Volume_2
Welcome (Vol.2)
Welcome to Community Care Communications, Volume 2. The purpose of this blog is to facilitate communications throughout the state about the program, the 646 waiver, network activities and other news. Community Care staff members welcome suggestions and comments.
End of Life Care Initiative
Community Care consultant Jonathan Fischer, MD, is hoping to meet with networks about End of Life services and resources across the state. Specifically, Dr. Fischer would like to meet with individual networks to provide the groundwork for the formation of various CCNC pilots in End of Life Care, and he is willing to attend upcoming network management, chronic care management, or network provider meetings in CCNC networks.
Under Dr. Fischer's project, Community Care is seeking to investigate possible pilot programs in End of Life, including initiatives that:
- Increase access to palliative and hospice care by an interdisciplinary team of skilled palliative care professionals, including, for example, physicians, nurses, social workers, pharmacists, spiritual care counselors, and others who collaborate with primary healthcare professionals.
- Enable patients to make informed decisions about their care by educating themselves on the process of their disease, prognosis, and the benefits of potential interventions.
- Develop health care and community collaborations to promote advanced care planning and completion of advance directives for all individuals.
- Make advance directives and surrogacy designations available across care settings.
Dr. Fischer, a Family Physician with the Carrboro Community Health Center, part of Piedmont Health Services, says, 'While advances in medical treatment have changed most causes of death into chronic conditions, our care systems have not adapted to serve those patients nearing the end of life.' He added, 'The availability and quality of health care for those nearing the end of life is largely thought to be unreliable and lacking.'
Patients with chronic illness are living longer, and patients living with long-term disabilities are more common. By 'reconceptualizing dying and end of life care,' Dr. Fischer believes practices can better utilize advanced directives and palliative care services for those with chronic disease. He also recognizes that one barrier to enhanced care is Medicare's restrictive hospice benefit. He is looking to interview leaders in local CCNC networks to discuss these and other issues relating to End of Life Care.
Chronic disease, while potentially challenging for a patient, their families and care providers, presents an interval of opportunity to introduce an end of life focus, he says. Effective treatment and support strategies include advance care planning, symptom relief, and attention to spiritual and family matters, and these strategies can emerge from a patient-centered approach to chronic disease management.
Dr. Fischer cites several national examples of collaboratives that improve the quality of End of Life Care, including those sponsored by the Institute for Healthcare Improvement and the Center to Improve Care of the Dying. Innovations have included the creation of new services, as well as the integration and strengthening of existing services. In one noteworthy example, the Franciscan Health System in Tacoma, Washington, asked physicians to identify high-risk patients and then gave those patients 'prehospice services' through palliative care, pastoral care and volunteers. Patients receiving earlier intervention used fewer hospital days, more died outside the hospital, their satisfaction with care was higher, and they used hospice care for more days before death than did a matched set of patients without special supportive services.
To make such improvements of care financially viable, the challenge remains to identify interventions that reduce the use of truly avoidable and unnecessary services such as repeated hospitalizations, while simultaneously enhancing the overall quality and access to care.
In meeting with networks, Dr. Fischer is seeking to learn more about community frustrations with the lack of resources or other barriers to quality End of Life Care. Please contact him to discuss these important issues further. Contact Jonathan Fischer, MD, at fischerj@piedmonthealth.org, or by phone at (919) 942-8741.
Networks Provide Transitional Care from Hospital to Home
Community Care networks are leading concerted efforts to provide Transitional Care that is improving outcomes for patients transitioning from the hospital after an acute illness. Two networks are highlighted below.
