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CareMore: Innovative Healthcare Delivery

CareMore: Innovative Healthcare Delivery

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Presentation at July 26th PFCD Hill Briefing
Presentation at July 26th PFCD Hill Briefing

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Published by: Partnership to Fight Chronic Disease on Jul 29, 2013
Copyright:Attribution Non-commercial


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Innovative Healthcare Delivery


• Welcome and Introductions • CareMore – Who We Are • Understanding CareMore’s Model of Care • CareMore Care Centers

• Question & Answer Session


CareMore – Who We Are
• CareMore started over 20 years ago caring for seniors as a Medical Group in Los Angeles, California. We were founded by a team of physicians and continue to be guided by the ideas and direction of physicians. • The name “CareMore” embodied the philosophy that inspired a proactive model of care with a caring touch and a focus on wellness. • Years later, CareMore began serving Medicare seniors as a Health Plan and continues to do so today through innovation of healthcare programs, technology, and strong provider partnerships. • CareMore is solely dedicated to the Medicare market in California, Nevada, Arizona, Virginia and New York.

CareMore Timeline
Company Expansion & Growth Highlights
2002 CareMore establishes its Pre & Post Hospitalization Program 2012 Care Center Expansions Downtown LA, CA 2010 Torrance, CA CareMore Expansion Corona, CA Maricopa County Upland, CA Pleasanton, CA

1995 Enrolled Medicare beneficiaries in Southern CA

2008 CareMore Expands to Santa Clara County

1993 1995
1993 CareMore Medical Center founded by doctors (CA)

2001 2002

2006 2008

2009 2010

2011 2012


2001 CM obtains CMS contract to become a Health Plan

2006 CM begins offering a Chronic Care Special Needs Plan (CSNP) (CA)

2011 CareMore Expansion Riverside County 2009 CareMore Expands to Modesto, Pima, Clark County 2011 WellPoint Acquires CareMore Health Plan

2013 WellPoint - CareMore East Expansions Richmond, VA
(Richmond City, Henrico, Chesterfield Counties)

Brooklyn, NY
(Kings County)

Key: CA = California CM = CareMore CMS = Centers for Medicare and Medicaid Services CSNP = Chronic Special Needs Plans NV = Nevada


= Virginia = New York


PFCD Statistics
Partnership to Fight Chronic Disease, April 2013 White Paper “Two out of three Medicare beneficiaries, including those covered by Medicaid,
have more than one chronic condition. More than half in Medicare have five or more chronic conditions reducing the quality of life for seniors and driving healthcare costs up significantly.”
Centers for Medicare and Medicaid Services, “Chronic Conditions Among Medicare Beneficiaries, Chart book: 2012 Edition,” 2013

“Almost $2 out of $3 spent on healthcare in the U.S. is directed toward care for the 27% of Americans with multiple conditions.”
G. Anderson, “Chronic Care” Making the Case for Ongoing Care,” Robert Wood Johnson Foundation, 2010


PHCD Statistics continued
Partnership to Fight Chronic Disease, April 2013 White Paper
“These statistics are startling. Yet, despite the high prevalence of multiple chronic conditions, their devastating health impact and the cost implications, there is a notable lack of medical research on how to effectively prevent and manage multiple chronic conditions. This leaves patients, family caregivers, and

health care providers with insufficient information on which to base important
health care decisions. Within the current base of medical evidence and, as a result, in the breadth of health care practice in the U.S., there is an unfortunate disconnect between focusing on the individual patient and focusing on the individual disease.
D Campbell-Scherer, “Multimorbidity: A Challenge for Evidence-based Medicine,” Evidence-Based Med 2010; 15(60): 165-66.


Disjointed Healthcare System

• The existing health care delivery model is disjointed and inefficient and ultimately fails to achieve the proper measurements of prevention, coordination of care, and the management of chronic illnesses for the frail and unhealthy. • Patients with serious conditions see an average of 11 different doctors which may result in lack of coordination of care and at times unnecessary multiple medications being prescribed. • This leads to poorly managed and redundant care which in turn increases cost and death rate.


CareMore Mission
• Provide a focused, proactive and innovative healthcare approach to counter the complex problems of the healthcare system and support the needs of the frail and unhealthy seniors. • Serve our members, caregivers and family by providing support, education, and access to services to prolong an active and independent life. • Protect precious financial resources of seniors and the Medicare Program through innovative methods of managing chronic disease, frailty and end of life.


CareMore Model



PCP Specialists Hospital Urgent Care/ER SNF (Contracted)


Care Center Extensivist Nurse Practitioner Medical Assistants Technicians Programs/Services NAF (Employed)

“The Triangular Relationship”


The CareMore Model
Non-Frail Population

Frail Population

Care Centers


Primary Care Physicians

CareMore Care Centers

Provider Relations

Primary Care Physicians

Member Services

Case Managers

CareMore Extensivists

Member Services

Continuous Frailty Assessment Tools


Close monitoring of non-frail members to proactively identify at-risk members

Intensive hospitalist management of frail members (approximately 20% of members) that account for 60% of medical costs


CareMore Integrated Patient Care Delivery System
COPD CAD CHF ESRD Diabetes Wound Clinic Healthy Start

Chronic Disease Support

Monitoring Hospice

End of Life Care
Palliative Care



Secondary Prevention

Foot care

Social Workers

Social / Behavioral Support

Clinical Care Centers (CCC)

