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AMERIGROUP Community Care• Entered Maryland market in 1999• Largest MCO in Maryland• Serving over 143,000 members in

Baltimore City and 20 counties in Maryland

• Located in Maryland

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AMERIGROUP Community Care

• Care Management – Utilization of overarching approaches and programs

aimed at improving healthcare– May include programs addressing provider availability,

pharmacy, hospital admissions, case management, etc.• Case Management

– “A collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health care needs through communication and available resources to promote quality cost-effective outcomes” (Case Management Society of America)

– Case managers are usually nurses or social workers

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AMERIGROUP Community CareCare Management of Chronic Illness• Management of lifelong illness or

disease that requires high level of ongoing intense medical care by multiple providers

• Examples of Chronic Illness – diabetes– heart failure– emhpysema – sickle cell disease– asthma

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AMERIGROUP Community Care: Chronic Disease Risk GroupsWho Are They• SSI members

– 15,000 SSI population: individuals that qualify for Medicaid based on illness or disease

– 80% Adults – Average length of membership: 3.5 years– 45% of SSI medical expenses spent on

inpatient hospital care• 2% (300 members) account for 50% of inpatient

hospital care: over $25 million inpatient hospital costs

• Behavioral health care: 20% substance abuse; 30% mental health

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AMERIGROUP Community Care: Care Management for Chronic Illness Challenges Presented• Severely ill with multiple chronic

diseases• Overwhelmed and exhausted • Difficulty navigating the health care

system• Concurrent mental health or

substance abuse issues

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AMERIGROUP Community Care: Care Management for Chronic IllnessApproaches to Care• Hospital Readmission Program

– Nurses and medical directors visit members and providers in the hospital

– Ensure members receive post discharge medication; receipt of home health care; access to PCP within 2 weeks of hospital discharge; transportation

• Risk Rank List– Predictive tool for future admissions

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AMERIGROUP Community Care: Care Management for Chronic IllnessApproaches to Care (Cont’d)• Disease management: specific optimal

care guidelines, expectations, pathways and desired outcomes– Disease specific pathways

• Graded approach, intervention proportional to need– Telephonic management– Case management– Field case management

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AMERIGROUP Community Care: Care Management for Chronic IllnessNetwork Development• Specific highly skilled providers• Use of community resources• Centers of Excellence• Community and home based

providers

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AMERIGROUP Community Care:Care Management for Chronic IllnessKey Elements for Success• Proactive identification and engagement of

member• Develop an individualized care strategy• Empower member

– Education – Community based case management and outreach– Incentives

• Encourage provision of care– Partnership among providers and MCO– Adherence to care plan

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AMERIGROUP Community Care: Care Management for Chronic IllnessOutcomes• Improved Quality of Life• Decreased Morbidity and

Mortality• Reduced Costs• Efficient Use of Resources