Community Care Plan of Eastern Carolina has been piloting a concentrated transitional care effort since last December. Following the lessons learned from the Chronic Care pilot in Bertie two years ago, Linda Jenkins, one of four project coordinators for the 27-county network, said network leaders believe their greatest chance for significant cost savings can come from focusing on hospital care and the transition of patients to their homes. With a focus on education, the network has case managers in five of the 18 hospitals in the network, which is the state's second-largest Community Care network. Those case managers review medications and eliminate redundancies, as well as review charts with the primary care provider. 'The hospital discharge is the best chance to change habits,' Jenkins said, and case managers look for those 'teachable moments' to improve patient compliance and patient self-care. Having real-time access to hospital data has proven critical to success with transitions to the home setting for these case managers and their patients.
In another large network, the seven-county Sandhills Community Care Network has six case managers who are hospital liaisons, visiting patients while they are hospitalized and having remote access to hospital data for those patients who are transitioning to home following a hospital stay. The network has seven hospitals in its region, ranging from FirstHealth Moore Regional with more than 300 beds to smaller 20-25 bed hospitals in rural counties. Tammie McLean, RN, Network Director, thinks this established hospital-to-home link makes them 'strategically more ready for the 646 waiver' to manage the care of the dual eligible patients in their network. Three of their counties - Hoke, Moore and Montgomery - are part of the initial 26 counties included in the 646 waiver. Hospital leadership has proven important to their success, as they have been willing to share data and support the network's efforts. Once the patient is released from the hospital, the case manager works to reconcile the various data, especially the medication list, and send it on to the primary care provider. The real obstacles have come from how to share data since hospitals do not want patient data printed in order to ensure privacy. McLean and her case managers have set up multiple computer screens so that case managers can accurately copy data from one screen (from the hospital data source) onto the network provider's database. Lisa Chase, the network's Chronic Care project coordinator, says this multiple screen approach has saved not only paper, but also improved accuracy, by allowing case managers to have multiple screens up at the same time.
Transitional Care also can be a key in cutting pharmacy costs in Medicaid. Case managers can make sure patients are on medications on Medicaid's Prescription Advantage List whenever possible.
State Employees Health Plan
Community Care has met with State Health Plan (SHP) leadership to identify potential opportunities for working together. SHP is interested in re-engineering their support services to be able to better support patients and physicians in a coordinated fashion and within the community. Since most of the physicians are also part of Community Care, they are interested in engaging the CCNC infrastructure in this effort. They seemed open to exploring a pilot project or in having NCCCN bid on the RFP either alone or in partnership with other groups. They provided some data on the plan and its members.
On October 14th, SHP issued the RFP for Population Health Management Services that would support the PCMH model of healthcare delivery and the Collaborative Care model for members with chronic disease. In addition to providing the standard array of disease and case management services through telephonic interactions, the contractor will provide support for primary care providers, provider groups or networks to assume or direct disease and case management activities for Plan Members locally. Bids were due December 15th, 2009. Community Care has participated with three bidders.
January Start Date
NCCCN signed the waiver agreement with the Federal government in December. The start date for the demonstration is January 1, 2010.
DMA Director Encourages CCNC
DMA Director Craigan Gray, MD, MBA, JD, said at October's Community Care meeting while Medicaid 'is removing $1.5 billion from the health care economy in North Carolina' through budget cuts, Gray sees this as an opportunity to fundamentally change the delivery of health care for Medicaid recipients in ways that can build for the future of health care in North Carolina. 'Every program is on the table,' he told Community Care leaders, and he urged them to view this as an opportunity to 'do what we've always wanted to do.' He said Community Care's leaders should value the model it has developed and how that model can lead the nation for reforming Medicaid.
Update on Prior Authorization for Non-Emergency Imaging, Specialized Therapies
Following utilization reviews, Medicaid will require Prior Authorization for non-emergency outpatient high-tech radiology and ultrasound procedures as well as specialized therapies, such as PT, OT, Speech therapy and Respiratory therapy. The November DMA Medicaid Bulletin (http://www.dhhs.state.nc.us/dma/bulletin/1109bulletin.htm), outlines the new requirements.
