APPENDIX A

CARE MODEL CASE STUDIES

The care models described here were presented or discussed as part of one of the workshop proceedings or came up during the deliberations of the planning committee or taxonomy workgroup.

Intervention Components

• Alignment Healthcare’s program is built around a new type of clinician, the extensivist, a highly trained physician who cares for five or six patients in the hospital, instead of the 30 that a hospitalist would see, and who not only treats the patient but also speaks to the patient’s family and primary care physician every day. (Furman, 2015)
• Any member of a participating health care system who was frail, whether posthospitalization or for any other reason, can be seen at a care center by a team that included the extensivist, nurse practitioners, social workers, and case workers functioning at the top of their licenses. These care centers also have teams of psychiatrists, psychologists, and psychiatric nurses who integrate mental health care and extend that care into nursing homes, skilled nursing facilities, and the patient’s home. (Furman, 2015)
• Care centers incorporate nutritional counseling, podiatry services, and other key components for seniors. (Furman, 2015)
• Technology and advanced analytics play a key role in supporting the care model, with the goal being to use analytical tools to develop earlier predictive patterns that inform preventive interventions before high-cost interventions are needed. (Furman, 2015)

Intervention Components

• “Specially trained care managers (usually RNs or social workers) located in primary care clinics perform person-centered assessment and work with families and providers to formulate and implement a care plan.” (McCarthy, 2015)
• “Care manager ensures continuity of care and regular follow-up in office, in the home, or by phone.” (McCarthy, 2015)
• “Continuity of care enhanced by specialized information technology system.” (McCarthy, 2015)
• “Care manager provides coaching and self-care education for patients and families.” (McCarthy, 2015)

Intervention Components

• An incentive-based program for primary care physicians that rewards them for managing patients and influencing the whole medical dollar, including the 94 percent of the plan’s expenditures on specialists, inpatient care, outpatient care, and prescription drugs. (O’Brien, 2015).
• Credible data and analytic support provided through a dedicated informational portal and high-touch, superior technical support promote collaboration among physicians, local nurses, and other health professionals to manage members’ care. These analytics provide primary care physicians with information to help them spot potential hot-spot individuals within their panels and then provide links to additional services for those patients. (O’Brien, 2015)
• Primary care physicians collaborate with the specialists and other medical professionals of their choice, informed by analytics that provide the primary care physician with cost and quality metrics for those other professionals, to more closely coordinate and track care for the sickest patients or those at highest risk for future illness. (CareFirst, 2017; O’Brien, 2015)
• Care plans are supported by local community-based care teams headed by a registered nurse. (O’Brien, 2015)

Intervention Components

• Health Resilience Specialists are paired with primary health homes and specialty practices to provide individualized high touch and trauma-informed support to patients with exceptional utilization with the primary emphasis of mitigating social determinants of health. (CareOregon, 2014)
• Staff are supported by clinically licensed supervisors who provide daily and weekly guidance, mentoring, and clinical supervision. (CareOregon, 2014)
• The Health Resilience Specialists, who have mental health and addictions training, an in-depth understanding of trauma dynamics, and extensive outreach experience with the Medicaid population, are paid and administered by CareOregon but operate as part of a primary care team. (CareOregon, 2014)
• The program also subcontracts with regional and culturally specific peer mentors to build longer-term sustainability into the program. (CareOregon, 2014)

Intervention Components

• For-profit model offers a one-stop-shop approach for delivering multispecialty services in the community utilizing a smaller physician panel size of 350 to 450 patients, allowing for intensive health coaching and preventive care. (Coye, 2016)
• Collaborative peer review, powered by customized information technology, is a central feature of this system. (Tanio, 2013)
• ChenMed practices offer a broad set of additional services on site, including dental care, digital x-ray, ultrasound, and acupuncture, as well as five to 15 high-volume specialists. (Tanio, 2013)
• Because access to care is a major issue with seniors, the practice provides door-to-door van transportation at no charge. (Tanio, 2013)
• To boost medication adherence, each practice has on-site physician pharmacy dispensing, which encourages patients to discuss side effects and other issues that interfere with medication adherence. (Tanio, 2013)

