Improving care for patients with chronic diseases has long been a priority for both public and private sector purchasers of health care. A robust body of literature demonstrates that a significant proportion of health expenditures are concentrated among medically complex patients in both the Medicare and working-age adult population.
Our general experience is no different — 40 percent of a typical Pacific Business Group on Health member’s health care spending goes towards caring for the 15 percent of their employees with multiple chronic conditions. Quality outcomes—particularly those related to care coordination and patient experience—are often substandard.
The IOCP Care Model
Fortunately, large purchasers are doing something about it. In 2009, Boeing began working directly with providers to implement a care management initiative called the Intensive Outpatient Care Program (IOCP). The California Public Employees’ Retirement System (CalPERS) and Pacific Gas and Electric Company (PG&E) quickly followed suit with a pilot in Northern California. IOCP utilizes care coordinators embedded with primary care physicians and medical groups.
In the IOCP model, care coordinators build a relationship with patients and work closely with them until their health is stabilized. Patients are identified through a combination of predictive risk modeling and retrospective utilization review. Crucially, both types of patient identification are used in tandem with clinical review by a physician or nurse, preferably one who knows the patient. Primary care providers are also encouraged to refer patients who do not show up on predictive or retrospective lists but may still benefit from the intervention.
The care model is driven by workforce training and includes seven core elements:
- Trained Care Coordinators such as nurse or social worker-led teams that can include community health workers and medical assistants;
- A face-to-face super-visit within one month of enrollment;
- Standardized longitudinal assessment tools for physical function, mental well-being, and patient engagement in care;
- Monthly, bi-directional communication between the care coordinator and patient;
- Shared Action Plan created with the patient’s own goals at its center;
- Warm handoffs to relevant support services such as home health, behavioral health, and transportation; and,
- 24/7 access to services, with communication to the care coordinator the next business day.
Participating delivery systems adapt implementation to their local environment, while maintaining these core requirements. While the IOCP model has similarities to other care models for complex patients, it is differentiated by the unique combination of these elements and close coordination with primary care providers.
Impact Of The IOCP Model
Previously-released data from IOCP in commercial populations show a reduction in costs among the medically complex by up to 20 percent. The early success of this program informed Anthem’s two-tier per member per month payment (PMPM) structure in the design of their ACO contracts with provider organizations in California. Specifically, medical groups were given a higher PMPM fee for members with more than two chronic condition diagnoses, thus incentivizing investments in robust IOCP-like case management support beyond traditional population health and disease management interventions.
These results also led to a CMS Innovation Center grant to expand the program to 23 delivery systems providing care to over 15,000 Medicare beneficiaries in five states. New data from a Milliman and PBGH analysis, shared for the first time below, show that high-risk Medicare beneficiaries treated by IOCP practices experienced decreases in hospital admissions, inpatient days, and emergency room visits.
Medicare beneficiaries receiving care from IOCP practices experienced health status improvements across a number of areas — patient activation, mental health, and physical functioning.
- Thirty-seven percent of IOCP patients moved to a higher level of patient activation while in the program. A synthesis of previous research shows that increased patient activation is highly correlated with better care experiences and outcomes. Increased patient activation in IOCP was associated with patients being more likely to successfully graduate from the program.
- The Patient Health Questionnaire (PHQ-9) is a multi-purpose tool for screening, diagnosing, monitoring, and measuring the severity of depression. One‐third of people with a serious medical illness experience symptoms of depression, making the IOCP patient population at higher risk for this condition. On average, patient PHQ scores improved 33 percent while in IOCP.
- The VR-12 is a health-related quality of life survey that summarizes both physical and mental health functioning. Patients in IOCP saw a 3.4 percent increase in mental functioning and 4.1 percent increase in physical functioning. Any increase in these scores are particularly noteworthy as they typically decline in senior populations with a high burden of chronic illnesses.
The IOCP program has also led to utilization and cost reductions in both acute care visits and total cost of care for Medicare beneficiaries.
- An analysis of a subset of patients continuously enrolled for at least nine months shows a significant reduction in inpatient utilization and emergency department use as a result of the program intervention. Actuarial analysis confirms that these reductions are attributed to improved care coordination, although regression to the mean could contribute to the magnitude of the reductions.
- Over a 12 month time period, the highest risk IOCP patients had a 21 percent reduction in average monthly cost of care, as measured on a PMPM basis. Patients also saw a 55 percent decrease in emergency department visits from the quarter before entering an IOCP practice to the third quarter after a patient was enrolled in IOCP practice. There were also reductions in inpatient admissions and bed days.
Many of the delivery systems performed their own internal analyses. Perhaps most telling, once the CMS grant program ended in July 2015, 90 percent of participating delivery systems continued the core elements of the program for Medicare patients and 15 of 23 expanded programs into their commercial populations.
Expanding On IOCP’s Success
Improving care for medically complex patients requires changing the status quo. While this is always challenging, our experience with IOCP shows that successful practice transformation is possible. All of the factors that contribute to effective implementation of the program within facilities are replicable:
- Strong senior leadership support including a dedicated physician champion
- A commitment to the seven core model elements
- Staff who can work collaboratively in a team-based care model
- Rigorous performance measurement and quality improvement processes
- Modern health IT infrastructure
Certainly there are other, less replicable delivery system characteristics, such as the presence of provider-hospital integration, assimilation into a population health strategy, a strong analytic capacity for program monitoring, and a degree of financial risk for patient cost and quality. But in working with a multitude of physician practices over the past six years, we have developed effective training and staff education modules that can be instituted in a variety of settings.
Ultimately, the program had a lasting impact on changing the way the participating providers practice medicine, and the way patients care for themselves. So what’s next? The model will soon by extended to California safety-net providers under the §2703 health homes program. And we will continue to collaborate with payers to reward those providers who are making infrastructure investments and delivering better outcomes to those patients who need it most.
The project described was supported by Grant Number 1C1CMS331047 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The analysis presented was conducted by the awardee. Findings might or might not be consistent with or confirmed by the findings of the independent evaluation contractor.