Case Manager/ NP

Risk Event Prevention


Mental Health

Frailty Support
Extensivist Management Fall


Strength Training

Predictive modeling

Integrated IT infrastructure

Longitudinal patient record

Evidence-based protocols

Point-of-care decision support


The Results – “They Work”
Clinical Outcomes • Average HgBA1C = 7.08 • Amputation rates 78% less than national average • ESRD Hospitalizations 48% less than national average • 30 day readmission rates 13.6% vs. 20% Medicare • Hospital ALOS = 3.0 days

CareMore Care Centers (CCCs)


“Care Center - Neighborhood/Community”

CareMore Neighborhood Care Centers
Care Center Facts
• 4,000 square feet of clinical and 1,500 of

therapy space • Support 5,000 patients • Located in the heart of the neighborhood • Typical staffing includes MDs, NPs, MAs, podiatrist, PT, nutritionist, psychologist, case managers, social workers

Social Environment
• Designed for seniors and disabled

Clinical Support
• Physician and NP support of chronic and • • • • • •

• Resource for family and caregivers • Frequent classes and activities to

promote engagement

frailty care Wound care Physical therapy and strength training Cardiac/pulmonary rehab Nutritional training Disease-specific group sessions Healthy Start

Serves as an anchor to a neighborhood

Our Friendly, Dedicated Staff
 Nurse Practitioners
Disease Management programs are the main function of the CCC.

 Extensivists
Pre-Op, Post-hospital, and most frail patients.

 Office Manager
Keeps office running smoothly by monitoring wait times and customer care provided by staff.

Our Friendly, Dedicated Staff, cont.
Medical Assistants Assist patients while in CCC and helps with coordination of care by submitting referrals ordered by clinicians.  Case Management Teams Case management teams assist frail and high risk patients by coordinating care between hospitals, skilled nursing facilities and CCC to ensure they receive proper follow-up.  (CCC based) Specialist Many CCC’s have mental health, podiatry, and dermatologists in order to better serve our patients in the neighborhood.


CCC Environment
 Safe and comfortable clean environment

 Low glare surfaces

 Modern clinical exam and consultation rooms with chairs

CareMore Care Centers - Programs


Care Center Programs
 Diabetes Management  Wound Clinic Program  Routine Podiatry Program  Smoking Cessation Program  Nutritional Counseling  Anti Coagulation Program  Fall Prevention Program  Hypertension Program  Congestive Heart Failure (CHF) Program  Chronic Kidney Disease (CKD) Program  Chronic Obstruction Pulmonary Disease (COPD) Program  End Stage Renal Disease (ESRD) Program

Healthy Start Program
 Goal: Complete within the first 30 days of membership
 Comprehensive head-to-toe medical assessment  Review their medications  On-site, same day lab results  Personalized Care Plan (Developed)  Referrals for Appropriate Treatment Plan


Exercise & Strength Training Programs


Nifty After Fifty
• Usually within the CCC or close by to offer strength training, physical fitness, and social interaction. • CareMore offers members access to several facilities that provide a supervised strength-training program for mature adults. • We have partnered with “Nifty after Fifty*” locations that offer a staff of highly trained specialists who have developed specific treatment programs.

Nifty After Fifty
• Programs specifically designed with a wide variety of orthopedic and neurological conditions to proactively reverse reduced muscle strength and mass that is common in mature adults. • State-of-the-Art workout equipment with senior-minded technology. o Air compressed machines. o Convenient adjustable settings to provide comfort.

o Easy to read digital boards to help monitor current workout with built in tracking mechanism for future progress.

CareMore Care Centers – The Results

CareMore – A Day In The Life
• CareMore has approximately 76,000 members now enrolled with CareMore. • CareMore serves 76,000 members through our 41 Care Centers.

• Today we will see 930 patients in the Care Centers for follow-up and chronic care management
• Today we provide more than 2,875 rides to patients to and from points of care • Today we will make or receive 115 phone calls arranging Healthy Start/Healthy Journey appointments • Today we make 85 post-discharge calls to our members • Today we see more than 76 new members to assess health, arrange care programs and document personal care plans

• Today we visit 30 homes to provide care or social support
• Today we will engage 8 families in end-of-life/hospice planning • Today we provide 1006 strength and exercise training sessions • Today we fill 6,450 prescriptions

CareMore – A Day In The Life continued
• Today we will make 300 care visits to patients residing in nursing homes/assisted living facilities • Today we will read 1165 blood pressures from monitors in the homes of hypertensive patients • Today we will read 1125 weights from monitors in the homes of chronic heart failure patients • Today we will see 105 behavioral visits, largely for depression • Today 765 patients are monitored by a nurse practitioner. • Today 158 visits for routine Podiatry services at the CCC.

• Today 80 visits to see a Podiatrist for medical services.


CareMore Contacts
Admin Offices at Robious Road CCC – 10030 Robious Road, Richmond, VA 23235, 804-212-3450
 Dr. Michael Neiderer, D.O. Regional Medical Officer michael.neiderer@caremore.com  Linda Larue, CPA, MS

General Manager, Virginia
linda.larue@caremore.com  Tammy Cauthorne-Burnette, MSN, FNP-BC, CLNC, WCC Nurse practitioner - Richmond tammy.cauthorne-burnette@caremore.com


Questions and Answers

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