Intervention Components

• Cigna Collaborative Care, modeled after accountable care organizations, embeds a care coordinator, typically a registered nurse, in a physician group with a substantial primary care component. (Davda, 2015)
• Care coordinators work closely with Cigna’s case managers to ensure that high-need individuals receive the screenings, follow-up care, educational materials, and access to Cigna’s clinical support programs, such as those for chronic condition management and lifestyle management, to help them manage their health better. (Davda, 2015)
• Cigna uses proprietary predictive modeling and analytics to provide the embedded care coordinator with a daily list of which members of a practice are in the hospital and will require a transition of care call at the time of discharge, and a monthly list of high-risk patients with multiple gaps in care, such as medication compliance issues and multiple emergency department visits. (Davda, 2015)

Intervention Components

• “Provides enhanced primary care and care coordination through multidisciplinary clinical teams led by nurse practitioners.” (McCarthy, 2015)
• “After a comprehensive assessment, individualized care plans are developed to promote independence and functioning.” (McCarthy, 2015)
• “Integration of behavioral health care for those who need it.” (McCarthy, 2015)
• “Care team available 24/7 in the home, in the hospital, or at the doctor’s office.” (McCarthy, 2015)
• “Patients’ records available 24/7 in proprietary electronic health record system.” (McCarthy, 2015)

Intervention Components

• “Provides ongoing care coordination between visits including communication with family, primary care providers, and specialists.” (Children’s National, 2017)
• “Helps families negotiate the health care system and provide a link to community resources.” (Children’s National, 2017)
• “Creates written care plans with the family to share with the primary care provider.” (Children’s National, 2017)
• “Provides comprehensive care coordination through a team approach that includes nurse case management, parent navigators, and social work.” (Children’s National, 2017)

Intervention Components

• Five dedicated CCPs lead teams of advanced practice registered nurses, social workers, care coordinators, and other specialists best suited to address the needs of patients who are expected to average 10 hospital days per year. (Meltzer, 2014)
• Each CCP has a panel of approximately 200 patients and serves as both primary care physician and supervisor for each panel member’s care while hospitalized. (Meltzer, 2014)
• The five CCPs visit hospitalized patients each morning while the other members of the care team provide care at the physicians’ clinics. One CCP is assigned afternoon rounds and weekend duties. “Providing these physicians with a high volume of inpatients and locating their clinics in or near the hospital allows them to offer many of the same benefits that hospitalists provide while offering the additional benefit of continuity across settings and over time.” (Meltzer, 2014)
• “The CCP or other care team member makes postdischarge calls to the patient and both telephone and text messages are used to keep the care team and patient connected.” (Meltzer, 2014)

Intervention Components

• A medical home model in which practices first risk-stratify their patients within physician panels. (Taylor, 2015)
• Practices use care management methods, including care planning, registries, proactive care monitoring, and enhanced access that include home-based and team-based care. (Taylor, 2015)
• While the program is not prescriptive per se, care management activities must include at least one of the following: behavioral health integration, self-management or support for beneficiaries, or medication management. (Taylor, 2015)

Intervention Components

• “Patient-centered primary care.” (Maeng, 2012)
• “Integrated population management.” (Maeng, 2012)
• “A medical ‘neighborhood’ that aligns key community partners, such as home health agencies, skilled nursing facilities, outpatient and ancillary services, hospital facilities, and community pharmacies. Comprehensive quality improvement. Value-based reimbursement redesign that includes a quality, outcome-based pay-for-performance program.” (Maeng, 2012)

Intervention Components

• “Support team consisting of advanced practice nurse and social worker work with elderly in the home and community.” (McCarthy, 2015)
• “In-home assessment and specific care protocols inform individualized care plan.” (McCarthy, 2015)
• “Support team works closely with larger interdisciplinary care team.” (McCarthy, 2015)
• “Patient education and self-management plans include tools for low-literacy seniors.” (McCarthy, 2015)

Intervention Components

• “Predictive modeling and 12 months of claims data used to identify the 20 to 25 percent of patients most at risk of needing complex care in the near future.” (McCarthy, 2015)
• “RNs trained in complex care management perform in-home assessments and develop care plans to coordinate care with multidisciplinary providers.” (McCarthy, 2015)
• “Patient education and self-management strategies focus on addressing issues before hospitalization becomes necessary.” (McCarthy, 2015)

