Coordinating Care for Adults With Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions

January 2012
AHRQ Publication No. 12-0010
Prepared For:
Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 540 Gaither Road, Rockville, MD 20850, www.ahrq.gov

Contract Number: HHSA290200900019I/HHSA29032005T
Prepared by: Mathematica Policy Research Princeton NJ
Authors: Eugene Rich, Mathematica Policy Research; Debra Lipson, Mathematica Policy Research; Jenna Libersky, Mathematica Policy Research; Michael Parchman, Agency for Healthcare Research and Quality.
Table 1. Profiles of Organization supporting primary care practices in serving complex-needs populations.
Program or Organization
  Commonwealth Care Alliance (CCA), MassachusettsCommunity Care of North Carolina (CCNC)Community Health Partnership (CHP), WisconsinHealth Care Homes (HCH), MinnesotaSumma Health System, Ohio
Source: Program details compiled from program Websites; published sources; and Mathematica-led phone calls with representatives from selected organizations, conducted between April 14 and May 10, 2011.
AAA = Area Administration on Aging
ACE = Acute Care for Elderly
ADLIFE = After Discharge Care Management of Low Income Frail Elderly
AHEC = Area Health Education Center
APN = Advanced practice nurse
CM= Case manager
CMIS = Case Management Information System
EHR = Electronic health record
ERISA = Employee Retirement Income Security Act
HCBS = Home and community based services
HEDIS = Healthcare Effectiveness Data and Information Set
MAPCP = Multipayer Advanced Primary Care Practice (Demonstration)
MCO = Managed Care Organization
NCQA = National Committee for Quality Assurance
NP = Nurse practitioner
OP = Outpatient
PC = Primary care
PCP = Primary care practice
PEACE = Promoting Effective Advance Care for the Elderly
QI = Quality Improvement
RN = Registered nurse
Rx = Prescription
SCO = Senior Care Options
SSI= Supplemental Security Income
SW = Social Worker
Region(s) Covered Boston Metro Area and some areas in eastern and western Massachusetts Statewide (Medicaid). Medicare demonstration for duals will be in 26 counties in 2011. Private payers (through MAPCP demo) will be in 7 other rural counties in 2011. Five counties surrounding Eau Claire Statewide Akron and surrounding four counties
Organization Sponsor Type Nonprofit health plan established in 2003 CCA is a Medicare Advantage Special Needs Plan (SNP) and has managed care contracts with the State Medicaid for its SCO program. Medicaid agency: North Carolina Department of Health and Human Services. A nonprofit, physician-led organization: NC Community Care Networks, Inc. (NCCCN). Nonprofit health plan: Partnership Health Plan (PHP), Inc., established in 1997 PHP is a fully integrated Medicaid/Medicare managed care plan participating in State’s Partnership Program State health and human services agencies: Minnesota Department of Health and Minnesota Department of. Human Services. Large integrated health care system (hospital, OP clinics, and so on) and health plan (Medicare Advantage)
Number of Primary Care Practices (PCPs) Participating 25 PCPs as of April 2011 More than 4,000 physicians in all 100 NC counties participate; about 1,480 PCPs participate (about half of all PCPs in State). 170 PCPs in five- county region as of April 2011 1,651 primary care clinicians in 134 clinics statewide Six hospitals, four large primary care groups, one multispecialty physician group. Summa Health System also works with external PCPs in the region.
Target Population Patients who receive SSI or are dual eligible and have multiple chronic conditions and/or behavioral health problems All patients, including those with multiple comorbidities, behavioral health needs, and those who are dually eligible Adults with physical disabilities, adults with mental disabilities, frail elderly All patients, including those with chronic conditions, mental health issues, or those who are dual eligible or uninsured. Patients who are frail, elderly, and/or dual eligible
