Klein, 2016)
Matched Segment
Not used in matching exercise

Intervention Components

  • For-profit model offers a one-stop-shop approach for delivering multispecialty services in the community utilizing a smaller physician panel size of 350 to 450 patients, allowing for intensive health coaching and preventive care. (Coye, 2016)
  • Collaborative peer review, powered by customized information technology, is a central feature of this system. (Tanio, 2013)
  • ChenMed practices offer a broad set of additional services on site, including dental care, digital x-ray, ultrasound, and acupuncture, as well as five to 15 high-volume specialists. (Tanio, 2013)
  • Because access to care is a major issue with seniors, the practice provides door-to-door van transportation at no charge. (Tanio, 2013)
  • To boost medication adherence, each practice has on-site physician pharmacy dispensing, which encourages patients to discuss side effects and other issues that interfere with medication adherence. (Tanio, 2013)
Outcomes
Well-being Utilization Cost
X X
Notes
  • For-profit Medicare Advantage model of managed care that accepts capitated payments and is at full risk for patients’ total health care costs. (Tanio, 2013)
  • ChenMed’s customized electronic health record and decision support software requires less documentation than most off-the-shelf electronic health records, allowing physicians to make concise notes and enhance productivity. (Hostetter, 2016)
  • Ninety percent of ChenMed’s diabetic patients reported they had an improved understanding of their medications and 80 percent reported improved communication with their physician. New Promoter Scores, a measure of how likely a member would be to refer a practice to a friend or colleague, was 90 percent compared to a national average for health insurance companies of 12 percent. (Klein, 2016)
SOURCES: Coye, 2016; Hostetter, 2016; Klein, 2016; Tanio, 2013
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
CIGNA COLLABORATIVE CARE MODEL
Target population
High-risk, high-cost patients identified based on having multiple comorbidities and through Cigna’s proprietary predictive modeling. (Davda, 2015)
Matched Segment
Not used in matching exercise

Intervention Components

  • Cigna Collaborative Care, modeled after accountable care organizations, embeds a care coordinator, typically a registered nurse, in a physician group with a substantial primary care component. (Davda, 2015)
  • Care coordinators work closely with Cigna’s case managers to ensure that high-need individuals receive the screenings, follow-up care, educational materials, and access to Cigna’s clinical support programs, such as those for chronic condition management and lifestyle management, to help them manage their health better. (Davda, 2015)
  • Cigna uses proprietary predictive modeling and analytics to provide the embedded care coordinator with a daily list of which members of a practice are in the hospital and will require a transition of care call at the time of discharge, and a monthly list of high-risk patients with multiple gaps in care, such as medication compliance issues and multiple emergency department visits. (Davda, 2015)
Outcomes
Well-being Utilization Cost
X X
Notes
  • Cigna offers ongoing training and best practice sharing for the care coordinators and connects them with other Cigna resources such as case managers, wellness coaches, and pharmacists to expand the clinical resources available to their patients. (Davda, 2015)
  • The medical group is rewarded through a pay for value structure if it meets targets for improving quality and lowering medical costs. (Cigna, 2014)
  • Large physician groups active two or more years have shown 3 percent better total medical cost and a 2 percent increase in quality performance. The return on investment for these “mature” practices is 2:1. (Davda, 2015) “Three of the highest-performing arrangements have each removed more than $3 million from the health care system.” (Cigna, 2017)
SOURCES: Cigna, 2014, 2017; Davda, 2015
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
COMMONWEALTH CARE ALLIANCE
Target population
Dual-eligible individuals 65+ in Senior Care Options program or dual-eligible individuals age 64 and younger in Disability Care Program, part of the Massachusetts One Care financial alignment demonstration. (McCarthy, 2015)
Matched Segment
Non-elderly disabled

