Care Management - Dr. David Hamburger

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					  identify                 stratify                         assess              impact




                 Case and Disease Management
                 David Hamburger, MD




                                PROVIDERS          CCR

                      PHARMACY                               ACM



                EPISODIC CARE            PATIENT                PRECERT/
                                                              REGISTRATION



                     HRA                 CORE DM                   DM VENDORS




                           REGIONAL DM             REGIONAL CM




March 6, 2003                       Proprietary and Confidential                    2
                Disease Management Programs

           Ø Asthma                          Ø Diabetes
           Ø Congestive Heart                Ø End Stage Renal
             Failure                           Disease
           Ø Coronary Artery                 Ø Low Back Pain
             Disease



March 6, 2003             Proprietary and Confidential           3




                Disease Management Programs

                Ø IDENTIFY most “actionable” members
                Ø FOCUS interventions early
                Ø EMPLOY evidence-based clinical
                  guidelines
                Ø FACILITATE member/physician
                  communication


March 6, 2003             Proprietary and Confidential           4
                Disease Management Programs
                Member Identification
                  • Real-time pharmacy data
                  • Hospitalization/discharge data
                  • Referrals from case managers,
                    concurrent reviewers & discharge
                    planners


March 6, 2003                       Proprietary and Confidential                     5




         What is Case Management?
                                         Member




                                         Advocacy


                                         Assessment
                                                             Communication
                                Evaluation        Planning
                                       Case Manager
                  Empowerment
                                                   Facilitation
                                  Coordination

                                                       Problem Solving
                         Collaboration

      Providers                                                              Aetna
                                      Source: CMSA


March 6, 2003                       Proprietary and Confidential                     6
 Aetna Case Management Goals and Objectives


         Collaborate with the member, the member’s family, physician(s) and
         other healthcare providers to develop and implement a Case
         Management plan that meets members’ needs
         Coordinate quality, cost effective sequencing of care
         Work to return members to optimal level of health with maximum level
         of independence and optimal level of function
         Increase member and provider satisfaction through collaboration on
         development and implementation of the Case Management plan
         Develop targeted interventions for Case Management populations
         Provide support and assistance to members and their families when
         dealing with end of life issues




March 6, 2003                       Proprietary and Confidential                          7




 CM Planning

         A collaborative process involving the member, family or significant
         other, care provider(s) and treating physician
         Includes short and long-term goals
         Based on interventions identified through assessment of member
         needs
         Interventions may include, for example


           § Coordinate benefits, e.g., DME               §Arranging care as needed
           § Identify and arrange community                        •Home health
                services                                           •Outpatient infusion
                                                                   treatment
                                                                   •Meals on Wheels




March 6, 2003                       Proprietary and Confidential                          8
 CM Planning (Cont’d)


         Identify and address member and care giver needs for
         education
           § Management of symptoms and treatments
           § Understanding of medications
           § Nutritional needs
           § Supportive services – both member and care giver

         Focus on
           § Arranging appropriate level of care
           § Coordinating multiple providers




March 6, 2003                          Proprietary and Confidential                           9




 Key concepts of a Care Management Team
 § Care Management Teams will be organized geographically and are responsible for the
    member’s continuum of care
 § Each member will be managed by the team member that makes the most difference in quality
    outcomes
 § The streamlined approach will decrease the number of Aetna staff contacting members and
    providers and increase operational efficiencies
                                              Medical Directors

                                           Managers/Supervisors
                                                    Motivates,
                                                    Mentors,
                                                Balances Workload


                                    Inpatient Care        Care Management        Disease
                                     Coordinator              Associate        Management

        Precertification
         (call centers)
                                                Case Manager

                                              Medical Directors
                                                                                Vendors

March 6, 2003                          Proprietary and Confidential                          10
  Attributes of a Care Management Team

                                                                                             National
  Efficient                      Medical Director                                           Consistency




                                                Member                             Care Management
    Case Manager (CM)                           Focused
                                                                                   Associate (CMA)




Promotes                               Inpatient Care
 Use of
 Clinical                        Coordinator (ICC)                                             Team
Judgment                                                                                      Oriented

March 6, 2003                          Proprietary and Confidential                                  11




 Teamwork was identified as a fundamental
 attribute of the medical services model



                                                 Inpatient Care
                                                                  Co
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                             Case                                           Disease
                                               Communication
                          Management                                      Management


 Open communication between care management team members is fundamental to the new medical
   services model
 Critical thinking and clinical judgment




March 6, 2003                          Proprietary and Confidential                                  12