Intervention Components

• Three strategic components of the HCH program are its certification process, a quality improvement process, and a learning collaborative. (LaPlante, 2015)
• At the time of certification, each clinic is evaluated by a team that includes a regional nurse planner, a consumer or patient under contract with her agency, and a community nurse or other community health professional. The purpose of the site visit is to ensure that clinics have enacted processes to redesign primary care. (LaPlante, 2015)

Intervention Components

• “Registered nurse care coordinators focus on changing patient behavior.” (McCarthy, 2015)
• “Focus on frequent in-person contact with both patients and physicians.” (McCarthy, 2015)
• “Evidence-based patient education including condition-specific self-monitoring training.” (McCarthy, 2015)

Intervention Components

• Provides a care manager to coordinate appointments, to assist with arranging transportation, and to connect patients with community resources and organizations. (HSCSN, 2016)
• Care Manager works with providers and patients to create a care coordination plan that’s updated at least twice per year. (HSCSN, 2016)

Intervention Components

• “Located on the campuses of Veterans Affairs medical centers, community-based outpatient clinics, and Community Resource and Referral Centers, H-PACT clinics colocate medical staff, social workers, mental health and substance use counselors, nurses, and homeless program staff. These professionals form a team that provides Veterans with comprehensive, individualized care, including services that lead to permanent housing.” (US VA, 2017)

Intervention Components

• “Potentially eligible patients are identified in the hospital emergency department or ambulatory care site. If they meet the validated criteria and consent to participate, they are evaluated by a physician and transported home, usually via ambulance.” (McCarthy, 2015)
• “One-on-one nursing for initial stage and at least daily nurse and physician visits thereafter.” (McCarthy, 2015)
• “Both nurses and physicians on call around-the-clock for urgent or emergent visits.” (McCarthy, 2015)
• “Some diagnostic services and treatments performed in home setting.” (McCarthy, 2015)
• “Same criteria and guidelines are used to judge patient readiness for transition to skilled nursing facility, or discharge from Hospital at Home as from hospital.” (McCarthy, 2015)

Intervention Components

• “Collaborative care: Primary care physician works with depression care manager (e.g., nurse, social worker, or psychologist supported by medical assistant or other paraprofessional) to develop and implement treatment plan including antidepressant medication and/or short-term counseling. Team includes consulting psychiatrist.” (McCarthy, 2015)
• “Care manager also educates patient about depression and coaches in self-care.” (McCarthy, 2015)
• “Providers utilize ongoing measurement and tracking of outcomes with validated depression screening tool, such as Patient Health Questionnaire-9, and adapt care to changing symptoms.” (McCarthy, 2015)
• “Once a patient improves, case manager and patient jointly develop a plan to prevent relapse.” (McCarthy, 2015)

Intervention Components

• Model that uses home-based primary care teams directed by physicians and nurse practitioners designed to improve health outcomes and reduce expenditures for Medicare beneficiaries with multiple chronic conditions. (CMS, 2016)
• “Selected participants, including primary care practices, will provide home-based primary care to targeted chronically ill beneficiaries for a five-year period. Participating practices will make in-home visits tailored to an individual patient’s needs and preferences.” (CMS, 2016)
• “This focus on timely and appropriate care is designed to improve overall quality of care and quality of life for patients served, while lowering health care costs by forestalling the need for care in institutional settings.” (CMS, 2016)

Intervention Components

• “Links people with dementia and their caregivers to community-based agencies, medical and mental health care providers, and community resources.” (JHU, 2014)
• “Delivered by an interdisciplinary team comprised of trained nonclinical community workers and mental health clinicians, who conduct comprehensive in-home dementia-related needs assessments and provide individualized care planning and implementation.” (JHU, 2014)
• “The team uses six basic care strategies: resource referrals, attention to environmental safety, dementia care education, behavior management skills training, informal counseling, problem-solving, as well as ongoing monitoring, assessment, and planning for emergent needs.” (JHU, 2014)
• “Each component of the intervention is based on best practice recommendations and evidence from prior research, and is combined for maximum impact.” (JHU, 2014)
• Provides individualized needs assessments, care planning, and monitoring for both patient and caregiver. (JHU, 2014)
• Provides education, skills training, and self-management support for patients and families. (JHU, 2014)
• Model is home-based, linking medical and community-based care services delivered by nonclinical staff with support from mental health practitioners. (JHU, 2014)