Intervention Components

  • “Provides enhanced primary care and care coordination through multidisciplinary clinical teams led by nurse practitioners.” (McCarthy, 2015)
  • “After a comprehensive assessment, individualized care plans are developed to promote independence and functioning.” (McCarthy, 2015)
  • “Integration of behavioral health care for those who need it.” (McCarthy, 2015)
  • “Care team available 24/7 in the home, in the hospital, or at the doctor’s office.” (McCarthy, 2015)
  • “Patients’ records available 24/7 in proprietary electronic health record system.” (McCarthy, 2015)
Outcomes
Well-being Utilization Cost
X
SOURCE: McCarthy, 2015
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
COMPLEX CARE PROGRAM AT CHILDREN’S NATIONAL HEALTH SYSTEM
Target population
Medically complex children with 2 or more chronic conditions. (Children’s National, 2017)
Matched Segment
Children with complex needs

Intervention Components

  • “Provides ongoing care coordination between visits including communication with family, primary care providers, and specialists.” (Children’s National, 2017)
  • “Helps families negotiate the health care system and provide a link to community resources.” (Children’s National, 2017)
  • “Creates written care plans with the family to share with the primary care provider.” (Children’s National, 2017)
  • “Provides comprehensive care coordination through a team approach that includes nurse case management, parent navigators, and social work.” (Children’s National, 2017)
Outcomes
Well-being Utilization Cost
X
Notes
  • Outcomes unavailable.
SOURCE: Children’s National, 2017
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
COMPREHENSIVE CARE PHYSICIAN (CCP) MODEL (UNIVERSITY OF CHICAGO)
Target population
Patients with multiple chronic illnesses who had at least one hospitalization in the previous year. (The University of Chicago, 2017)
Matched Segment
Not used in matching exercise

Intervention Components

  • Five dedicated CCPs lead teams of advanced practice registered nurses, social workers, care coordinators, and other specialists best suited to address the needs of patients who are expected to average 10 hospital days per year. (Meltzer, 2014)
  • Each CCP has a panel of approximately 200 patients and serves as both primary care physician and supervisor for each panel member’s care while hospitalized. (Meltzer, 2014)
  • The five CCPs visit hospitalized patients each morning while the other members of the care team provide care at the physicians’ clinics. One CCP is assigned afternoon rounds and weekend duties. “Providing these physicians with a high volume of inpatients and locating their clinics in or near the hospital allows them to offer many of the same benefits that hospitalists provide while offering the additional benefit of continuity across settings and over time.” (Meltzer, 2014)
  • “The CCP or other care team member makes postdischarge calls to the patient and both telephone and text messages are used to keep the care team and patient connected.” (Meltzer, 2014)
Outcomes
Well-being
(study not yet completed)
Utilization
(study not yet completed)
Cost
(study not yet completed)
Notes
  • Shared saving based on risk-adjusted estimates of predicted costs.
SOURCES: Meltzer, 2014; The University of Chicago, 2017.
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
COMPREHENSIVE PATIENT-CENTERED MEDICAL HOME INITIATIVE
Target population
This model is being tested in seven states encompassing 31 payers, nearly 500 practices, and approximately 300,000 Medicare beneficiaries (Taylor, 2015)
Matched Segment
Not used in matching exercise

Intervention Components

  • A medical home model in which practices first risk-stratify their patients within physician panels. (Taylor, 2015)
  • Practices use care management methods, including care planning, registries, proactive care monitoring, and enhanced access that include home-based and team-based care. (Taylor, 2015)
  • While the program is not prescriptive per se, care management activities must include at least one of the following: behavioral health integration, self-management or support for beneficiaries, or medication management. (Taylor, 2015)
Outcomes
Well-being Utilization Cost
(study not yet completed) (study not yet completed) (study not yet completed)
Notes
  • Practices receive monthly case management payments of $20 per month per patient over the first two years of the program and $15 per month for years three and four. They also have an opportunity to earn shared savings on reductions in total Part A and B Medicare expenditures. (Taylor, 2015)
SOURCE: Taylor, 2015
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
GEISINGER’S PROVENHEALTH NAVIGATOR PATIENT-CENTERED MEDICAL HOME
Target population
Elderly Medicare patients.
Matched Segment
Not used in matching exercise

