Transcript St. Johns River Rural Health Network

St. Johns River
Rural Health Network
Comprehensive Diabetes Management
and Education Program
Serving:
Baker  Bradford  Clay  Nassau  Union
Brief Background on
Rural Health Networks
(RHN’s) In Florida
• 9 Rural Health Networks in Florida

28/33 rural counties and parts of 13 non-rural counties
• Established by State Statute 381.0406 in 1993
• Intended to address 3 fundamental problems:

Inadequate Funding for healthcare in rural areas

Recruitment and retention of health professionals

Migration of patients from rural to urban providers
• Core function to integrate public and private health resources;
and to emphasize cooperation over competition.
St Johns River Rural Health Network, Inc.
Overall Goal
of RHN’s
“The ultimate goal of rural health
networks shall be to ensure that quality
health care is available and efficiently
delivered to all persons in rural areas.”
St Johns River Rural Health Network, Inc.
St Johns River
Rural Health Network
Incorporated in 1994; Certified by the AHCA in 1995
Baker, Clay, Flagler, Nassau, Putnam, St. Johns, and
Volusia (also services in Union, Bradford)
Active membership: CHD’s, AHEC, medical providers, rural
hospitals, FQHC’s, RHC’s, behavioral health providers,
Universities, others…
Health Planning Council of Northeast Florida provides staff
support and administrative services under contract from
FDOH, Office of Rural Health
St Johns River Rural Health Network, Inc.
Mission of SJRRHN
To recognize, encourage, and support
partnerships that improve the health of rural
communities in Baker, Clay, Flagler, Nassau
St. Johns, Putnam, and Volusia Counties.
St Johns River Rural Health Network, Inc.
Strategic Priorities
for 2009 - 2012
Develop the SJRRHN into a relevant leader and primary information
source for Health Information Technology or Informatics among
rural healthcare providers.
Enhance and expand the RHN’s existing Chronic Disease
Management and Education program (LIP Program), and related
Care Coordination activities.
Become a prime resource among rural health providers for
information and technical support related to rural healthcare funding,
reimbursement issues, and overall Sustainability.
Coordinate a mechanism to foster and facilitate comprehensive realtime health status, healthcare services/resources, and outcomes
information sharing among rural providers in Northeast Florida.
St Johns River Rural Health Network, Inc.
Regional Assessment
MUA/MUP’s and HPSA’s in Rural NEFL
All of Baker, Bradford and Union
Low-Income groups in Clay, Nassau
Socio-Economically Disadvantaged
Per capita income as much as 55% below avg. for FL
Population below FPL as high as 23.6% (Union)
Higher rates of Medicaid enrollment and un-insured
Health Indicators
Leading Mortality: Cancer, Heart Disease/CVD, Respiratory Disease, Injuries, Diabetes
High/Very High rates of overweight and obesity (BRFSS)
Very high rates of hospitalization and lower-limb amputations (Hosp. utilization data)
St Johns River Rural Health Network, Inc.
Program Area
• 2,371 sq. miles
• 320,000 (est.) population
Target population
• Un-insured Adult (Ages 18-64)
• Low-income (≤150% FPL)
• Resident of Baker, Bradford, Clay, Nassau, or Union
• Clinical diagnoses of Diabetes
St Johns River Rural Health Network, Inc.
Program Partners
5 County Health Departments (Baker, Bradford, Clay, Nassau, Union)
St. Johns River Rural Health Network, Inc.
Independent Eye and Foot specialists in each county
Nassau County Government (provides local match $$)
Winn-Dixie Pharmacies (and others)
Florida Academy of Family Physicians (DMCP)
Hospitals (referrals)
St Johns River Rural Health Network, Inc.
Program Components
Primary Care and Medical Home
• Labs
• Immunizations
Disease-specific Specialty Services
Prescription Medications and Supplies
Care Coordination
Individual Disease Self-Management Education and Support
Group Level Education using Accredited Programs
FAFP Diabetes Master Clinician Program and EPR
Ongoing Community Support Groups
St Johns River Rural Health Network, Inc.
Primary Care Services
and Medical Home
Enrollment:
Baker
Bradford
Clay
Nassau
Union
TOTAL
40
40
80
60
40
260
•
100% of clients are screened for eligibility for Medicaid
and Drug Assistance Programs.
•
100% of enrolled clients given a medical home.
•

