Presentation by Felicia Cojocnean, FNP-MSN, BC, Family Nurse Practitioner, Chronic Disease Management, Wellpoint/CareMore

1. Felicia Cojocnean MSN, FNP, AANP-BC
Chronic Disease Management Programs
Wellpoint/CareMore Health Plan
Orange Co/LA, California
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2. CAREMORE
• 1995 –Medical Group with enrolled Medicare
beneficiaries
• 2001-CareMore Health Plan
• 2006- CareMore Special Needs Plan
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3. CAREMORE
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4. CAREMORE
Health Spending & Chronic Disease
Five chronic diseases make up the vast majority of this category*
Diabetes
Congestive Heart Failure
Coronary Artery Disease
Asthma
Depression
* Hypertension contributes to complications
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5. THERE IS GREAT OPPORTUNITY
CHRONIC DISEASES CAN BE MANAGED… BUT USUALLY ARE NOT
Dr Peter B. Bach (6/21/07),study of Medicare in the New England Journal of Medicine
Patients with chronic conditions do not need more doctors, they need a few who
cooperate.
Patients are best served when they have at most a few physicians who work together
well
Commonwealth Fund Health Care Quality Survey,Report (July 2007)
Medical Homes result in better outcome
Elizabeth A. McGlynn et al (2003)
Patients receive appropriate care only half of the time
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6. THERE IS GREAT OPPORTUNITY
CHRONIC DISEASES CAN BE MANAGED… BUT USUALLY ARE NOT
Diabetic complications could be cut 90% with best care and involved patients (Center for
Disease Control and Prevention), yet
Diabetes related admissions have risen from 3.5 to 6.5 million since 1993
Low income diabetics are 80% more likely to be hospitalized
Second heart attacks can be reduced 40% (J.R. Jowers)
More doctors involved in care decreases information exchange and leads to unnecessary
hospitalizations (Wennberg/ Dartmouth)
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7. OUR MISSION
Providing innovative and focused
healthcare approaches to the
complex process of aging.
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8. WHY OUR MISSION
We are here to:
serve our members by prolonging active and independent life
serve caregivers and family by providing support, education,
and access to services
protect precious financial resources of seniors and the
Medicare Program through innovative methods of managing
chronic disease, frailty, and end of life
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9. CAREMORE
A Chronic Care Special Needs Plan
•>70K members nationwide
•Average age = 72 years
•44% Diabetics
•40% HTN and CHF
•16% COPD and Renal Disease
•20% Medicare – Medicaid
•50% with annual income < $30,000
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10. CAREMORE INTEGRATED PATIENT
CARE DELIVERY SYSTEM
COPD
COPD
CAD
CAD
CHF
CHF
Diabetes
Diabetes
Wound Clinic
Wound Clinic
Chronic Disease
Chronic Disease
Support
Support
ESRD
ESRD
Healthy Start
Healthy Start
Monitoring
Monitoring
Hospice
Hospice
End of Life Care
End of Life Care
PCP
PCP
Secondary
Secondary
Prevention
Prevention
Extensivist
Extensivist
Nutritionist
Nutritionist
Palliative
Palliative
Care
Care
Foot care
Foot care
Social /
Social /
Behavioral
Behavioral
Support
Support
Social
Social
Workers
Workers
Clinical
Clinical
Care Centers
Care Centers
(CCC)
(CCC)
Case Manager/
Case Manager/
NP
NP
Risk Event
Risk Event
Prevention
Prevention
Exercise
Exercise
Pre-Op
Pre-Op
Mental Health
Mental Health
Frailty Support
Frailty Support
Extensivist
Extensivist
Management
Management
Predictive
modeling
Integrated IT
infrastructure
Strength
Strength
Training
Training
Longitudinal patient
record
Coumadin
Coumadin
Fall
Fall
Evidence-based
protocols
Point-of-care decision
support

11. THE CAREMORE MODEL
Summary: Integrated care involves nurses, pharmacists and others on care
teams, all working together to achieve a common goal. WellPoint's recent
purchase of CareMore, which provides care for 15 percent of Medicare
Advantage beneficiaries who account for 75 percent of costs, is an example
of successfully integrated care.