Intervention Components

  • “Patient-centered primary care.” (Maeng, 2012)
  • “Integrated population management.” (Maeng, 2012)
  • “A medical ‘neighborhood’ that aligns key community partners, such as home health agencies, skilled nursing facilities, outpatient and ancillary services, hospital facilities, and community pharmacies. Comprehensive quality improvement. Value-based reimbursement redesign that includes a quality, outcome-based pay-for-performance program.” (Maeng, 2012)
Outcomes
Well-being Utilization Cost
X X
Notes
  • “The program aims to move resources further upstream in the primary care settings to reduce downstream costs from the highest acuity settings resulting from uncontrolled exacerbations of chronic disease, hospital readmissions, and unnecessary duplication of services.” (Maeng, 2012)
SOURCES: Maeng, 2012; xG Health Solutions, 2017
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
GRACE
Target population
Low-income seniors with medical complexity.
Matched Segment
Major complex chronic with social risk and behavioral health factors

Intervention Components

  • “Support team consisting of advanced practice nurse and social worker work with elderly in the home and community.” (McCarthy, 2015)
  • “In-home assessment and specific care protocols inform individualized care plan.” (McCarthy, 2015)
  • “Support team works closely with larger interdisciplinary care team.” (McCarthy, 2015)
  • “Patient education and self-management plans include tools for low-literacy seniors.” (McCarthy, 2015)
Outcomes
Well-being Utilization Cost
X X
Notes
  • “Program was cost-neutral in the first two years among high-risk patients, and cost-saving in the third year (postintervention).” (McCarthy, 2015)
SOURCES: Counsell, 2009; Indiana University, 2017; McCarthy, 2015
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
GUIDED CARE
Target population
“Older adults with multiple chronic conditions.” (McCarthy, 2015)
Matched Segment
Major complex chronic

Intervention Components

  • “Predictive modeling and 12 months of claims data used to identify the 20 to 25 percent of patients most at risk of needing complex care in the near future.” (McCarthy, 2015)
  • “RNs trained in complex care management perform in-home assessments and develop care plans to coordinate care with multidisciplinary providers.” (McCarthy, 2015)
  • “Patient education and self-management strategies focus on addressing issues before hospitalization becomes necessary.” (McCarthy, 2015)
Outcomes
Well-being Utilization Cost
X X
SOURCE: McCarthy, 2015
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
HEALTH CARE HOME (HCH) PROGRAM (OF MINNESOTA)
Target population
Medicare and Medicaid recipients who have two or more chronic illnesses. (Minnesota Department of Health, 2017)
Matched Segment
Not used in matching exercise

Intervention Components

  • Three strategic components of the HCH program are its certification process, a quality improvement process, and a learning collaborative. (LaPlante, 2015)
  • At the time of certification, each clinic is evaluated by a team that includes a regional nurse planner, a consumer or patient under contract with her agency, and a community nurse or other community health professional. The purpose of the site visit is to ensure that clinics have enacted processes to redesign primary care. (LaPlante, 2015)
Outcomes
Well-being Utilization Cost
X X X
Notes
  • Racial disparities were significantly smaller for Medicaid, Medicare, and dual-eligible beneficiaries served by HCH versus non-HCH clinics for most measures. (Wholey et al., 2015)
  • HCH organizations report being better able to capture care coordination payments from Medicaid than from Medicare, private managed care, or commercial insurers. (Wholey et al., 2015)
  • Financial incentives were not a primary driver of a clinic or organization participating in the HCH initiative. (Wholey et al., 2015)
  • Minnesota did develop a care coordination tier assignment tool to support care coordination billing. (Wholey et al., 2015)
SOURCES: LaPlante, 2015; Minnesota Department of Health, 2017; Wholey et al., 2015.
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
HEALTH QUALITY PARTNERS
Target population
“Medicare beneficiaries with chronic conditions.” (McCarthy, 2015)
Matched Segment
Major complex chronic
Multiple chronic