As reported in the last special edition of the Community Care Chronicle, MedSolutions, the new prior approval fiscal agent for certain radiology procedures, including CT, MR, PET scans, and ultrasounds, has contacted providers about their services. Please refer providers to the December Medicaid bulletin (http://www.ncdhhs.gov/dma/bulletin/1209bulletin.htm#radiopa) for the latest updates and to view populations exempt from the PA process. Providers who have questions also can call DMA's Practitioner and Clinic Services at 910-355-1883.
As of December 1, 2009, PA for outpatient specialized therapies (occupational therapy, physical therapy, speech therapy, respiratory therapy, and audiology services) will once again be required for recipients under 21 years of age. Effective with date of service January 1, 2010, PA for outpatient specialized therapies will also be required for recipients 21 years of age and older. Prior authorization will be required for all therapy treatments regardless of the setting. The Carolinas Center of Medical Excellence (CCME) will introduce a new prior authorization web site where providers can access detailed information and instructions for registering and submitting requests. All requests must be submitted via the CCME web site (http://www.medicaidprograms.org/nc/therapyservices/pages/home.aspx).
Prior authorization is not required for dually eligible Medicaid/Medicare recipients. In addition, for Local Education Agencies (LEAs), the prior authorization is deemed met by the UEP process.
New Name for Fiscal Agent
In August 2008, Hewlett-Packard (HP) acquired EDS, fiscal agent for the N.C. Medicaid Program, and as a result, EDS is changing its name to HP Enterprise Services.
North Carolina Medicaid providers will not be affected by this change and will probably notice very few changes. Providers will begin to see the HP logo or the HP Enterprise Services name on correspondence and forms. The mailing address is not changing but providers should address the mail to HP Enterprise Services. E-mail correspondence will come from an '@hp.com' e-mail address rather than an '@eds.com' e-mail address. Also, providers will hear the HP name when contacting the Raleigh call center. The Medicaid Bulletin states: 'Think of it as a sports team changing jerseys. The same players are on the field working hard to deliver the outstanding Medicaid services you've come to expect from a trusted business ally.' Providers can contact HP Enterprise Services at 1-800-688-6696 or 919-851-8888.
Online Reports from Informatics Center
Chronic Care Reports and Quality Measurement and Feedback (QMAF) Reports are now available in the Informatics Center Reports Site. QMAF Reports include claims-derived quality measures which will be updated quarterly, with network, county, and practice-level results. These reports include measures pertaining to diabetes, asthma, heart failure, and post-MI care; as well as adult cancer screening and pediatric preventive services. Chart review reports with Practice and Patient-level results are typically posted within 24 hours of completed reviews for each practice. These reports include measures pertaining to diabetes, asthma, hypertension, heart failure, and ischemic vascular disease care. A final set of 2009 chart review reports will be posted in December, displaying internal and external benchmarks for provider reference.
Chronic Care Reports are now posted in a web-based reporting format, and will be updated quarterly.
Reports include:
- Patient demographic, diagnosis, cost and utilization detail for Chronic Care enrollees, with identification of patients meeting screening criteria for additional care management services
- Hospitalization details for patients with frequent readmission
- Summary statistics by network and county
- Quarterly trends in cost, utilization, and readmission rates
- Enrollment by practice
If you do not yet have authorized access to the Informatics Center, talk to your Network Administrator.
Coming Soon to the Informatics Center
Staff at the Center will soon provide an enhanced user permissions structure, which will allow NAMs to authorize users with limited access to specific regions, counties, or practices within the network; an authorization category for external users, that will allow direct provider access to Pharmacy Home features and allow CA PCP access to their own practice reports; and secure file sharing within network, region, or practices.