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12. CareMore CLINICAL MODEL
Design:
•Provide support
system for PCPs
•So, Chronically ill &
Frail seniors receive all
the services necessary
to live an active &
independent lifestyle
• And, avoid
hospitalizations & other
unnecessary acute
episodes
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13. CAREMORE
Neighborhood Clinical Model
Care
Center
Community
Focus
•Located in the heart
of the neighborhood
Social
Environment
•Designed for seniors
•Resource for family and caregivers
•Frequent classes and activities
Clinical
• Disease Management
• Foot Center
• Healthy Start
• Pre- Op
• Fall Prevention
• Wellness programs
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14. CAREMORE MODEL OF CARE
For the chronically ill:
 The CareMore Care Center serves as a “home” for patients where questions are
answered, care is delivered and coordinated.
 A variety of support services are provided , designed to “fool proof” patient noncompliance with care programs
 transportation
 remote house monitoring through Telehealth services
 home visits
 social service support
 Constant vigilance and use of predictive modeling to allow for early and rapid
intervention
 Healthy Start–complete evaluation within 30 days of enrollment
 Predictive Modeling eg. CARS
 Monitor risk indicators
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15. CAREMORE
A Chronic Care Special Needs Plan
Benefits that fit the need
Free insulin and diabetic supplies
Routine wound care
Free home-based electronic monitoring (Ideal Life)
Blood Pressure
Weight
Blood Glucose
Free Transportation to CareMore Care Centers
24 hour help line
Caregiver support
Home Care
Respite Care
Healthy Start (comprehensive assessment within 30 days of enrollment and individual plan)
A Personal Care Plan for every member
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16. RESULTS
CareMore has consistently produced results that compare favorably to
community norms
In many cases these results have been dramatically superior
CareMore has not tried to change or work “through” the conventional
system but has built a new model that recognizes the increased demands
of the chronically ill
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17. DIABETIC MANAGEMENT
Observation
Many patients with out-of-control diabetes were not brought in control
through insulin use. Common wisdom was that inability to correctly self
administer or improper dosing were driving results. Further, insufficient
support in the areas of nutrition and exercise were observed.
CAREMORE Redesign
Established insulin “starts” and insulin “camps”. At the “start” day,
patient is trained in all aspects of self-administration of insulin. At
“camps”, patients are brought to the center for a full day to observe
all of their behaviors and monitor glucose levels at all points of self
care. A personal nutrition counselor was assigned.
Result
Average HbA1c for those attending our diabetic clinic is 7.08, with
7.0 being considered good control.
1, 2
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18. DIABETIC WOUND MANAGEMENT
Observation
Routine diabetic wound care was being primarily delivered by vascular and
orthopedic surgeons, who were not inclined to supply the highly-repetitive,
low intensity health care necessary to heal wounds. This resulted in frequent
amputations.
CAREMORE Redesign
Nurse Practitioners became certified in wound care and took
responsibility for high-touch wound intervention.
Result
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Amputation rates are 78% less than the national average.
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19. REDUCTION IN STROKE RISK
Observation
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High blood pressure increases risk of stroke. Hypertension is not controlled in
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70% of patients with this condition. Physicians have limited ability to get
correct readings between patient visits which resulted in poor control of
hypertension.
CAREMORE Redesign
Equip patients with blood pressure monitors with wireless cuffs for
recording three times a day. Readings taken at CareMore’s Care
Center. Make immediate, same day medication changes when
pressure levels change.
Result
48% of the patients had > 10mm in Hg reduction in systolic
blood pressure. Patients with systolic blood pressures of 160 mm
Hg or > had an average drop of 23mm Hg. Those patients with
blood pressure of 150-160 mm Hg had an average drop of 19mm.
Those results had shown to reduce the instances of stroke over
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the long term by 40% in patients.
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20. CHF READMISSION
Observation
Congestive Heart Failure is a leading cause of hospital admissions and
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readmissions in the Medicare population. Primary care physicians were not
able/willing to collect accurate weight on a daily basis and intervene quickly.
Self-reported weights were inaccurate. Primary care physicians were not
adequately responsive to immediate care needs of patients who require
intervention within a few hours of onset of symptoms.
CAREMORE Redesign
Equip each patient with a wireless scale that sets off alerts if weight
gain is 3 lbs overnight or 1 lb per day for more than 3 days. Sameday visit with clinician if alert is triggered. Proactive hospice planning
with changes in condition.