Health insurance coverage for patients served by program Medicaid only, or Medicare and Medicaid (dual eligible) enrolled in the SCO program, a managed care, capitated program for duals. (CCA operates one of four SCO programs in the State.) Medicaid only, or Medicare and Medicaid In 2011, Medicare-only and privately or insured join. Medicaid only, or Medicare and Medicaid enrolled in the Wisconsin’s Partnership Program, a capitated program for duals. (CHP operates one of three programs in the State). Any type of health insurance or none (includes Medicaid, dual eligible, privately insured programs, State employees, Medicare-only through MAPCP demo). ERISA-based insurance not covered Any type of health insurance, but the majority served are Medicaid or Medicare and Medicaid (dual eligible)
Services Coordinated Primary and specialty medical care; mental health services; home assessments; HCBS; hospice care; long term care; pharmacy. Primary and specialty medical care; mental health services; HCBS; hospice care; transition care; clinical pharmacy. Primary and specialty medical care; mental health services; home visits; HCBS; hospice care. Primary and specialty medical care; mental health services; HCBS; hospice care Primary and specialty medical care; mental health services; home assessments; HCBS; hospice care.
Case management approaches CMs (NP geriatric SW teams) assigned to each PCP to provide enhanced primary care and case management. In addition, CCA employs geriatricians, pharmacists, APNs, RNs, social workers, behavioral health specialists, palliative care specialists, and others for consultation with PCPs, and to provide direct care to enrollees. 14 regional networks hire case managers who collaborate with PCPs. CMs housed in large PCPs, and shared person across small PCPs; varies by network. Clinical directors, pharmacists, psychiatrics, behavioral health specialists, and QI professionals available from the network to consult and assist CMs. Patient assigned to a case management team (one RN, one NP, and one social service coordinator per team). A member of the team accompanies the patient to PCP visits and provides direct care and assessment in the home. Case management required for all certified practices. Four general models: (1) single, designated CM who coordinates all care; (2) single, designated CM who delegates some functions to team; (3) multiple CMs sharing functions multiple CMs sharing functions (4) multiple, defined CM roles distributed across a team with one CM coordinating the work Multidisciplinary teams (NP, MD/DO, local AAA, and so on) meet in person to discuss needs for referred patients; other “virtual” team members (cardiologist, pulmonologist, psychologist, and so on) are on call. PCPs can refer patients for inpatient, outpatient, and in-home consults.CM meets with patient at PCP clinic visits.
Information technology (IT) systems IT enhancements provided to PCPs to establish and maintain Web based electronic medical records for SCO enrollees. NCCCN helps regional networks identify high risk patients and develop performance measures. Regional networks use a common CMIS which gives CM team near real-time access to patient data (claims, enrollment status, some medical records) from anywhere in the State. CMIS also used to document CM interventions, assessments, care plans, and so on. Provider portal allows PCPs, hospitals, and participating specialists to view comprehensive patient data. Separate EHR kept at CHS (no Rx information included), and paper assessment provided to PCP. CM also accompanies patient to PC visits and directly communicates health history and care plan All PCPs required to have electronic and searchable patient registries; low or no cost systems available. Mini-grants available to practices to support HCH implementation, including IT capabilities, care planning tools, or registries required for HCH certification Providers maintain separate EHR systems. In inpatient settings, clinician stake notes on the same record. Information shared via alpha page, email, fax, and phone.
Quality improvement methods CCA collects data from Web based EHRs (see above), compares each PCP to overall SCO rates on various performance measures, and shares results with PCPs every quarter to identify areas for improvement.

