Application of Predictive Modeling to Identify, Stratify, and Triage Members in Care Management...
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Transcript of Application of Predictive Modeling to Identify, Stratify, and Triage Members in Care Management...
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