Intervention Components

  • “Registered nurse care coordinators focus on changing patient behavior.” (McCarthy, 2015)
  • “Focus on frequent in-person contact with both patients and physicians.” (McCarthy, 2015)
  • “Evidence-based patient education including condition-specific self-monitoring training.” (McCarthy, 2015)
Outcomes
Well-being Utilization Cost
X X
Notes
  • Reduced average monthly Medicare Part A and B expenditures by 21 percent. (Brown, 2017)
SOURCES: Brown et al., 2017; McCarthy et al., 2015
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
HEALTH SERVICES FOR CHILDREN WITH SPECIAL NEEDS
Target population
High-need, high-cost pediatric patients.
Matched Segment
Under 65 disabled
Children with complex needs with social risk and behavioral health factors

Intervention Components

  • Provides a care manager to coordinate appointments, to assist with arranging transportation, and to connect patients with community resources and organizations. (HSCSN, 2016)
  • Care Manager works with providers and patients to create a care coordination plan that’s updated at least twice per year. (HSCSN, 2016)
Outcomes
Well-being Utilization Cost
Notes
  • Outcomes unavailable
SOURCES: Health Services for Children with Special Needs, Inc., 2016
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
HOMELESS PATIENT ALIGNED CARE TEAM (H-PACT)
Target population
Homeless veterans coming to the emergency department with complex medical and social problems.
Matched Segment
Non-elderly disabled with social risk and behavioral health factors

Intervention Components

  • “Located on the campuses of Veterans Affairs medical centers, community-based outpatient clinics, and Community Resource and Referral Centers, H-PACT clinics colocate medical staff, social workers, mental health and substance use counselors, nurses, and homeless program staff. These professionals form a team that provides Veterans with comprehensive, individualized care, including services that lead to permanent housing.” (US VA, 2017)
Outcomes
Well-being Utilization Cost
X
Notes
  • Launched in 2012, so limited data are available but evidence exists to support decreased utilization.
SOURCE: US Department of Veterans Affairs, 2017
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
HOSPITAL AT HOME
Target population
Older patients who are acutely ill and require hospital-level care. (Johns Hopkins, 2013)
Matched Segment
Advancing illness

Intervention Components

  • “Potentially eligible patients are identified in the hospital emergency department or ambulatory care site. If they meet the validated criteria and consent to participate, they are evaluated by a physician and transported home, usually via ambulance.” (McCarthy, 2015)
  • “One-on-one nursing for initial stage and at least daily nurse and physician visits thereafter.” (McCarthy, 2015)
  • “Both nurses and physicians on call around-the-clock for urgent or emergent visits.” (McCarthy, 2015)
  • “Some diagnostic services and treatments performed in home setting.” (McCarthy, 2015)
  • “Same criteria and guidelines are used to judge patient readiness for transition to skilled nursing facility, or discharge from Hospital at Home as from hospital.” (McCarthy, 2015)
Outcomes
Well-being Utilization Cost
X X X
Notes
  • Utilization outcomes were based on a prospective quasi-experiment. (McCarthy, 2015)
  • Per patient average costs were 19 percent lower than similar inpatient per-patient average costs but excluded physician costs. (McCarthy, 2015)
    • Cost savings were due to lower average length of stay and few diagnostic and lab tests. (McCarthy, 2015)
    • Cost savings did not factor in physician costs. (McCarthy, 2015)
SOURCES: Johns Hopkins School of Medicine, 2013; McCarthy, 2015
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
IMPACT
Target population
“Older adults suffering from depression.” (McCarthy, 2015)
Matched Segment
Frail elderly with social risk and behavioral health factors Multiple chronic with social risk and behavioral health factors

Intervention Components

  • “Collaborative care: Primary care physician works with depression care manager (e.g., nurse, social worker, or psychologist supported by medical assistant or other paraprofessional) to develop and implement treatment plan including antidepressant medication and/or short-term counseling. Team includes consulting psychiatrist.” (McCarthy, 2015)
  • “Care manager also educates patient about depression and coaches in self-care.” (McCarthy, 2015)
  • “Providers utilize ongoing measurement and tracking of outcomes with validated depression screening tool, such as Patient Health Questionnaire-9, and adapt care to changing symptoms.” (McCarthy, 2015)
  • “Once a patient improves, case manager and patient jointly develop a plan to prevent relapse.” (McCarthy, 2015)
Outcomes
Well-being Utilization Cost
X X
Notes
  • “Total health care costs for IMPACT patients were $3,300 lower per patient on average than those of patients receiving usual primary care, net of program cost.” (McCarthy, 2015)
SOURCE: McCarthy, 2015
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
INDEPENDENCE AT HOME DEMONSTRATION
Target population
“Medicare beneficiaries with multiple chronic conditions.” (CMS, 2016)
Matched Segment
Not used in matching exercise

