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Tammy Yount, MSHAI, PCMH, CCE – Care Management in Managed Medicaid
Episode 5616th May 2024 • Move to Value • CHESS Health Solutions
00:00:00 00:14:11

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Today, we're discussing Care Management in Managed Medicaid with Tammy Yount, CHESS Application System Analyst. We'll explore why it's essential for organizations to tailor their care management programs to fit their own unique needs, so they can holistically focus on the patient while optimizing value in healthcare.

Tammy Yount, welcome to the Move to Value podcast.

Thank you Thomas, for inviting me and I'm happy to be here.

So, Tammy, let's talk about care management in managed Medicaid. How does a care management program save money and healthcare?

I would say that saving money is one goal of a care management program. However, I would offer that the goals of a care management program should align with the triple aim that's born out of the 2001 Institution of Medicine report Crossing the Quality Chasm. So that report underscored 3 aims, if you will, one primary aim and two secondary aims. So the primary aim is to improve the health of populations with the secondary aims of improving the patient experience of care and at the same time reducing the per capita cost. So these are lofty aims given our current healthcare landscape and the payment models that we exist in. Not all organizations are the same. You have some large organizations that have a plethora of resources and smaller organizations with very limited resources. So each organization has its own unique structure and individual challenges and there's no one-size-fits-all care management program. So I would say there are many ways to build a care management program that will allow you to achieve the triple aim and organization needs to find the blueprint that works best for them. So when an organization's doing the right things, measuring the right things and focusing on improving the right things, the cost savings should follow. And I believe it was W Edward Demmings that said it best, you know, manage the cause, not the result. That's not to say that the organization doesn't need to have a clear understanding of the underlying processes, cost drivers, the population characteristics. He also said if you can't describe what you're doing as a process, you don't know what you're doing. And my favorite quote for him is in God we trust, and all other things bring data.

Tammy, tell me, how would a practice create a care management program?

So it's a bit of a chicken and egg conundrum when you're trying to create your care management program, you need many things in the least of which is data. I would say you need to start with the data, but few organizations have the data to inform their program design. Most organizations design their care management program backwards, meaning they design the program around the resources they have versus identifying the resources that they need based on the characteristics of the populations they're managing. So I would say the first thing you need to do is collect data and evaluate the data. So from the data that you've captured, then you would begin to develop your road map for how you're going to operationalize your care management program. And these would be very specific to each organization because each organization serves different patient populations, has different resources and different needs.

What are the keys to a successful care management program?

It's going to depend on who you ask. So I'm a data person, so in my world, all things starting in with data. But if you were to ask the payer, the nurse, the CEO, the CFO, the CIO, and most importantly, the patients, their families or caregivers, you're going to get a different response and varying perspectives. For a care management program to be successful, it's going to need to combine all of these perspectives. And critical to any successful program is having a mission, vision and values. And you'll need to operationalize your plan with those elements. And so you know, it brings to mind another quote by Deming, which says that every system is perfectly designed to get the result it does. So the organization will need to create a vision that aligns and fits with their cultures and values and understanding that at the center of the program is always the patient and any successful care management program revolves around that patient family and caregivers. It's not unlike a cell. And so I'm a biology major, so I take things back to the cell. So a cell is made of a nucleus and then the surrounding cytoplasm and all the organelles that are in that. And just like in the cell, the, the key component is the nucleus. It's where all the DNA is housed. And so that represents the patient. All of the organelles in the cytoplasm are all the other key stakeholders and they have their own function. But you always have to keep it patient centric. So a successful care management program is going to be one where the patient is at the center.

How do you identify the criteria and then the patients for care management? I mean are there tools available?

There are tools available and how you identify patients and criteria for your care management programs going to be dependent upon your particular organization. Some organizations have more broad resources. They may have systems in place that do complex algorithms that can output list of patients who could benefit from care management. Other organizations have more tight resources, so they don't have complex systems to identify patients via complex algorithm. So they may use something that's more simplistic like pulling reports and looking at patients who have multiple chronic conditions or pulling reports that can show that patients have a high utilization. If they have access to cost information, they may use that to identify. It can just be something as simple as your clinical judgements. So what you need though in any care management program is that everyone who is in the practice organization, care management organization, they have a shared mental model on what that criteria is.