CMIS generates reports at networks and state for QI activities. AHEC audits charts and compares to HEDIS and NCQA goals.

NCCCN provides clinical and technical assistance to 14 networks, and conducts training for networks and providers on new QI initiatives. Networks also lead QI activities.

CHP conducts an annual member satisfaction survey to gauge whether the consumer’s goals and outcomes have been met. State law requires clinics to publish data to the online statewide quality reporting system. Annually, PCPs are required to demonstrate improvements in cost, quality, and patient experience to recertify as a health home. State-led PCP learning collaborative facilitates change. In person team meetings include local AAAs, and other partners who discuss care coordination processes. PCPs and specialists participate virtually. Multiple trials to test and improve model(ACE, AD-LIFE, PEACE, and so on).
Table 2. Characteristic and case management approaches of practicing primary care practice, by programs.
Program or Organization
  Commonwealth Care Alliance (CCA), MassachusettsCommunity Care of North Carolina (CCNC)Community Health Partnership (CHP), WisconsinHealth Care Homes (HCH), MinnesotaSumma Health System, Ohio

Source: Program details compiled from program Websites; published sources; and Mathematica-led phone calls with representatives from selected organizations, conducted between April 14 and May 10, 2011.

AAA = Area Agency on Aging
ACO = Accountable Care Organization
AHEC = Area Health Education Center
BCBS = Blue Cross Blue Shield
CC = Care coordination
CHC = Community health center
CM= case manager
EHR = Electronic health record
FQHC = Federally qualified health center
IDS = Integrated delivery system
IPA = Independent Practice Association
LTC = Long term care
MAPCP = MultiPayer Advanced Primary Care Practice (Demonstration)
NCQA = National Committee for Quality Assurance
NP = Nurse practitioner
PC = Primary care
PCP = Primary care practices
QI = Quality improvement
RN = Registered nurse
Rx = Prescription
SW = Social Worker

A crosswalk of the NCQA and MN Health Care Home certification standards is available at http://www.health.state.mn.us/healthreform/homes/certification/CertificationAssessmentTool_100423.doc.a

Range in size of practices (number of physicians or clinicians) About one dozen of the 25 participating PCPs employ 10 or fewer physicians.

Most are small (65% serve < 500 patients) but can be large practices.

Also includes CHCs, residency programs, and so on.

Most clinics are part of large systems; two very large (Mayo and Marshfield), one IPA with about 50 PCPs, and one practice with <12 PCPs. Many small practices in MN (<5) are affiliated with large clinic networks. 1,000 MDs in Summa Health System IDS; 57family practice physicians in Summa Physicians Inc.;100300 non Summa Health System physicians.
Practice types or specialities Of the 25 practices, 10 are FQHCs; the other 15 include academic practices, small group practices, and an IPA that contracts with some one- or two- physician practices. All types, including independent practices, CHCs, residency programs, and health departments Most are PCPs or multispecialty clinics; also two large IDSs (Mayo and Marshfield). All types, including FQHCs, large specialty groups, and small independent practices All inpatient and outpatient specialties (including geriatrics and palliative care units), and a physician/NP visiting house-calls team.
Medical home certification requirements Internal requirements. CCA offers support to practices on approaches and standards of care, behavioral health integration, etc. as needed. CCA also ensures access by providing a professionally staffed24/7 call center for SCO enrolled patients in participating practices (can substitute for or complement PCP afterhours coverage).

PCPs sign agreement certifying that they meet State standards and have contracted with one of the regional networks.

PCPs in MAPCP demonstration must meet NCQA Level 1 certification by 2012.

BCBS also paying more for NCQA certified practices through PCMH Blue Quality Physician Program.

Information not collected Minnesota health care home certification standards (exceed NCQA in some domains).a Standards integrate patient and family centered care concepts as key component.

Using NCQA standards Working toward

ACO certification

Staffing or team requirements PCPs must establish multidisciplinary teams with staff from PCP and CCA ; CCA provides enhanced primary care, including home visits, comprehensive assessments, and developing individualized care plans with PCP. CM (nurse, social worker, or other clinical professional) roles determined by the network. Some CMs are imbedded in PCP and function as part of PCP team, others work with patients across multiple PCPs. Case management team (one RN, one NP, and one social service coordinator) members provide direct care and assessment in the home, and accompany the patient to PC visits. Care team staffing, design, scheduling, and site of operation is flexible and structured so PCP can best meet CM requirements. Core team includes PCP/geriatrician, RN/NP, pharmacist, CM/social worker from local AAA. On call team of specialists (pulmonologist, cardiologist, psychiatrist, physical/occupational therapist). Core team meets in person weekly to discuss care and calls on specialists when needed.
Electronic health record /information technology (IT) requirements PCPs must maintain web based EHRs for SCO enrollees, from which CCA collects data and shares results with PCPs every quarter.