Intervention Components

  • Model that uses home-based primary care teams directed by physicians and nurse practitioners designed to improve health outcomes and reduce expenditures for Medicare beneficiaries with multiple chronic conditions. (CMS, 2016)
  • “Selected participants, including primary care practices, will provide home-based primary care to targeted chronically ill beneficiaries for a five-year period. Participating practices will make in-home visits tailored to an individual patient’s needs and preferences.” (CMS, 2016)
  • “This focus on timely and appropriate care is designed to improve overall quality of care and quality of life for patients served, while lowering health care costs by forestalling the need for care in institutional settings.” (CMS, 2016)
Outcomes
Well-being
(study not yet completed)
Utilization
(study not yet completed)
Cost
(study not yet completed)
Notes
  • “The Independence at Home Demonstration will award incentive payments to health care providers who succeed in reducing Medicare expenditures and meet designated quality measures.” (CMS, 2016)
SOURCE: CMS, 2016
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
MIND AT HOME (JOHNS HOPKINS UNIVERSITY)
Target population
Elderly with memory disorders.
Matched Segment
Frail elderly with social risk and behavioral health factors

Intervention Components

  • “Links people with dementia and their caregivers to community-based agencies, medical and mental health care providers, and community resources.” (JHU, 2014)
  • “Delivered by an interdisciplinary team comprised of trained nonclinical community workers and mental health clinicians, who conduct comprehensive in-home dementia-related needs assessments and provide individualized care planning and implementation.” (JHU, 2014)
  • “The team uses six basic care strategies: resource referrals, attention to environmental safety, dementia care education, behavior management skills training, informal counseling, problem-solving, as well as ongoing monitoring, assessment, and planning for emergent needs.” (JHU, 2014)
  • “Each component of the intervention is based on best practice recommendations and evidence from prior research, and is combined for maximum impact.” (JHU, 2014)
  • Provides individualized needs assessments, care planning, and monitoring for both patient and caregiver. (JHU, 2014)
  • Provides education, skills training, and self-management support for patients and families. (JHU, 2014)
  • Model is home-based, linking medical and community-based care services delivered by nonclinical staff with support from mental health practitioners. (JHU, 2014)
Outcomes
Well-being Utilization Cost
X X
Notes
  • “Primary outcomes were time to transfer from home and percent of unmet needs” (both significant effects). (Samus, 2014)
SOURCES: Johns Hopkins University, 2014; Samus et al., 2014
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
MISSIONPOINT HEALTH PARTNERS
Target population
Serving 250,000 members in seven states. (MissionPoint, 2017b)
Matched Segment
Not used in matching exercise

Intervention Components

  • MissionPoint Health Partners is a population health management organization that uses a global financing model to provide a clear picture of the resources needed for this patient population and enable personalized responses to patient needs and iterative learning and resource shifting. This iterative approach, supported by a clear leadership commitment, is a major feature of the program’s profit-and-loss strategy. (Coye, 2016)
  • “Central to the MissionPoint model is [its] wraparound clinical management framework, a skilled team of Health Partners who help members solve problems and connect their medical care with everyday life. . . . [The Health Partners, who] are experienced health care professionals and social workers, are provided at no cost to members and help support members when they most need it, such as after an emergency department visit, hospital stay, or diagnosis of a chronic disease.” (MissionPoint 2017a)
  • Advanced analytics notify Health Partners “of members’ health events within the network and provide them with relevant medical data so that the Health Partners can work hand-in-hand with members and caregivers to . . . navigate the health care system, problem-solve complex issues, and remove barriers to self-care.” (MissionPoint, 22017a)
Outcomes
Well-being Utilization Cost
X X X
Notes
  • Medicare shared savings plan and additional incentives for expanding member access with extended hours or email support.
  • A key component of MissionPoint’s success in improving the health status of its members while lowering overall health care costs is its ability to create clinically integrated networks in the communities it serves.
SOURCES: Coye, 2016; MissionPoint, 2017a, 2017b.
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
NAYLOR TRANSITIONAL CARE MODEL (UNIVERSITY OF PENNSYLVANIA)
Target population
“Hospitalized, high-risk older adults with chronic conditions.” (McCarthy, 2015)
Matched Segment
Frail elderly

