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NDHI NAT IONAL DIALOGUE FOR Healthcare Innovation Complex Community Care Initiative Organization Overview • BlueCross BlueShield of Tennessee (BCBST) is a not-for-profit health insurance organization • BCBST provides benefits to about 12,000 companies and serves 3.3 million people • BCBST offers BlueCare Tennessee, a managed Medicaid program that serves 602,000 members Background In the United States, 5% of the patient population generally represents 50% of the total cost across all payers. This patient population is complex and dynamic, often struggling with factors such as chronic physical and mental illness, poverty, and social isolation. For these individuals, the standard care system is not effective, as demonstrated by high utilization rates coupled with poor outcomes. BCBST believes that the primary need for these patients is not additional resources, but rather, improved care design and greater member and community engagement. In 2014, BlueCare leadership commissioned a multifaceted work group to address these needs, which represented departments such as Clinical Improvement, Population Health, Case Management, Medical Informatics, and others. The workgroup developed a collaborative partnership with the Institute for Healthcare Improvement (IHI) in 2015, which led to the implementation of the Complex Community Care Initiative, an integrated “community care” model for a small subpopulation of BCBST’s Medicaid population with complex needs. BCBST is now building relationships with primary care teams, hospitals, and affiliated entities who are willing and able to participate in redesigned care for individuals with complex needs. Program Details BCBST utilized claims data analysis and predictive modeling to identify a small subset of the overall Blue- Care Tennessee population that would benefit most from intensive community-based care management. BCBST identified 285 BlueCare Core members with over $50,000 in medical spend for 2014 and at least 8 inpatient admissions in a two-year period. These patients were enrolled in the Complex Community Care Initiative, with the specific objectives to: • Provide patients with the knowledge, skills and confidence to manage their conditions effectively • Reconnect these members with community supports and care teams that meet their complex needs • Improve patients’ health and experience, while reducing their healthcare expenditures An Initiative of the 55 | Complex Community Care Initiative
NDHI NAT IONAL DIALOGUE FOR Healthcare Innovation The Complex Community Care Initiative offers a personalized approach to complex care management: • Individual case reviews are completed to identify themes and patterns • Each patient is assigned to a case manager who conducts face-to-face interviews in the member’s home • Patients are connected to care teams to manage their complex needs The Complex Community Care Initiative continues to be improved through an iterative design approach. Based on the results of testing and review of the most recent iteration of a design, changes and refinement are made to continuously improve the program. Value Delivered BCBST has developed a methodology to measure the short-term cost impact of the program, based on the number of inpatient medical admissions for 2016 compared to their previous two year history. While it is too early to tell whether BCBST has lowered overall costs, the program has: • Improved its member engagement rate significantly without any increase to staffing • Enabled BCBST to target its case management resources to members with the highest needs and highest potential impact of intensive care management • Increased patient satisfaction by providing a person-centered approach to care Path Forward The immediate next steps for the Complex Community Care Initiative are to continue delivering care to the initial study group and maintain tracking of this population to determine cost savings, care improvement, and other metrics. In the long term, BCBST intends to expand this approach to its Long Term Services and Supports (LTSS) and Dual Special Needs Medicare Advantage plan in 2017. BCBST has also developed a “Real Time Radar” process to identify individuals beginning to “superutilize” inpatient medical services, so that those individuals can be enrolled in the new case management model. The Complex Community Care Initiative is well organized to facilitate future improvements in care delivery models, and BCBST is working with both hospital-based providers and primary care teams toward this goal. Some future improvements include: • Integration of medical and behavioral health professionals within the health plan, primary care system, at home, and the community • Development of locally-tailored coordination teams, based on standard design, but with regional expressions that reflect existing community and provider assets • Enhancement of information systems to allow for timely automated reports, in lieu of manual tracking and trending In order for the program to expand and flourish, BCBST intends to collaborate with the Bureau of TennCare and other Medicaid MCOs. Together, they would be able to assess population health management reporting requirements to better reflect interventions that are proving to be successful. BCBST hopes to help federal and state government leaders identify opportunities for benefit redesign to provide more stable care and lower costs for vulnerable populations. Complex Community Care Initiative | 56
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