Transcript Slide 1

INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
CLARION Interprofessional
Case Competition
“The Heart of the Matter”
1
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Our Team
Nathaniel Arnold
Natalie Nguyen
Darshan Pandya
Andrew Rock
Medical Director
of the Heart
Failure Clinic at
Central Hospital
Head of
WestPlan’s
Head of
WestPlan’s
Home Care and
Hospice
Nurse Manager
from Central
Hospital
health plan
Disease and Case
Management
Program
2
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
The Heart of the Matter:
Chronic Heart Failure (CHF)
5.1 million
50% CHF
patients are
readmitted
50%
mortality
within 5
years
Hospital
Readmissions
Reduction
Program
Demands improvements in quality of
care and patient safety for CHF
Our Purpose
To recognize and eliminate
the gaps and failure points
that prevent optimal heart
failure care at WestPlan
3
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Chronic Heart Failure & WestPlan
• 1,817 WestPlan members have CHF
• 184 (10.2%) members participate in our Disease and Case
Management Program
Central Hospital treated 2,346 patients with CHF in 2013
Inpatient Admissions: 1,644
Outpatient Visits: 1,105 (87 ER Visits)
Visits per patient
Visits per patient
1 to 2
1,513 (92%)
1 to 2
984 (89%)
3 to 5
125 (7.6%)
3 to 5
111 (10%)
More than 5
7 (0.4%)
More than 5
15 (1.3%)
4
INTRO
THE CASE
RCA
69 Years
Old
Margie
Reeves
RECOMMENDATIONS
Insured by
Medicare
IMPLEMENTATION
Stressors
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Retired
Mechanic
Harlan Reeves
Robert &
Lisa
Reeves
BUDGET
Sedentary
Lifestyle
& Poor
Diet
Family
History
Smoking
&
Drinking
5
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
6
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
7
INTRO
THE CASE
RCA
Development/dx
of DM II (12 years ago)
High BMI due
to poor lifestyle
Family History
of DM II
Low health literacy
No regular medical
checkups
Smoking/drinking
to deal with
stressors
Unhealthy
Lifestyle
RECOMMENDATIONS
MI at home/placement
of stent/pacemaker
at Central Hospital
(7months ago)
Poor handling of
CHF dx 14 mos. ago
Non-adherence to
cardiac medication regimen
Poor coordination of
care for DM II and CHF
Fragmented
health records
Unmanaged DM II
Continued smoking and
sedentary lifestyle
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Hospitalization for deteriorating
condition and admitted as an
inpatient to the transitional care
unit (2 weeks ago)
Admitted only for
observation 3 weeks ago
…no Transitional Care
Margie and Lisa now
physically unable to
care for Harlan
Rejected palliative
care 7 months ago
Never referred to Heart
Clinic or transferred to
Transitional Care
The
system
failed
Harlan
Reeves
FH of heart disease
Age/gender: 69 y/o M
Development/dx
of Grade III CHF
(14 months ago) 8
Inadequate home
care
Diabetic and Cardiac
Events in the 7 months
following MI/Rushed
to the ER (3 weeks ago)
8
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Harlan’s Health Care
Access to
Needed Care
Optimal
Evidence-based
Disease
Management
Prevention of
Disease State
Interdisciplinary
Coordination
9
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Our Recommendations
1. Achieve Advanced
Certification in Heart Failure
by The Joint Commission
2. Partner with the Dunnelly
community to implement
population health
management
Images retrieved from: http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx Institute of Healthcare Improvement
10
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Recommendation 1
Advanced Certification in
Heart Failure
11
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
BARRIERS &
OUTLOOK
Recommendation Strategy
Cardiac Care Checklist
Hospital Stay
Hospital
Discharge
Post-Acute
Care
[ ] Joint Commission Core
Measures in Heart Failure
[ ] Joint Commission
requirements for Advanced
Certification in Heart Failure:
INPATIENT and OUTPATIENT
Outpatient
Home Care &
Hospice
[ ] WestPlan considerations for
Standards of Care
12
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Pathway to Advanced Certification for CHF
Tactic 1
• Integrate and improve Health
Information Technology
Tactic 2
• Coordinated Transitions of Care
Tactic 3
• Medication Management
Tactic 4
• Optimize Home Care and Hospice
services for CHF patients
13
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Tactic 1 : Information Technology
• Existing EHR Clinical Decision Support Tool
– Cardiac Care Checklist
– CHF Risk Assessment Checklist
• Oregon’s Health Information Exchange program
(Care Accord)
– Integrating health records from WestPlan and
outside of WestPlan networks
14
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Tactic 2: Transition Coordinators
• Transform discharge planners into Transition Coordinators
• Ensures smooth transition from hospital to next care setting
• Follow-up by post-discharge day 7 & connect with Home
Care and Hospice services
• Goals to achieve:
– 80% patient follow-up with PCP, cardiologist, or Heart
Failure Clinic or other WestPlan Service
– 100% of medications prescribed are filled at discharge
with medication instructions understood by the patient
 Reduce CHF readmissions by 15% within year 1
15
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Tactic 3: Medication Management
• Medication Reconciliation
– Obtaining medication histories
– Reconciling patient’s home medications with updated
medication action plans
– Interdisciplinary effort
– Improving medication safety across the continuum of care
• Inpatient stays
• Outpatient appointments
• Updated personal patient medication lists
16
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Tactic 3: Medication Management
• Medication Regimen Dose Optimization
– Adding a clinical pharmacist to the WestPlan Heart
Failure Clinic to help optimize heart failure regimens in
the most critical and complex patients
• Medication Therapy Management (MTM)
– Adding an MTM pharmacist to the Disease and Case
Management Program to help improve medication
safety for patients not regularly seen in the WestPlan
Heart Failure Clinic
17
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
P4: Home Care and Hospice
Why is Home Care and Hospice important for CHF patients?