Intervention Components

  • “Multidisciplinary provider team led by advanced practice nurses engages in comprehensive discharge planning.” (McCarthy, 2015)
  • “Three-month postdischarge follow-up includes frequent home visits and telephone availability.” (McCarthy, 2015)
  • “Involve patients and family members in identifying goals and building self-management skills.” (McCarthy, 2015)
Outcomes
Well-being Utilization Cost
X X X
Notes
  • “38 percent reduction in total costs.” (McCarthy, 2015)
  • “36 percent fewer readmissions.” (McCarthy, 2015)
  • “Short-term improvements in overall quality of life and patient satisfaction.” (McCarthy, 2015)
SOURCE: McCarthy, 2015.
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
PACIFIC BUSINESS GROUP ON HEALTH’S INTENSIVE OUTPATIENT CARE PROGRAM
Target population
Individuals having two or more chronic conditions and behavioral and psychosocial needs that are not being met by the current health care system. (Mangiante, 2015)
Matched Segment
Not used in matching exercise

Intervention Components

  • This high-touch, care-coordinated, patient-involved program uses team-based care with both licensed and unlicensed care coordinators to ensure seamless transitions and links to needed services. (Mangiante, 2015)
  • Individuals in 23 participating delivery systems and 500 practices are identified using a predictive risk model plus cognitive assessment, as well as through physician referrals. (Mangiante, 2015)
  • Interdisciplinary care teams developed longitudinal relationships with clients and provide warm handoffs to support services outside of the health care system. (Stremikis, 2016)
  • Care coordinators complete a face-to-face “supervisit” within 1 month of a member’s enrollment in the program. Because medically complex patients can be anxious and depressed, coordinators are particularly attentive to their patients’ social and psychological needs, providing or supplying referrals for behavioral, psychosocial, and community services. (Mangiante, 2015)
  • Coordinators proactively provide patients with tools for effective self-management, helping them to develop action plans and to recognize signs of exacerbations of illness, and engage in two-way communication with members at least once per month, with intensity decreasing as patients become stable. (Mangiante, 2015)
Outcomes
Well-being Utilization Cost
X X X
Notes
  • Being tested in Pioneer and Medicare Shared Savings Program accountable care organizations as well as Medicare Advantage plans. (Mangiante, 2015)
  • After CMS grant ended, “90 percent of participating delivery systems continued the core elements of the program for Medicare patients and 15 of the 23 expanded programs into their commercial populations.” (Stremikis, 2016)
  • 3.3 percent improvement in physical health functioning, 4.2 percent improvement in mental health functioning, and 31 percent improvement on depression score. Patient Activation Measure (PAM) scores increased in 37 percent of participants, and 30 percent increase in graduation from program among participants with increased PAM scores. (Mangiante, 2015)
SOURCES: Mangiante, 2015; Stremikis et al., 2016
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
PARTNERS HEALTHCARE INTEGRATED CARE MANAGEMENT PROGRAM
Target population
“Medicare beneficiaries who are high cost and/or have complex conditions” (McCarthy, 2015) (also expanded to children) (Partners Healthcare, 2016).
Matched Segment
Major complex chronic
Children w/complex needs