Result
56% reduction in hospital admission rate in 3 months.
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21. CAREMORE A DAY IN THE LIFE
CAREMORE SERVES 30,000 MEMBERS THROUGH 11 CARE CENTERS IN LOS
ANGELES AND ORANGE COUNTY CALIFORNIA
ON AN AVERAGE BUSINESS DAY, CAREMORE…
 Provides more than 900 rides to patients to and from points of care
 Makes or receives 3,385 phone calls arranging for care
 Sees 40 new members to assess health and establish personal care plans.
 Provides more than 950 hours of homemaker services for the frail
 Visits 27 homes to provide care or social support
 Engages 4 families in end-of-life/hospice planning
 Makes 235 follow up calls to patients in care programs
 Provides 191 strength training sessions
 Makes 90 care visits to patients residing in nursing homes/assisted living
 Reads 567 blood pressures from monitors in the homes of hypertensive patients
 Reads 369 weights from monitors in the homes of chronic heart failure patients
 Sees 413 patients in our Care Centers for follow up and chronic care management
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22. REFERENCES
1.
Genuth S, Eastman R, Kahn R, Klein R, Lachin J, Lebovitz H, Nathan D, Vinico F (2002). Implications of the United
Kingdom Prospective Diabetes Study. Diabetes Care Volume 25, Supplement 1
2.
National Diabetes Information Clearinghouse. DCCT and EDIC: The Diabetes Control and Complications Trial and
Follow-up Study.
3.
Krop JS, Bertoni AG, Anderson GF, Brancati FL (2002). Diabetes-Related Morbidity and Mortality in a National Sample
of U.S. Elder. Diabetes Care 25:471-475
4.
USRDS Annual Data Report (2008). ESRD: Overall Hospitalization- Morbidity and Mortality. www.usrds.org
5.
Zinberg SS, Furman DS, Austin J. Older and Wiser (2007). Advance for Directors in Rehabilitation. p.39,40,48
6.
Tinetti ME (2003). Preventing Falls in Elderly Persons. The New England Journal of Medicine. Volume 348:42-49
7.
Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C (2002). Prevention of Falls in the Elderly Trial
(PROFET): a Randomized Controlled Trial. National Center for Biotechnology Information (NCBI) www.ncbi.nih.gov
8.
Ray WA, Thapa PB, Gideon P (2000). Benzodiazepines and the Risk of Falls in Nursing Home Residents. National
Center for Biotechnology Information (NCBI) www.ncbi.hih.gov
9.
Medicare.gov Nursing Home Compare, Advancing Excellence Campaign in Nursing Facilities
www.nhqualitycampaign.org
10.
Anderson G, Herbert R. Johns Hopkins University Analysis of Medicare Standard Analytical Files (SAF) 5% Inpatient
Data. The Commonwealth Fund www.commonwealthfund.org
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23. REFERENCES
11.
Ostehega Y, Yoon SS, Hughes J, Louis T (2008). Hypertension Awareness, Treatment, and Control- Continued
Disparities in Adults: United States, 2005-2006. NCHS Data Brief: National Center for Health Statistics
12.
Denny CH, Greenlund KJ, Ayala C, Keenan NL, Croft JB (2007). Prevalence of Actions to Control High Blood
Pressure---20 States 2005 www.cdc.gov/mmwr
13.
Lewington S, Clarke R, Qizilbash N, Peto R, Collins R (2002). Age Specific Relevance of Usual Blood Pressure to
Vascular Mortality: A Meta-analysis of Individual Data for One Million Adults in 61 Prospective Studies The Lancet
v.360, i. 9349, p.1903-1913
14.
Canadian Hypertension Education Program Recommendations (2007). Hypertension as a Public Health Risk
www.hypertension.ca
15.
HCUP Fact Book No. 1(2000). Hospitalization in the United States. AHRQ Publication No. 0031 www.ahrq.gov
16.
Garnett C (2000). Don’t Accept the Blues: Depression in the Elderly is Treatable. National Institutes of Health (NIH)
www.nih.gov
17.
Depression in Late Life: Not a Natural Part of Aging (2009). Geriatric Mental Health Foundation www.gmhfonline.org
18.
NIH Senior Health (2007). Depression Frequently Asked Questions. National Institute of Mental Health
www.nihseniorhealth.gov
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