• Quality of Life
• Patient Safety
• Reducing hospital re-admissions!
WestPlan’s Home Care and Hospice services are underutilized. Why?
• Stigma
• Access
Our current team:
Geriatricians, Nurse Practitioners, Nurses, Social Workers, Assisted Living
specialists (home aides), Chaplains
Which roles do we want to add or enhance?
• Transition Coordinators
• Dietician
• Clinical pharmacist
18
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
P4: Home Care and Hospice
How will our improved interdisciplinary team help CHF patients?
Health Professionals
Transition coordinators
• Medicare resources
• Coordination amongst the team
NPs/Nurses
• Medication management
• Fluid volumes
Social workers and Chaplains
• Family meetings
Dieticians
• Menu planning
Home aides
• Assistance with ADLs
Geriatricians and Pharmacists
• Effective and personalized care and
medication plans
Roles in Patient Safety
Sharing medical information
Preventing medication errors
Monitoring any sudden changes
Individualized patient care
Patient-specific dietary needs
Preventing accidents and reducing
caregiver burden
Individualized patient care
19
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Recommendation 2
Population Health Management
20
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Population Health Management
10%
Level 3
High risk
Multiple Chronic
Illnesses
20%
Level 2
Moderate risk
Single Chronic Illness
or Risk Factors
70%
Level 1
Low Risk
OUR COMMUNITY
Intensive Case & Disease Management
• Chronic disease self-management
• Increased enrollment through electronic
medical records (EMR)
Health Coaching & Lifestyle Management
• Coaching lifestyle choices
• Programs for modifying risk factors
Health Education & Promotion
• Raising health awareness
• Health promotion programs
Community Partnerships
• Incentives
• Screening & Annual Visits
• Outreach & Awareness
21
Risk Stratification
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
CHF RISK STRATIFICATION
Risk Levels
HIGH RISK
MODERATE
RISK
LOW RISK
Community
Risk Criteria
1.
2.
3.
4.
5.
6.
Any cardiac condition or hospitalization for a cardiac condition
Valvular Heart Disease
MI
Cardiomyopathy
Left Ventricular Hypertrophy
CHF Grade II, III, IV
One or more of the following:
Conditions:
1. Smoking
1. CHF Grade I
2. Alcohol use-due to impact on risk factor
2. Diabetes
conditions for CHF
3. Hypertension 3. Poor Diet
4. High
4. Stress
cholesterol
5. Low Physical Activity
6. Overweight
Defined by exclusion of all of the above
All those who have not come into contact with our healthcare
system, not currently patients, or we do not have any health
assessment information
22
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
WestPlan Community Care-a-Van
• Interdisciplinary Team (Allocated Part Time)
– 1 Public Health Specialist (Epidemiologist)
– 2 Registered Nurses
– 1 Social Worker
•
Services provided
– Blood Pressure and Blood Glucose Readings
– BMI Assessments
– Tobacco and Alcohol Use Assessments (ASSIST)
– Individual Health Risk Assessments
– Referrals to WestPlan providers
• Care-a-Van operations
would partner with the
Million Hearts Campaign
23
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Raising Health Awareness
•
WestPlan Community Care-a-Van
– “Honoring Choices”
– Onsite patient counseling
• Health Education and Promotion
– Classes on various health topics
– Specialized for inpatients, outpatients,
or the general public
• Community Partnerships
– Health Fairs
– Engagement with community stakeholders
24
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Recommendations
1. Achieve Advanced
Certification in Heart
Failure by The Joint
Commission
2. Partner with the Dunnelly
community to implement
population health
management
Images retrieved from: http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx Institute of Healthcare Improvement
25
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Tactic 1-4 Expenses
Table E: Salary Expense
Annual Salary
Monthly Salary
Allocated for Central Hospital
Registered Nurse(RN)**
$
69,000.00
$
5,750.00
$
51,750.00
9 months
Registered Nurse(BSN)**
$
73,000.00
$
6,083.33
$
54,750.00
9 months
Social Worker (MSW)**
$
58,233.00
$
4,852.75
$
43,673.00
9 months