Networks collect claims and patient outcome data (through chart review). CM uses data to identify high need, high cost users; PCP uses outcome reports for QI.

Independent chart audits through AHEC

CHP maintains EHR system; uses claims data to populate a relational database with cost, utilization, diagnostic, and demographic information that is used for State reports. HER does not currently include Rx information. Paper copy of patient record and health assessment provided to PCP. All PCPs must have electronic and searchable patient registries; system design varies by PCP. Providers maintain separate EHR systems. In inpatient settings, clinician stake notes on the same record and share info w/PCP via alpha page, email, fax, and phone.
Case manager location/ sponsorship CCA CM staff are jointly recruited by CCA and participating PCPs; may be exclusive to one PCP if case mix warrants, otherwise CCA CMs spread time among practices. Regional networks hire case managers; some CMs work with multiple PCPs; some work in one PCP if it is large and/or has many complex patients. CM staff employed by CHP and each team works with multiple PCPs, who see CHP and non CHP patients. CM or CM team directly employed by the PCP or PCP’s affiliated health care network or contracted with vendor or community public health agency CM employed by local AAA; services funded by Medicaid HCBS waiver
Allocation of case management resources to complex patients and caseload CCA assigns primary care CMs to each PCP; each CCA NP manages 40 to 65 SCO dual eligible enrollees, along with geriatric social workers. Identified by physician referral and from Medicaid claims data. Patients with multiple ER visits, Rx claims, or certain diagnoses are selected for intensive “high touch” CM (about 58% of all Medicaid beneficiaries). Average CM case load of 1: 4,000 patients. Level of interaction depends on the needs of the patient. About 60 patients assigned to each CM team. PCPs assess each patient’s complexity (rated on a scale of 04) and use a patient registry to identify patients who have the most complex needs. More complex patients receive more case management support/time. Identified by physician referral and upon discharge. Area duals get care at Summa Health System and at AAA (shared population). CM is responsible for needs assessment.
Features each program believes contribute to success Offers both enhanced primary care and case management. Participating PCP must designate a clinician “champion” to determine how best to apply the CCA care model to that practice’s staffing and patient mix; CCA may reimburse for clinical leader’s time. Physician leadership and buy in; CMs and clinicians regularly share treatment plans; some networks pay physicians for their consultation time; delivery model innovation/variation at the network level. Patient centered program design; patient focused leadership and staff. Critical mass of 2030 CHP patients in a PCP helps a practice understand CHP’s system. Strong administrative and physician leadership and buy in; statewide momentum built early on; State-led learning collaborative to support PCP transformation; many small clinics affiliated with large health systems can access additional resources Physician and administrative leadership; AAA culture of innovation; leadership has demonstrated program savings to the sponsoring hospital
Table 3. Financing resources and payment for case management of complex populations, by program.
Program or Organization
  Commonwealth Care Alliance (CCA), MassachusettsCommunity Care of North Carolina (CCNC)Community Health Partnership (CHP), WisconsinHealth Care Homes (HCH), MinnesotaSumma Health System, Ohio

Source: Program details compiled from program Web sites; published sources; and Mathematica-led phone calls with representatives from selected organizations, conducted between April 14 and May 10, 2011.

