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Live from iHT2-Boston: Care Management In the Trenches: One MD Leader Shares a Success Story

May 19, 2015
by Mark Hagland
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In his keynote address at iHT2-Boston, David Ramirez, M.D. of CareMore shares with his audience some of the secrets so far of his organization’s care management work

In his late-morning keynote address at the Health IT Summit in Boston on May 19, David Ramirez, M.D., chief quality officer at the Cerritos, Calif.-based CareMore healthcare delivery system shared with his audience some of the secrets of success so far of his organization in that medical group’s care management initiatives. Ramirez spoke to an audience gathered at the Hyatt Regency Cambridge (Massachusetts), on the first day of the Health IT Summit, sponsored by the Institute for Health Technology Transformation (iHT2—a sister organization of Healthcare Informatics under their corporate parent, the Vendome Group LLC).

CareMore is a healthcare delivery system with 41 locations in six states (Arizona, California, Nevada, Ohio, Tennessee, and Virginia); it employs about 40 physicians and 80 nurse practitioner care managers, and manages the care of 80,000 plan members under its owned health plan. The physicians it employs are known as extensivists: they are physicians trained as hospitalists who also care for the same patients across both the inpatient and outpatient spheres. Ramirez himself practiced as an intensivist hospitalist for years before joining CareMore as an executive.

David Ramirez, M.D. addresses the iHT2 audience

In his keynote presentation Tuesday morning, Dr. Ramirez recounted his own journey towards care coordination, including describing how he had been practicing at a hospital system in Austin, Texas, when that system reached out to CareMore executives for advisement on how to optimally care-manage their current patients, as an alternative to building greater bed capacity in its hospitals. Ultimately, Ramirez, attracted to the CareMore model, joined CareMore himself, and is currently helping to lead its innovations.

So in an era of intensifying resource pressures on providers, how can the leaders of patient care organizations really improve their clinical and resource outcomes? There are a few key principles, Ramirez told his audience. First, he said, “You need control and accountability. One person’s got to be in charge of making the tough decisions and managing the patient. Second,” he said, “You need urgency. There’s got to be urgency and aggressiveness, in terms of putting treatment decisions in place. Third, you need continuity of care: you need a consistent individual relationship throughout the different healthcare settings. Sometimes,” he noted, it can be a primary care physician, and that’s great, but in these acute-care settings, you need more, which is why the extensivist model works.”

The CareMore healthcare system has intensive care management programs, called special needs programs, in five areas, Ramirez noted: diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), kidney disease, and institutional care.

Ramirez shared a few highlights of the CareMore COPD program., which has been organized along the same lines as the other care management programs at the organization. That program is headed by a dedicated nurse practitioner lead; its team approach is coordinated with other providers; strives for holistic management and education; and uses protocols based on nationally recognized practice guidelines. As a result of the rigorous work in that program, CareMore has achieved a 9-percent readmissions rate among its COPD patients, versus, a national Medicare Advantage rate of 18 percent.

Ramirez and his colleagues at CareMore have also been innovating along a number of different dimensions, particularly with regard to connecting wireless devices from patients’ homes to their electronic health record and data repostiroy. So far, they’ve connected CHF patients’ weight scales, hypertensive patients’ wireless blood pressure cuffs, and diabetic patients’ wireless glucometers. Ramirez noted that he and his colleagues will continue to advance with regard to wireless device data upload and integration, as in other areas.

What’s more, Ramirez and his colleagues at CareMore are now engaged inwhat they call a “10,000-member initiative,” with the goal of proactively managing the top 10-percent highest-risk members of their health plan, including COPD patients on oxygen; CHF patients who have had recent hospitalizations; and patients in kidney failure who are in dialysis. They are already doing analytics on those populations, generating lists of the patients who should be proactively care-managed according to those criteria, and using a rules engine and analytics to pull data out of the organization’s enterprise data warehouse.

“Some of this is common sense,” Ramirez told his audience. We have developed interventions, resources, and programs, for these members and patients who need care management. We have all the data, are able to pull the lists of patients, to risk-stratify, to prioritize care interventions, and to manage the care of the patients who most need care management.”

Beyond what he called the commonsensical aspects of this work, Ramirez reemphasized the core principles of clear accountability, coordination of care across the continuum, and a sense of urgency. “There needs to be a sense of urgency in the healthcare system,” he said, “with the goal of matching the care desired with the care received, and vice-versa.”