Extended clinic hours in most locations

24Hr on-call service for urgent needs

Access to nutrition and other education programs
All diabetes-related medications and supplies, plus others
OUTCOME: Self-reported ER utilization reduced by ≥50%.
Estimated savings to area hospitals due to reduced Emergency Room
utilization and reduced Admissions/Re-Admissions is over $344,500.
St Johns River Rural Health Network, Inc.
Care Coordination and
Specialty Services
• Referral and linkage to specialty services
and other community-based resources:

Vision/Eye Care

Podiatry

Education and Support

Social Services
• Applications for drug assistance programs

Receipt, distribution, tracking, and follow-up
• Follow-up to ensure services are received
St Johns River Rural Health Network, Inc.
Disease Management
and Education
• 2 FTE Disease Managers/Health Educators
– Outcome-based Disease Self-Management Education
– Community Outreach and Home Visits
– Individual and Community-based Group Education
– Ongoing Support Groups
• FAFP Diabetes Master Clinician Program
– Diabetes Registry
– Group Visits
St Johns River Rural Health Network, Inc.
Accredited and Proven
Education Programs
Diabetes Conversation Maps:
• Developed jointly by ADA and Merck
• 5 Total Maps (Conversations)
• 1-2 Hours each
“Take Charge of your Diabetes”
• CDC Program
• 12 Sessions (1-2 per week)
• 1.5-2 Hours each
St Johns River Rural Health Network, Inc.
FAFP Diabetes Master
Clinician Program
• As developed by Dr. Edward Shahady, MD and FAFP in 2003
• Currently more than 80 practices participating (17,000+ patients)
• Internet based “relational” database (HIPPA Compliant)
• Based on American Diabetes Association recommended goals:
– HbA1c ≤ 7%
– LDL’s ≤ 100
– BP ≤ 130/80
• Individual Client Report Cards and Aggregate Provider/Clinic Reports
• Projected cost-saving up to $1,122 per client/year
(Totaling at least $291,720/yr in overall savings for all clients enrolled.)
St Johns River Rural Health Network, Inc.
Background on Estimated
Annual Cost Savings*
• Hb A1C: Good control (<7%) = $279
• Blood pressure: <130/80 = $464
• LDL: Reduced to <100mg/dl = $369
• Total: All 3 targets met = $1,112
*
Towers Perrin 2005 actuarial analysis conducted for
ADA/NCQA for Diabetes Physician Recognition Program
St Johns River Rural Health Network, Inc.
Patient Report Cards
St Johns River Rural Health Network, Inc.
Provider Reports
St Johns River Rural Health Network, Inc.
Population
Management Tools
St Johns River Rural Health Network, Inc.
Services Provided
in FY 2008 - 2009
• 3,475+ Primary Care visits
• 473+
Specialist visits (foot and eye)
• 3,288+ Prescriptions filled
• 1,905
Labs performed
• 2,504
Disease Management encounters
• 1,180
Care Coordination activities
St Johns River Rural Health Network, Inc.
Program Expenditures
More than $2.3M in services provided in FY08-09
Disease
Management
17%
Pharmaceuticals
31%
Vision/Eye Care
6%
Podiatry
3%
Primary Care
43%
St Johns River Rural Health Network, Inc.
Sample Outcomes
Average Percent of Diabetics achieving all 3 goals:
United States
SJRRHN Clients
Annual
Exams
7%
15%
% through
11/6/07
% through
1/5/09
Eye Exam
48%
70%
Foot Exam
48%
70%
St Johns River Rural Health Network, Inc.
Estimated Hospital
Costs from Diabetes
Emergency Department Outpatient visits
Based on ICD-9 code 250.xx (diabetes, unspecified)
Adults ages 18-64, regardless of insurance status
Pt. County of Residence
Average Charges
# of OP visits
Sum of Charges
Calculated #
Admitted from ER
Total
ER Encounters
% of ER Visits
resulting in
Admission
Baker
Bradford
Clay
Nassau
Union
$
$
$
$
$
2,899
2,183
3,791
2,753
1,938
63
25
137
82
15
$
$
$
$
$
182,610
54,566
519,421
225,746
29,066
23
21
163
69
8
86
46
300
151
23
27%
46%
54%
46%
35%
Totals
$
3,141
322
$
1,011,409
284
606
47%
Sum of Charges
Hospital In-Patient/Admissions
Based on ICD-9 code 250.xx (diabetes, unspecified)
Adults ages 18-64, regardless of insurance status
Pt. County of Residence
Average Charges
# of Admissions
% Admitted from ER
