1. Felicia Cojocnean MSN, FNP, AANP-BC Chronic Disease Management Programs Wellpoint/CareMore Health Plan Orange Co/LA, California1

2. CAREMORE 1995 Medical Group with enrolled Medicare beneficiaries 2001-CareMore Health Plan 2006- CareMore Special Needs Plan2 3. CAREMORE3 4. CAREMORE Health Spending & Chronic Disease Five chronic diseases make up the vast majority of this category* Diabetes Congestive Heart Failure Coronary Artery DiseaseAsthma Depression* Hypertension contributes to complications 4 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 wellCommonwealth Fund Health Care Quality Survey,Report (July 2007) Medical Homes result in better outcomeElizabeth A. McGlynn et al (2003) Patients receive appropriate care only half of the time5 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)6 7. OUR MISSION Providing innovative and focused healthcare approaches to the complex process of aging.7 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 8 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 < $30,0009 10. CAREMORE INTEGRATED PATIENT CARE DELIVERY SYSTEM COPD COPDCAD CAD CHF CHFDiabetes Diabetes Wound Clinic Wound ClinicChronic Disease Chronic Disease Support SupportESRD ESRDHealthy Start Healthy StartMonitoring MonitoringHospice HospiceEnd of Life Care End of Life CarePCP PCPSecondary Secondary Prevention PreventionExtensivist ExtensivistNutritionist NutritionistPalliative Palliative Care CareFoot care Foot careSocial / Social / Behavioral Behavioral Support SupportSocial Social Workers WorkersClinical Clinical Care Centers Care Centers (CCC) (CCC)Case Manager/ Case Manager/ NP NPRisk Event Risk Event Prevention PreventionExercise ExercisePre-Op Pre-Op Mental Health Mental HealthFrailty Support Frailty Support Extensivist Extensivist Management ManagementPredictive modelingIntegrated IT infrastructureStrength Strength Training TrainingLongitudinal patient recordCoumadin Coumadin Fall FallEvidence-based protocolsPoint-of-care decision support 11. THE CAREMORE MODELSummary: 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.11 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 episodes12 13. CAREMORE Neighborhood Clinical Model Care CenterCommunity Focus Located in the heart of the neighborhoodSocial Environment Designed for seniors Resource for family and caregivers Frequent classes and activitiesClinical Disease Management Foot Center Healthy Start Pre- Op Fall Prevention Wellness programs13 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 Startcomplete evaluation within 30 days of enrollment Predictive Modeling eg. CARS Monitor risk indicators14 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 member15 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 ill16 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, 217 18. DIABETIC WOUND MANAGEMENT ObservationRoutine 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 RedesignNurse Practitioners became certified in wound care and took responsibility for high-touch wound intervention.Result 3 Amputation rates are 78% less than the national average.18 19. REDUCTION IN STROKE RISK Observation 11High blood pressure increases risk of stroke. Hypertension is not controlled in 12 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 RedesignEquip patients with blood pressure monitors with wireless cuffs for recording three times a day. Readings taken at CareMores Care Center. Make immediate, same day medication changes when pressure levels change. Result48% 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 13,14 the long term by 40% in patients.19 20. CHF READMISSION ObservationCongestive Heart Failure is a leading cause of hospital admissions and 15 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 RedesignEquip 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. Result56% reduction in hospital admission rate in 3 months.20 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 management21 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 12.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 25:471-4754.USRDS Annual Data Report (2008). ESRD: Overall Hospitalization- Morbidity and Mortality. www.usrds.org5.Zinberg SS, Furman DS, Austin J. Older and Wiser (2007). Advance for Directors in Rehabilitation. p.39,40,486.Tinetti ME (2003). Preventing Falls in Elderly Persons. The New England Journal of Medicine. Volume 348:42-497.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.gov8.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.gov9.Medicare.gov Nursing Home Compare, Advancing Excellence Campaign in Nursing Facilities www.nhqualitycampaign.org10.Anderson G, Herbert R. Johns Hopkins University Analysis of Medicare Standard Analytical Files (SAF) 5% Inpatient Data. The Commonwealth Fund www.commonwealthfund.org22 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 Statistics12.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/mmwr13.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.1903-191314.Canadian Hypertension Education Program Recommendations (2007). Hypertension as a Public Health Risk www.hypertension.ca15.HCUP Fact Book No. 1(2000). Hospitalization in the United States. AHRQ Publication No. 0031 www.ahrq.gov16.Garnett C (2000). Dont Accept the Blues: Depression in the Elderly is Treatable. National Institutes of Health (NIH) www.nih.gov17.Depression in Late Life: Not a Natural Part of Aging (2009). Geriatric Mental Health Foundation www.gmhfonline.org18.NIH Senior Health (2007). Depression Frequently Asked Questions. National Institute of Mental Health www.nihseniorhealth.gov23