Complex Care Management (CCM) model is a retrospective, systems-based approach to improving the quality and efficiency of care by deploying state-of-the-art, patient-centric decision support technologies into the hands of healthcare providers. The CCM model utilizes Complex Care Indicators™ (CCIs), or data filters that are developed and customized to mirror best practice guidelines and identify patient care practices and prescribing patterns inconsistent with accepted best practices.

As part of the current CCM model, Informed Decisions analyzes large volumes of claims data and compares them to the established CCIs. Practices that are incongruent with the filters are identified at the physician, pharmacist, and patient level.

Once identified, a variety of intervention strategies are implemented to enhance the adoption of vetted patient care plans. These interventions include mailing a list of patient-specific complex care issues and medications in question along with supportive clinical content to providers, scheduling academic detailing sessions to enable the provider an opportunity for a peer review of the applicable complex care issues, or providing a combination of mailing and face-to-face sessions to further assist providers with the adoption of best practice guidelines.

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Informed Decisions implemented a plan-specific quality initiative for Amerigroup that focused on the optimal use of atypical antipsychotic therapies. The initiative employed a proactive approach to rectify the disproportionate growth in expenditures through prescriber-based interventions, where a third party takes action to alter the prescribing behavior of a physician that is systematically utilizing medications inconsistent with published best practices.

Low intensity interventions consisted of mailing a letter to the physician, informing them of their prescribing habits and their impact on cost and patient safety. Other interventions were more intense such as having a consultant pharmacist conduct a face-to-face medication review with the appropriate physicians. The quality initiative consisted of three stages:

• defining the optimal use parameters for atypical antipsychotics
• targeted interventions using two formats: mail-based interventions and face-to-face interventions when applicable, and
• analysis of the data. The initiative proved successful in that it allowed Amerigroup to see a significant cost savings as well as a change in provider prescribing behavior; when appropriate, providers prescribed medications for their patients who were in line with published best practices. Based on these outcomes, Amerigroup has decided to implement a renewal initiative in Florida and add additional states around the country.

An innovative firm, the Center for Managing Healthcare Innovations is transforming the healthcare industry. Managed by seasoned executives, the CMHI is poised to respond to the growing demands of quality, accoutability, and efficiency in the healthcare industry.