HIT Collaborative Submits Plan
The Health Information Technology Collaborative, appointed by Governor Perdue and led by the Health and Wellness Trust Fund, has submitted an application for ARRA funds for the development of secure and meaningful statewide health information technology. Allen Dobson, MD, and Laura Gerald, MD, represent Community Care on the collaborative, which submitted their proposal in mid-October. The group has been working to build upon the model and infrastructure already in place in Community Care networks, Gerald said. The full plan can be viewed online at http://www.ncrecovery.gov/calendar/CarolinaInfoTechPlan.aspx
Legislative Briefing Available
Community Care of Wake and Johnston Counties has put together a useful legislative briefing summarizing Community Care, its cost savings, and other useful information in a two-page summary that can be shared with legislators and others interested in the structure of the program. Titled 'Improving Patient Health, Saving Medicaid Hundreds of Millions of Dollars,' the briefing contains four case summaries and can be used by all networks. Contact Betsy Tilson, MD, Medical Director for Community Care of Wake/Johnston Counties for more information at (919) 792-3621 or btilson@wakedocs.org.
Nurse Practitioners in Nursing Homes
The Northwest Community Care Network reports that using a nurse practitioner to provide care in a nursing home is increasing accessibility and efficiency of care, as well as helping increase patient and family satisfaction. At the October Community Care meeting, Jim Graham, director of the Northwest Community Care Network, said their pilot uses a nurse practitioner at a 130-bed facility in Wilkes County to support the medical director as an extension of community-based primary care. In a recent report from The Commonwealth Fund, the presence of a nurse practitioner reduced hospitalizations by 45 percent, with no change in mortality; reduced emergency department visits by 50 percent; and estimated cost savings at $103,000 a year in hospital costs per nurse practitioner. At this time, neither Medicare nor Medicaid reimburses nursing homes for employment of Nurse Practitioners. Graham and others are meeting with CMS and Long-Term Care Association to explore implementing reimbursement for those services and expand this model in the state.
HealthNet Gets Another $2 Million
HealthNet, a program that works with the Community Care networks to find medical homes for the uninsured, received a $2 million increase from the General Assembly this summer, and the Office of Rural Health and Community Care is seeking to get more Community Care providers participating in HealthNet. HealthNet now has $4.8 million in state appropriations. Through grants to community networks, HealthNet supports communities' efforts to connect a low-income or uninsured person to available health care services in his or her area. ORHCC Director John Price said the program now is in 38 counties and serves about 50,000 individuals.
Sharing the Vision
The Louisiana Health Care Review group visited Southern Piedmont Community Care Plan and Carolina Community Health Partnership on July 20th and 21st. To the credit of Cindy Oakes, Debbie Clapper, and their teams and the overall program overview provided by Dan Gottovi, MD, the Louisiana physicians that were on the trip 'were blown away by both the processes you all have put in place and the resulting outcomes.' They intend to implement pilot programs in Louisiana and Mississippi modeled after Community Care. On October 29th, there was a follow-up call with the Mississippi Medicaid Director and medical leaders regarding a reform strategy built around a PCCM/Community Care type initiative.
On August 20th and 21st, the Milbank Fund, in collaboration with Brookings, Dartmouth, and Commonwealth, hosted a meeting with representatives from Indiana and North Carolina to discuss the development of the 646 Medicare Demonstration and the lessons for building accountability-based payment reform within Medicare. A paper on the proceedings will be prepared to help guide Medicare policy development efforts.
On October 30th, Dr. Tom Irons presented on North Carolina's delivery system innovations as part of a congressional briefing in Washington, D.C. sponsored by the Alliance for Health Reform, a congressional education group led by Senators Rockefeller and Collins.
On October 27th, Dr. Allen Dobson met with Kentucky's Medicaid Director and senior policy staff and presented to the House / Senate Committee on Health.
Ed Homan, MD, Chairman - Health and Family Services Policy Council, Florida House of Representatives, Carol Gormley, Council Director, and Eric Pridgeon, Staff Director - Health Care Appropriations, met with Allen Dobson, MD, Tork Wade, and Denise Levis on November 12th to learn about North Carolina's medical home program. Dr. Dobson met with Dr. Homan's legislative committee.
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