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HLCCompendium
HLCCompendium
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NDHI<br />
NAT IONAL DIALOGUE FOR<br />
Healthcare Innovation<br />
Complex Community Care<br />
Initiative<br />
Organization Overview<br />
• BlueCross BlueShield of Tennessee (BCBST) is a<br />
not-for-profit health insurance organization<br />
• BCBST provides benefits to about 12,000 companies<br />
and serves 3.3 million people<br />
• BCBST offers BlueCare Tennessee, a managed<br />
Medicaid program that serves 602,000 members<br />
Background<br />
In the United States, 5% of the patient population generally<br />
represents 50% of the total cost across all payers.<br />
This patient population is complex and dynamic, often<br />
struggling with factors such as chronic physical and<br />
mental illness, poverty, and social isolation. For these<br />
individuals, the standard care system is not effective,<br />
as demonstrated by high utilization rates coupled<br />
with poor outcomes. BCBST believes that the primary<br />
need for these patients is not additional resources, but<br />
rather, improved care design and greater member and<br />
community engagement.<br />
In 2014, BlueCare leadership commissioned a multifaceted<br />
work group to address these needs, which<br />
represented departments such as Clinical Improvement,<br />
Population Health, Case Management, Medical<br />
Informatics, and others.<br />
The workgroup developed a collaborative partnership<br />
with the Institute for Healthcare Improvement (IHI) in<br />
2015, which led to the implementation of the Complex<br />
Community Care Initiative, an integrated “community<br />
care” model for a small subpopulation of BCBST’s<br />
Medicaid population with complex needs. BCBST is<br />
now building relationships with primary care teams,<br />
hospitals, and affiliated entities who are willing and<br />
able to participate in redesigned care for individuals<br />
with complex needs.<br />
Program Details<br />
BCBST utilized claims data analysis and predictive<br />
modeling to identify a small subset of the overall Blue-<br />
Care Tennessee population that would benefit most<br />
from intensive community-based care management.<br />
BCBST identified 285 BlueCare Core members with<br />
over $50,000 in medical spend for 2014 and at least<br />
8 inpatient admissions in a two-year period.<br />
These patients were enrolled in the Complex Community<br />
Care Initiative, with the specific objectives to:<br />
• Provide patients with the knowledge, skills and<br />
confidence to manage their conditions effectively<br />
• Reconnect these members with community supports<br />
and care teams that meet their complex needs<br />
• Improve patients’ health and experience, while<br />
reducing their healthcare expenditures<br />
An Initiative of the<br />
55 |<br />
Complex Community Care Initiative