ADB = Aged, blind and disabled
ACO = Accountable Care Organization
BCBS = Blue Cross Blue Shield
CC = Care coordination
CM= Case manager
ERISA = Employee Retirement Income Security Act
FFS = Fee for service
IT = Information technology
MAPCP = Multi-Payer Advanced Primary Care Practice (Demonstration)
P4P = Pay for performance
PMPM = Per member per month
QI = Quality Improvement
SNP = Special Needs Plan

Source of funds for from case management or care coordination provided by primary care practices Medicaid and Medicare (CCA is a SNP) Medicaid; State funds for CM of uninsured through Health Net; Medicare and some commercial payers, starting in 2011 through 646 and MAPCP demos.
CMS Federal grant funds to state for demonstrations. Some regional and networks get private grants to augment State support.
Medicaid and Medicare (CHP is an SNP) Medicaid, Medicare (through MAPCP demonstration), private insurance and State employee group. Non-ERISA based. Initial grant funding from AHRQ and National Palliative Care Research Center for ADLIFE and PEACE Trial. Medicaid, Medicare Advantage, professional fees, and subsidies from affiliated hospital and hospice.
Method and amount of payment to PCP for CM/CC

CCA pays PCPs full or modified capitation rates for each enrollee.

From total premiums received, CCA pays for the investments in the PCPs (for example, IT enhancements); added wraparound staff.

Total payment of $18.72 PMPM for each participating Medicaid ADB patient, which is split between the PCP and network. PCPs not participating in CCNC can receive $1PMPM for each ADB patient. CCNC-participating PCPs receive $5.00 PMPM. No current payment to PCPs. In the past, CHP has tried to pay PCPs $25 per month or $125 per care plan review for CM. The payments were incompatible with large PCP billing systems, so CHP discontinued CM payments.

State pays PMPM CM fees, tiered by patient complexity and established by standardized assessment

Five tiers: (0) = none, (1) = $10.14, (2) = $20.27, (3) = $40.54, (4) = $60.81.

Rates increase by 15% for patients whose primary language is not English or who have serious and persistent mental illness.

In 2011 CMS MAPCP demo, Medicare pays State rates(above). Proposal under review.

Private pay CC rates separately negotiated by clinics and insurers.

In gran-funded AD-LIFE and PEACE trials and the pilot for program through Summa Health System’s Medicare Advantage plan, PCPs paid onetime $75 “participation” fee to cover costs of reviewing the initial patient care plan, and to meet with the case managers and health coach. In ADLIFE and PEACE trial, PCPs paid $75 for each patient enrolled in the intervension group.
Method and amount of payment to program sponsor for CM/CC

Medicaid and Medicare pay risk adjusted premiums to CCA for SCO enrollees; CCA pays hospital, home health agencies, and specialists based on Medicare or Medicaid fee schedules.

From total premiums received, CCA pays costs for CCA team members complement PCP staff in conducting multi-disciplinary assessment home visits, and coordinating all care

Total payment of $18.72 PMPM for each participating Medicaid ADB patient, which is split between the PCP and network. The regional support networks receive $13.72 PMPM. Capitated payments from Medicaid and Medicare paid for each covered member using a formula based on 95% of area nursing home costs. State uses risk tiered PMPM fee structure to pay PCPs directly for CM services. (See methodology described below). CM payment to AAA through Medicaid waiver (external to Summa Health System).
Bonuses or extra pay to PCP for meeting performance thresholds? CCA shares a portion of rewards networks for asthma and diabetes care improvement. Networks determine payment to PCPs. Statewide Physician Incentive Program rewards networks for asthma and diabetes care improvement. Networks determine payment to PCPs. N/A MN runs a separate P4P system to pay PCPs that meet or exceed quality measures reported by the statewide system. Certified health care homes are eligible for payment. P4P through some health plans.
New Payer Developments BCBS of Massachusetts may contract with CCA to provide comprehensive care to people with spinal cord injuries. In Medicare 646 demonstration for dual enrollees, CCNC eligible for savings to be used for QI. Seven counties will participate in CMS MAPCP demonstration. N/A MN will participate in CMS MAPCP demonstration. Summa Health System transitioning to certified ACO.

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