Cayuga Area Preferred/ Plan (CAP) Expands its Care Management Program in Tompkins County

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When Care Compass Network (CCN) announced its inaugural Innovation Fund program, Cayuga Area Preferred/ Plan (CAP) saw an opportunity to expand its Care Management Program to an additional population of individuals: the Medicaid population.

As a physician-led clinically integrated network, CAP has made a commitment to better coordinate patient care across community practices and providers through coordinated care management efforts that focus on enhancing the quality of healthcare services while simultaneously working to reduce unnecessary expenditures. This work is done through a uniquely collaborative approach between the CAP Care Coordination Nurse and the patient’s Primary Care Physician (PCP). CAP’s Care Management Program began doing this type of work in 2015, actively engaging patients within a much smaller employer-based pilot population, which has since shown improved patient outcomes. Having shown success in its pilot stage, in 2016 CAP began to explore ways to expand its model to provide care coordination services to additional populations, and CCN’s Innovation Fund offered an opportunity to do just that. CAP submitted a proposal for review to bring its same integrated-care approach to the Medicaid population, and was one of the nine Innovation Fund recipients CCN announced in April 2016, receiving over $500,000 of the $2 million award.

With these funds, CAP expanded its Care Management Program in early 2017 to include Medicaid members within the network, focusing on those patients attributed to a CAP PCP, although care coordination happens across all specialties including community-based organizations. CCN innovation funds gave CAP the means to hire two additional Registered Nurses (RNs) to provide care coordination services at the CAP practice level. CAP not only partners with the patients and their providers within the network through the Cayuga Area Physicians Alliance (CAPa), but also with insurance payers, and the local hospital – Cayuga Medical Center – to minimize gaps in care delivery.

CAP Care Coordination RNs work in collaboration with CAP PCPs to identify patients at various risk levels who, based on a number of qualifying criteria, would benefit from ongoing engagement. CAP nurses then outreach those patients, meeting them in person whenever possible to promote patient engagement, and works with them to develop self-management goals. CAP Care Coordination RNs work closely with the patients they’ve engaged, in collaboration with their entire care team, to provide the patients with tools and resources to not only meet those goals, but sustain them for the long term. In doing this CAP has seen a decrease in avoidable emergency room admissions, an increase in patient compliance with medications, and overall reduction in care gaps and an anticipated cost savings to the network in the long run.

CAP utilizes data in many forms to track the successes of its care management endeavors, but the one piece that cannot be measured is the direct impact on patient quality of life. One of CAP’s greatest successes has been working with a particular Medicaid patient referred for care coordination by his Primary Care Provider just prior to the CCN innovation award. This particular patient was in the ER nearly 60 times in the 12 months prior to engagement with his CAP Care Coordination RN. Since that time, in 4 months of intensive case management and education provided by his CAP nurse, he has not been to the ER once. Additionally, he has not missed an appointment with any of his doctors and, for the first time in years, if ever, is taking his (29 different daily) medications as prescribed.

“Our team has the unique ability to see the patient through their own eyes,” says Emily Mallar, Director of CAP Care Management. “Through relationship development and having the flexibility to meet patients where they are we have the ability to be innovative with our care delivery to best meet the true needs of the patients we serve.”

Additionally, CAP’s program has been helpful in enhancing the relationship between the patient and their Primary Care Provider. “To have someone like the doctor or the nurse say, ‘I’m so proud of you,’ and for the patients to be proud of [themselves], can really go a long way when it comes to changing behaviors,” Mallar says. Patients with the most intense needs now have an advocate and a voice that moves with them beyond the walls of the office and into the walls of their home allowing provider to better treat them based not just on their diagnosis, but in a way that is practical for the patients in their world, better setting them up for success with the plan of care.

Without the support of CCN through their Innovation Funds the Medicaid population in Tompkins County would not be receiving the same opportunities for care coordination that they are now through CAP. Mallar says, “These funds have allotted us the resources to expand our program more rapidly than we could have anticipated in order to meet the needs of our Medicaid population. It’s the right thing to do, and we are just so thankful to be able to provide this service to our patients, to our community.”

To learn more care CAP or their Care Management Program, please contact CAP at 607-252-3690.