What is a comprehensive risk stratification process for selecting patients for care management and could you, perhaps, share some of the common techniques used in the selection?

So in the Medicaid space, we use what's called the CDPSRX risk algorithm to identify patients and it combines claims, clinical data, and pharmacy data to identify patients who are at various levels of risk. And so you can use that as a risk stratification model. The AAFP has another model of risk stratification, it's a six level risk stratification. Medicare utilizes CMS and HHS, HCC risk stratification. So there are many different risk stratification models that you can use. These are some of the more common techniques. While it's not, these are not the only techniques that you can use and you can have your own defined risk stratification model. So it's going to depend on your particular situation, resources, your unique characteristics.

Great. Can you tell me, here at CHESS, what technique we use for the selection?

So at CHESS, we utilize our own risk scoring methodology that incorporates the CDPSRX risk model that we use to normalize risk across all of our various Medicaid payers. So the PHPS or the Medicaid payers send us patient risk scores on a monthly cadence and we run on a monthly cadence our CDPSRX risk model and we compare the two risk values and then we impute the higher of the two risk values and that is the CHESS risk score. So once we've initially outreach to the patient and we have determined that they are interested in care management, then we complete a comprehensive health assessment which also identifies their need. So that is the process we use for stratifying our patients and identifying them for care management.

So, Tammy, how does a practice monitor patients for care management?

There are many ways to monitor patients for care management. And again, it goes back to the uniqueness of the practice or the organization. So you can have very sophisticated systems that will allow you to aggregate all your patients into a system that will identify patients who need care management at the point of care. You can also have something as simple as a patient registry, an Excel spreadsheet, having a mechanism within your EHR system that will flag and tag or identify these patients that are either in your care management program or are eligible for or would benefit from care management. So it varies from situation to situation and you would just need to evaluate what the needs are of the particular practice.

That's great. What advice do you have for providers who are motivated to implement a care management program in their practice?

So my advice would be to try to understand, to envision what kind of program you want to create. So you need to have a clear vision of the program and then what you need to do is collect the data and just determine like what program fits best with your particular situation. And then once you have the vision and you have the data to support it, then you can begin to create your blueprint and your road map and determining the key resources that you need and identifying key stakeholders and partners. If you can't always, you may not always be able to do everything in house. It may be that you want to partner with someone, someone like CHESS, who could help you implement this program. You don't have to go, you don't have to be able to do everything by yourself. You just have to create a vision for what you want and then identify resources and partners.

So, Tammy, why, why is data so important in this? And tell me if you would, what types of data your team looks at when assessing some of these new programs.

So data is important because it's the basis for decision makings. If you're not using data then are you making good decisions? And I will say that on our team, we aggregate a lot of data, we aggregate claims data, we aggregate encounter data, we aggregate clinical data, we aggregate risk data. So having a holistic point of view, it kind of helps you to evaluate like the the populations that you're serving, where's the low hanging fruit, how do you allocate these resources, what are their needs? Data is the key to informing all of these decisions. It's not just about cost drivers, it's about health drivers. And so having available data helps you to make these decisions.

Why is care management important in Medicaid? What's the big deal?

Well, the big deal is, is that in Medicaid, we have some of the most vulnerable and costly patients. And we have the opportunity to bend the cost curve if we can get these patients into a care management program so that we can organize the care for them and make sure that we're eliminating duplication. That we're connecting them to the resources that they need, providing them with resources for social needs, helping them understand their care conditions, helping them understand how to utilize the healthcare system, when to utilize the healthcare system and provide this support system underneath them the safety net to be able to manage their health.

Tammy Yount, thank you for joining us today on the Move to Value podcast.

Thank you for having me, Thomas.




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