Calculated #
Admitted from ER
Average LOS*
Baker
Bradford
Clay
Nassau
Union
$
$
$
$
$
48,815
18,265
37,264
27,911
34,743
34
23
191
86
18
67.6%
91.3%
85.3%
80.2%
44.4%
23
21
163
69
8
8.44
4.61
4.85
4.98
4.78
$
$
$
$
$
1,659,725
420,102
7,117,427
2,400,328
625,375
Totals
$
34,724
352
80.7%
284
5.21
$ 12,222,957
* The average Length of Stay (LOS), in days, for diabetic patients is approximately 75% longer than for the total population among this age group.
This equals approximately 1 additional day per diabetic patient admission when compared to other illnesses/conditions.
Data source for all figures: AHCA hospital utilization monthly data submissions
St Johns River Rural Health Network, Inc.
LIP Program - Estimated
Hospital Cost Savings
Client self-reported ER utilizatation:
At least 11.5% of enrolled clients indicated visiting an Emergency Room in relation to their diabetes during the
2 year period before they were enrolled in the LIP disease management program in 2006.
Within 24 months of program activity, the percentage of enrolled clients who reported visiting an
emergency room within the previous 2 years had declined to 5%.
This represents a 56.5% reduction in self-reported ER utlization within 2 years.
Calculated Cost Savings (based on 273 unduplicated clients served) :
ER Utilization %
Calc. # of
ER visits
Calc. ER Cost
(Assumes 1 visit/cl/yr)
Baseline
Current (calculated)
Difference (SAVINGS)
Calc. # of
Admissions
Calculated
In-patient costs
Total
Hospital Costs
11.5%
31.4
$
98,611.70
14.7
$
510,900.06 $ 609,511.75
5%
13.7
$
42,874.65
6.4
$
222,130.46 $
265,005.11
6.5%
17.7
$
55,737.05
8.3
$
288,769.60 $
344,506.64
Estimated direct savings to area hospitals. Does not include primary care cost savings such as reduced need for prescription medications
and fewer needed follow-ups achieved through effective disease management.
St Johns River Rural Health Network, Inc.
Return on Investment
Total Program Funding:
$
650,000
Cost-Limit Estimate of Services Provided:
$
2,315,000
Estimated Savings to area Hospitals:
$
344,500
Sub-Total
$
2,659,500
*Potential Primary Care Savings (goals met):
$
39,551
TOTAL POTENTIAL RETURN ON INVESTMENT:
$
2,699,051
4.15
ROI only Match dollars
$
289,900.00
9.31
4.09
St Johns River Rural Health Network, Inc.
Success Stories
“John” enrolled July, 2008
– Type II Diabetes
– Stroke in May, 2008
• Weight at enrollment: 309.6lbs
• Cholesterol: 210
• Triglycerides: 309
• HbA1c: 7.9
St Johns River Rural Health Network, Inc.
Success Stories
• HbA1c reduced to 5.3 within 5 months
• John lost more than 35 lbs in 7 first months
• Learned to inject his own insulin
• Now attends all appts. and classes
• Reports feeling much more energized and is able to get around
much easier!
• Total weight loss as of 6/09: 88
• Last HbA1c:
lbs.
5.1
St Johns River Rural Health Network, Inc.
Success Stories
“Mary” enrolled in July, 2007
Weight: 373 lbs
Highest HbA1c: 8.1
No daily blood glucose checks
Repeatedly no-showed for appointments
St Johns River Rural Health Network, Inc.
Success Stories
Mary in July, 2009 (2 years later)…
• Testing blood glucose several times daily
• Attends all regular medical appointments
• Regularly attends education classes
• Improved diet/nutrition
• Began exercise – thanks to a new dog!
• Improved confidence
• Total weight loss: 103
lbs!!
St Johns River Rural Health Network, Inc.
Program Enhancements
Behavior Change assessment and evaluation

Based on proven Readiness to Change theory

Baseline assessment at enrollment

Periodic 6 month re-evaluations

Longitudinal monitoring of individual clients to better target
intervention and education strategies
St Johns River Rural Health Network, Inc.
Contact Information
St. Johns River Rural Health Network, Inc.
Nikole Helvey, MS HSA, Program Director
(904) 723-2162 Ext. 109
[email protected]
Health Planning Council of Northeast Florida, Inc.
Dawn Emerick, Ed.D., MPA, Executive Director
(904) 723-2162 Ext. 110
[email protected]
St Johns River Rural Health Network, Inc.