Definition of Serious and Complex Medical Conditions (1999) / Chapter Skim
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3 Conclusions and Recommendations
3 Conclusions and Recommendations
Pages 43-54
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From page 43... ...
Specifically, the committee has chosen to provide guidance to HCFA and health care plans to support initial steps to address the major issues confronting health care plans and their beneficiaries with serious and complex medical conditions. This guidance is supported by presentation of possible strategies that might be used to screen enrollees for the presence of serious and complex medical conditions.
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From page 44... ...
For example, research in correlating patient volume with patient outcomes, differentiating access to services as a function of health plan benefits, and addressing variations in quality of care has just begun to yield meaningful results about particular groups of patients. The committee anticipates that this research will continue to evolve and will provide more definitive conclusions to guide the efforts of health plans to identify patients with serious and complex medical conditions and ensure appropriate levels of treatment and care management.
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From page 45... ...
Recommendation 2: The committee recommends that the Health Care Financing Administration should provide guidance to health plans to assist their efforts to identify patients with serious and complex medical conditions. Specifically, the committee recommends the following language be used to facilitate efforts of plans to identify their enrollees with "serious and complex conditions": "A serious and complex condition is one that is persistent and substantially disabling or life threatening that requires treatments and services across a variety of domains of care to ensure the best possible outcomes for each unique patient of member." The committee recognizes the importance at this time of providing health plans with guidance to facilitate operationalization of their own definitions of serious and complex medical conditions.
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From page 46... ...
The committee anticipates that this research will continue to evolve and provide more definitive conclusions to guide the efforts of health plans to identify patients with serious and complex medical conditions and help plans to provide appropriate levels of treatment and care management. The committee urges health care plans, in collaboration with federal agencies and research institutions, to support this ongoing research and facilitate a synthesis of emerging results.
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From page 47... ...
Treatment or care planning is also recommended by the committee as an essential element of a care management strategy for patients with serious and complex medical conditions. Such planning supports the development of individualized, goal-focused care plans (based on assessment findings and drawing on evidence-based treatments when available)
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From page 48... ...
These strategies should be consistent with the guidance outlined in Recommendation 2 to determine which patients meet a plan's threshold for serious and complex medical conditions and would benefit from a coordinated care management strategy. The committee recommends that health plans identify specific categories ot patients or health conditions for which screening for the presence of serious and complex conditions should occur on a routine basis.
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From page 49... ...
Similarly, home health agencies or medical professionals could identify frail elderly patients who require care management to sustain homeostasis. These agents could refer patients' names to health plans for development of a formal management program for serious and complex medical conditions.
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From page 50... ...
Recommendation 5: The committee recommends that health care plans develop a care management strategy that integrates the participation of all those involved in the care of the patient, including primary care physicians; medical and surgical specialists; nurses and nurse specialists; behavioral and mental health specialists; physical, occupational, and speech therapists; social workers; allied health professionals; and community-based service providers. The development of a collaborative care management strategy involving all those who participate in providing care to the individual patient is critical to the treatment of patients with serious and complex conditions.
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From page 51... ...
The Health Care Financing Administration should establish a formal mechanism to evaluate a Medicare+Choice provider organization's program to monitor the outcomes of care for patients with serious and complex medical conditions. The committee recognizes that the monitoring and evaluation programs will vary between health plans but recommends that all programs include population-based monitoring of the outcomes of care for patients with serious or complex conditions, as well as individual case monitoring, assessment of provider interventions, and evaluation of best practices of care.
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From page 52... ...
This is primarily due to the fact that the committee lacked sufficient information and time to conduct informed deliberations about the implications of alternative definitions for serious and complex medical conditions for Medicaid and commercial programs, especially when applied to Medicare beneficiaries who are dual eligible. The committee strongly recommends that HCFA, in collaboration with Medicare and Medicaid provider plans, establish this as a research priority.
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From page 53... ...
This should be a priority area for collaborative research on policy issues to ensure continuous improvements in the care of populations with serious and complex medical conditions covered by Medicaid and fee-for-service Medicare plans. · Consumer Education and Participation.
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From page 54... ...
The work of this committee is intended to support and provide direction for future work to be conducted by HCFA, in collaboration with all types of health care plans and consumer organizations, to design innovative strategies to ensure adequate reimbursement, access to broad care management, and the highest possible quality of treatment services required by patients with serious and complex medical conditions.
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