Intervention Components

• MissionPoint Health Partners is a population health management organization that uses a global financing model to provide a clear picture of the resources needed for this patient population and enable personalized responses to patient needs and iterative learning and resource shifting. This iterative approach, supported by a clear leadership commitment, is a major feature of the program’s profit-and-loss strategy. (Coye, 2016)
• “Central to the MissionPoint model is [its] wraparound clinical management framework, a skilled team of Health Partners who help members solve problems and connect their medical care with everyday life. . . . [The Health Partners, who] are experienced health care professionals and social workers, are provided at no cost to members and help support members when they most need it, such as after an emergency department visit, hospital stay, or diagnosis of a chronic disease.” (MissionPoint 2017a)
• Advanced analytics notify Health Partners “of members’ health events within the network and provide them with relevant medical data so that the Health Partners can work hand-in-hand with members and caregivers to . . . navigate the health care system, problem-solve complex issues, and remove barriers to self-care.” (MissionPoint, 22017a)

Intervention Components

• “Multidisciplinary provider team led by advanced practice nurses engages in comprehensive discharge planning.” (McCarthy, 2015)
• “Three-month postdischarge follow-up includes frequent home visits and telephone availability.” (McCarthy, 2015)
• “Involve patients and family members in identifying goals and building self-management skills.” (McCarthy, 2015)

Intervention Components

• This high-touch, care-coordinated, patient-involved program uses team-based care with both licensed and unlicensed care coordinators to ensure seamless transitions and links to needed services. (Mangiante, 2015)
• Individuals in 23 participating delivery systems and 500 practices are identified using a predictive risk model plus cognitive assessment, as well as through physician referrals. (Mangiante, 2015)
• Interdisciplinary care teams developed longitudinal relationships with clients and provide warm handoffs to support services outside of the health care system. (Stremikis, 2016)
• Care coordinators complete a face-to-face “supervisit” within 1 month of a member’s enrollment in the program. Because medically complex patients can be anxious and depressed, coordinators are particularly attentive to their patients’ social and psychological needs, providing or supplying referrals for behavioral, psychosocial, and community services. (Mangiante, 2015)
• Coordinators proactively provide patients with tools for effective self-management, helping them to develop action plans and to recognize signs of exacerbations of illness, and engage in two-way communication with members at least once per month, with intensity decreasing as patients become stable. (Mangiante, 2015)

Intervention Components

• “Care managers are integrated into primary care practices.” (McCarthy, 2015)
• “Care managers provide patient education and address both medical and psychosocial needs.” (McCarthy, 2015)
• “Focus on preventing exacerbations that lead to emergency department visits and inpatient admissions.” (McCarthy, 2015)
• “Case managers also support end-of-life decision making.” (McCarthy, 2015)

Intervention Components

• “Each PACE site provides comprehensive preventive, primary, acute, and long-term care and social services, including adult day care, meals, and transportation.” (McCarthy, 2015)
• “Interdisciplinary team meets regularly to design individualized care plans.” (McCarthy, 2015)
• “Goal is to allow patients to live independently in the community.” (McCarthy, 2015)
• “Patients receive all covered Medicare and Medicaid services through the local PACE organization in their home and community and at a local PACE center, thereby enhancing care coordination.” (McCarthy, 2015)
• “Clinical staff are employed or contracted by the local PACE organization, which is paid on a per-capita basis and not based on volume of services provided.” (McCarthy, 2015)

Intervention Components

• “Upon joining the program, SCC patients are assigned to care teams and complete a comprehensive intake process that focuses on the question, ‘Where do you want to be in a year?’” (CHCS, 2015)
• “Care teams include a physician, registered nurse or other provider, and a care coordinator/medical assistant trained to act as a coach and navigator, as well as a social worker who specializes in trauma informed care, a physical therapist who specializes in chronic pain, and a clinical pharmacist.” (CHCS, 2015)
• Care coordinators/medical assistants perform routine preventive services and chronic disease monitoring between clinic visits for a panel of 100 patients with the goal of encouraging patients to follow through on their action plans. (AHRQ, 2016)
• The care team focuses on improving each patient’s self-management by supporting the patient’s self-identified goals and assisting the patient to develop achievable action plans scaled according to the patient’s PAM score. (CHCS, 2015)

REFERENCES