Intervention Components

  • “Care managers are integrated into primary care practices.” (McCarthy, 2015)
  • “Care managers provide patient education and address both medical and psychosocial needs.” (McCarthy, 2015)
  • “Focus on preventing exacerbations that lead to emergency department visits and inpatient admissions.” (McCarthy, 2015)
  • “Case managers also support end-of-life decision making.” (McCarthy, 2015)
Outcomes
Well-being Utilization Cost
X X
Notes
  • “7 percent annual savings after accounting for intervention costs.” (McCarthy, 2015)
  • “20 percent reduction in hospital admissions.” (McCarthy, 2015)
  • “13 percent reduction in emergency department visits.” (McCarthy, 2015)
SOURCES: McCarthy, 2015; Partners Healthcare, 2016
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAM
Target population
Frail elderly, dual-eligible individuals, functional and/or cognitive impairments.
Matched Segment
Frail elderly

Intervention Components

  • “Each PACE site provides comprehensive preventive, primary, acute, and long-term care and social services, including adult day care, meals, and transportation.” (McCarthy, 2015)
  • “Interdisciplinary team meets regularly to design individualized care plans.” (McCarthy, 2015)
  • “Goal is to allow patients to live independently in the community.” (McCarthy, 2015)
  • “Patients receive all covered Medicare and Medicaid services through the local PACE organization in their home and community and at a local PACE center, thereby enhancing care coordination.” (McCarthy, 2015)
  • “Clinical staff are employed or contracted by the local PACE organization, which is paid on a per-capita basis and not based on volume of services provided.” (McCarthy, 2015)
Outcomes
Well-being Utilization Cost
X X X
Notes
  • “Fewer hospitalizations but more nursing home admissions.” (McCarthy, 2015)
  • “Better quality for certain aspects of care such as pain management, and lower mortality, than comparison groups.” (McCarthy, 2015)
  • “Cost-neutral to Medicare; may have increased costs for Medicaid—more research is needed.” (McCarthy, 2015)
SOURCE: McCarthy, 2015
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
STANFORD COORDINATED CARE
Target population
Top 20 percent of Stanford’s employees and dependents with complex medical needs, who have two or more emergency room visits related to underlying medical conditions over the past year, and poor adherence to treatment recommendations. (Glaseroff, 2015)
Matched Segment
Not used in matching exercise

Intervention Components

  • “Upon joining the program, SCC patients are assigned to care teams and complete a comprehensive intake process that focuses on the question, ‘Where do you want to be in a year?’” (CHCS, 2015)
  • “Care teams include a physician, registered nurse or other provider, and a care coordinator/medical assistant trained to act as a coach and navigator, as well as a social worker who specializes in trauma informed care, a physical therapist who specializes in chronic pain, and a clinical pharmacist.” (CHCS, 2015)
  • Care coordinators/medical assistants perform routine preventive services and chronic disease monitoring between clinic visits for a panel of 100 patients with the goal of encouraging patients to follow through on their action plans. (AHRQ, 2016)
  • The care team focuses on improving each patient’s self-management by supporting the patient’s self-identified goals and assisting the patient to develop achievable action plans scaled according to the patient’s PAM score. (CHCS, 2015)
Outcomes
Well-being Utilization Cost
X X X
Notes
  • Surveys show staff and patient satisfaction ratings in the 99th percentile. Care coordinators working under protocol and informed by a care gap dashboard are effective at ensuring routine monitoring for prevention and chronic disease management. (AHRQ, 2016)
  • PAM scores increased in 34 percent of participants, with a net improvement of 23 percent. Mental composite score increased in 50 percent of participants and physical composite score increased in 64 percent of participants. (Glaseroff, 2015)
  • Care coordinators working under protocol and informed by a care gap dashboard are effective at ensuring routine monitoring for prevention and chronic disease management. (Glaseroff, 2015)
SOURCES: AHRQ, 2016; Center for Health Care Strategies, 2015; Glaseroff, 2015
Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

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Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

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Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

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Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

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Suggested Citation:"Appendix A: Care Model Case Studies." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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Next: Appendix B: Workshop Agendas »
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To advance insights and perspectives on how to better manage the care of the high-need patient population, the National Academy of Medicine, with guidance from an expert planning committee, was tasked with convening three workshops held between July 2015 and October 2016. The resulting special publication, Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health, summarizes the presentations, discussions, and relevant literature.

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