Epidemiologist (MPH)**
$
86,132.00
$
7,177.67
$
71,776.67
10 months
Dietician (RDN)
$
57,034.00
$
4,752.83
Clinical Pharmacist (PharmD)
$
109,974.00
$
9,164.50
Pharmacist (PharmD)
$
105,049.00
$
8,754.08
Social Worker Manger (MSW)
Total Salary Expense and Training and
Orientation Time
$
65,000.00
$
5,416.67
$
623,422.00 $
31,171
26
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Tactic 1-4 Cost Savings
Intervention
Cardiac Rehabilitation
Guideline Directed Medical Therapy
Multidisciplinary Teams
Transitional Care Coordination
Enhanced Medication Management by Pharmacist
Discussions about Advanced Directives
$
$
$
$
$
Total Savings
671,381.50
161,349.60
3,661,981.80
4,401,682.50
2,929,585.44
HCAPS Increase
27
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Scenario 3
Care-a-Van
Pro Forma Analysis
Care-a-Van Volume (low performance)
Year
Patient Volume
2015
480
2016
528
2017
581
2018
639
2019
703
(1day x 48weeks x 10patients) (10% annual growth)
Table B : Cash Savings from Heart Attack Prevention
Number of M.I. prevented
Cost per M.I. = $14,000
2015
2016
2017
2018
2019
5
8
10
12
15
14,000
14,000
14,000
14,000
14,000
Annual Cost Savings
$
70,000.00
$
112,000.00
Table E: Salary Expense
Annual Salary
Monthly Salary
Registered Nurse(RN)
$
69,000.00
$
5,750.00
$
17,250.00 3 months
Registered Nurse(BSN)
$
73,000.00
$
6,083.33
$
18,250.00 3 months
Social Worker (MSW)
$
58,233.00
$
4,852.75
$
14,558.25 3 months
Epidemiologist (MPH)
$
86,132.00
$
7,177.67
$
14,355.33 2 months
$
64,413.58
Total Salary Expense
$
140,000.00
$
168,000.00
$
210,000.00
Allocated for Care-a-Van
28
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
BUDGET
Care-a-Van Pro Forma Analysis
Assumption of Scenario 3 - Low performance conservative estimates.
Care-a-Van Pro Forma
a
b
Initial Capital Outlay
Cash Savings ( M.I. prevention)
c
d
e
2014
2015
2016
2017
2018
2019
$ (75,000.00)
$
70,000
$
112,000
$
140,000
$
168,000
$
210,000
Donations
Net Revenue (earned and saved)
Less: Salary Operating Expense
$
$
$
1,200
71,200
64,414
$
$
$
1,320
113,320
65,702
$
$
$
1,452
141,452
67,016
$
$
$
1,597
169,597
68,356
$
$
$
1,757
211,757
69,723
f
Less: Supply Operating Expense
$
868
$
955
$
1,050
$
1,155
$
1,271
g
Less: Depreciation Expense
$
14,000
$
14,000
$
14,000
$
14,000
$
14,000
h
i
j
Net Operating Income
Add: Depreciation Expense
Net Operating Cash Flow
$
$
$
(8,081) $
14,000 $
5,919 $
32,664
14,000
46,664
$
$
$
59,386
14,000
73,386
$
$
$
86,086
14,000
100,086
$
$
$
126,763
14,000
140,763
k
l
Add: Salvage Value
Project Cash Flows
100,086
$
$
5,000
145,763
$
m Cost of Capital
n Present Value Interest Factors
o
p
Annual Present Value of Cash Flows $ (75,000.00) $
Net Present Value $ 331,548.39
5,919
$
3%
0.9709
46,664
3%
0.9426
5,746.35 $
IRR
43,985.03
$
73,386
$
3%
0.9151
$ 67,155.55
3%
0.8885
$
88,926.32
3%
0.8626
$ 125,735.15
51%
29
INTRO
THE CASE
RCA
RECOMMENDATIONS
Harlan Reeves
Development/dx
of DM II (12 years ago)
 Community Care
Partners
 Health Promotion
& Education
FH of DM II
High BMI due
to poor lifestyle
Lack of education
No regular medical
checkups
Smoking/drinking
to deal with
stressors
Poor lifestyle
management
MI at home/placement
of stent/pacemaker
at Central Hospital
Poor handling of
CHF dx 14 mos. ago
Non-adherence to
cardiac medication regimen
Poor coordination of
care for DM II and CHF
Unmanaged DM II
 Health Coaching &
Continued smoking and
Lifestyle
Management
sedentary
lifestyle
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Hospitalization for deteriorating
condition and admitted as an
inpatient to the transitional care
unit (2 weeks ago)
Admitted only for
observation 3 weeks ago
…no Transitional Care
 Disease & Case
Management
Margie and Lisa now
physically
to
 Home Care
&unable
Hospice
care for Harlan
Rejected palliative
care 7 months ago
Never referred to Heart
Clinic or transferred to
Transitional Care
The
system
failed
Harlan
Reeves
FH of heart disease
Age/gender: 69 y/o M
Development/dx
of Grade III CHF
(14 months ago)
Margie suffering from
caregiver’s burden
Diabetic and Cardiac
Events in the 7 months
following MI/Rushed
to the ER (3 weeks ago)
30
INTRO
THE CASE
RCA
RECOMMENDATIONS
IMPLEMENTATION
BUDGET
OUTLOOK
BARRIERS &
TAKEAWAYS
OUTLOOK
Thank You
31