What health Medicaid, Medicare, commercial, large public or private plans are organizations? involved? Opportunity to combine datasets Can create data challenges when assembling an all-payer claims database Who provides Will the program work with PCPs to enhance their capacity and the services; provide alternative intensive services? what is their Will the program transfer patients from primary care to a specialized relationship to setting? primary care providers? Program options Centralized: care managers are embedded in primary care practices identified as serving a high volume of Medicaid patients, or they are high-performing PCMHs with the infrastructure to work with additional staff (see VT, CareOregon) Supportive networks: Not-for-profit, community-based organizations provide care managers to support a regional network of PC practices. Care managers travel between practices and build capacity within the practices (see NC) Community-based teams: Regional interdisciplinary teams visit patients in their homes and community settings. Teams target the highest utilizers, but work with PC practices to identify referrals and patient coordinate care (See ME) Short-term intervention in a super-utilizer clinic: provides comprehensive medical, mental health, addiction treatment and social services for a limited duration, typically 6-9 months (see Spectrum) Permanent Ambulatory ICU: takes over care when the PCP agrees the patient has complex needs beyond the capacity of the practice. Clinic is staffed with multi-disciplinary providers (see Hennepin Health) What is the Overall, targets patients are likely to experience high levels of cost targeting and are impactable. Specific targeting approaches include: strategy? Targeting based on high observed-to-expected costs Targeting specific patterns of care: such as fragmented care, high ED utilization, high volume of preventable hospitalizations combined with no primary care visits or visiting multiple primary care or specialty care providers in a very short time Targeting very high levels of utilization of inpatient admissions and/or ED visits within 6-18 months: This method may identify people with more severe, chronic medical illness Targeting based on referrals and follow-up investigation: programs accept referrals from local providers and other community resources, then use a data-based and interview-based approach to determine impactability Excluding candidate clients with medical conditions associated with high, but non-preventable costs such as cancer, acute trauma Targeting by community: target underserved communities to
What health plans are involved? Medicaid, Medicare, commercial, large public or private organizations? Opportunity to combine datasets Can create data challenges when assembling an all-payer claims database Who provides the services; what is their relationship to primary care providers? Will the program work with PCPs to enhance their capacity and provide alternative intensive services? Will the program transfer patients from primary care to a specialized setting? Program options Centralized: care managers are embedded in primary care practices identified as serving a high volume of Medicaid patients, or they are high-performing PCMHs with the infrastructure to work with additional staff (see VT, CareOregon) Supportive networks: Not-for-profit, community-based organizations provide care managers to support a regional network of PC practices. Care managers travel between practices and build capacity within the practices (see NC) Community-based teams: Regional interdisciplinary teams visit patients in their homes and community settings. Teams target the highest utilizers, but work with PC practices to identify referrals and patient coordinate care (See ME) Short-term intervention in a super-utilizer clinic: provides comprehensive medical, mental health, addiction treatment and social services for a limited duration, typically 6-9 months (see Spectrum) Permanent Ambulatory ICU: takes over care when the PCP agrees the patient has complex needs beyond the capacity of the practice. Clinic is staffed with multi-disciplinary providers (see Hennepin Health) What is the targeting strategy? Overall, targets patients are likely to experience high levels of cost and are impactable. Specific targeting approaches include: Targeting based on high observed-to-expected costs Targeting specific patterns of care: such as fragmented care, high ED utilization, high volume of preventable hospitalizations combined with no primary care visits or visiting multiple primary care or specialty care providers in a very short time Targeting very high levels of utilization of inpatient admissions and/or ED visits within 6-18 months: This method may identify people with more severe, chronic medical illness Targeting based on referrals and follow-up investigation: programs accept referrals from local providers and other community resources, then use a data-based and interview-based approach to determine impactability Excluding candidate clients with medical conditions associated with high, but non-preventable costs such as cancer, acute trauma Targeting by community: target underserved communities to
6-%20CHT%20Program%20Literature%20Review%20Part%20I%20Addressing%20high%20risk%20high%20cost%20patients%20to%20improve%20health-quality%20and%20reduce%20cost.docx