Care Management - Integrated Care Coordination

On average, a person with SPMI experiences three co-occurring serious medical conditions, such as cardiovascular disease, hypertension, substance abuse, obesity, diabetes, or respiratory illness. Frequently, patients do not receive treatment, resulting in higher costs from emergency-based care and interventions for chronic, untreated medical illness. When patients do get treatment, information about treatments that a patient receives for medical conditions is not available to mental health providers, and vice versa. As well, the treatment staff (medical and mental health) usually do not receive alerts when patients do not refill their prescriptions for critical medications. If they do become aware, it is often too late for preventive interventions. Given their complex needs, the fragmentation in funding for care, and the long-term nature of SPMI, these individuals are often engaged with multiple systems of care with infrequent or no cross-system coordination. Therefore, it may not be surprisingthat the level of success in providing the required holistic approach to treatment for people with SPMI has been limited.

Using medical claims data, CNS has developed a targeted patient-based approach to improve outcomes for patients with complicated, chronic medical and behavioral illness. CNS’ unique examination of pharmacoeconomic information, bridges otherwise disparate care management providers with actionable considerations around the care of a particular patient. CNS provides modules to address the challenges present in the treatment of SMPI including schizophrenia, bipolar disorder, and the co-morbidities of behavioral illness at both ends of the age spectrum (children/adolescents and the elderly). By combining pharmacy effectiveness and focused disease management tools, even greater impact can be realized for improving patient outcomes. The case illustration of Mark helps illuminates these facts.

Program components of CNS’ approach to care coordination for patients with SPMI include:

Risk-modeling and predictive algorithms. Identification of patients with complex needs most at risk for poor health outcomes through risk stratification and the application of predictive algorithms, using retrospective claims data.
Focus on the quality of prescribing. Patient-specific behavioral pharmacy review of prescribing practices that may deviate from best practice, including ongoing examination of patients’ Medication Possession Ratio (MPR). Behavioral Pharmacy Management is embedded in the ICC program to provide treating psychiatrists and primary care physicians with educational alerts about their prescribing practice patterns that deviate from best practice or expert consensus guidelines.
Strategies to improve adherence. Retrospective analyses and continuous monitoring of pharmacy claims is also an embedded feature of the ICC program to provide caregivers with medication utilization tracking and rapid clinical alerts for improving patient medication adherence. This involves a weekly analysis of point-of-sale pharmacy claims for failures to refill prescriptions as well as retrospective and prospective analysis for monitoring patients’ MPR over time. Call center telephony is used for alerts to clinicians and/or case management staff. MPR rates are reported in the Integrated Health Profile, a key communication tool for ICC.
Clarity around the psychiatric and medical information center. A CNS Health Liaison works to identify patient's psychiatric and medical ‘homes’ as well as their primary case manager through which care is coordinated. The identification process involves locating each patient’s psychiatrist, primary care physician and clinical case manager as reliance on specialty care requires strong communication across all caregivers. By linking information among medical, psychiatric, and community providers a more rapid healthcare provider response can ensue when needed.
Simplifying complex information into easy-to-use clinical tools. The patient-focused Integrated Health Profile (IHR) includes comprehensive and current information across medical, behavioral, and pharmacy treatments. The IHR details medications prescribed for past 90 days (including MPR trending), best practice Clinical Considerations™, Health Alerts for special attention, hospital stays and emergency visits for thepast year, outpatient visits for the last 12 months or maximum of 40 claims; and identification of a lead primary care physician, psychiatrist, mental health case manager and most frequent-specialist.
Educational Monographs. Behavioral health case managers are provided with best practice health information regarding chronic medical conditions important for their role in assuring proper coordination across psychiatric and medical care. If present, medical case managers receive best practice information regarding psychiatric issues important to their role with emphasis on care management strategies for patients with a chronic medical condition and a co-occurring SPMI.
Program Reporting. Quarterly reports tracking cost and utilization patterns across pharmacy, inpatient/ER, outpatient services for all identified high-need ICC patients are provided to the client. Annual reports of total services and costs are also available.