Transcript 2009 Business Strategy - Practice Change Fellows

The I PiCC Program
(Integrated Patient Centered Care)
Karyn Rizzo RN, CHPN, GCNS
"
Twice I have asked Alan Greenspan what he considers the greatest threat to the U.S. economy,
and both times he has answered immediately with a single word:
It's a multitrillion-dollar
Medicare.
problem that's about to get dramatically worse.
In the next President's first term, Medicare Part A will go cash-flow-negative, and it's all downhill from there.
As the country ages, Medicare and Medicaid will devour growing chunks of US economic output.
Then by 2070, when today's kids are retiring, Medicare, Medicaid, and Social Security will consume the entire federal budget,
with Medicare taking by far the largest share.
No Army, no Navy, no Education Department – just those three programs.
"
Geoff Colvin, Senior Editor, Fortune Magazine
March 4, 2008
A primary care system on the verge of crisis
•
•
•
•
Annual US healthcare expenditures have grown to over $2 trillion per year, and are expected to double in 10 years
Only 10% of patients account for nearly 70% of healthcare expenditures
Shift away from PCP reimbursement, fewer MD’s moving towards primary care role
Current PCP model does not meet the needs of the aging client
The Drivers are Clear
Admissions account for the majority of healthcare expenses
• 13% of population is 65+, yet account for 36% of total healthcare expenses
Re-admissions only exacerbate the problem
•
1 in 5 are readmitted in 30 days
•
75% are preventable and related to medications
Chronic illnesses causing over-utilization and contributing to PCP crisis
• 44% of total healthcare expenditures and second biggest driver of admissions
•
Medicare and private insurance companies are focused on preventing admissions and re-admissions
– In 2009 Medicare is requiring mandatory reporting of readmissions and in 2010 is proposing hospital
penalties
– National payers are focused on incentives (PCMH, Transitions, Chronic Illness management) to reduce
admissions and improve health management programs for complex patients
– Tufts Health Plan (MA) is making discharge transition programs mandatory in 2009
Project “Setting”: Patient-Centered Medical Home
Patient-Centered Medical Home (PCMH) model “accepted” by Medicare was developed by NCQA staff in
concert with the ACP, AAFP, AAO and AOP as well as other stakeholders to address improvements by
the development of specific standards in patient centered care
The PPC-PCMH has 9 standards (see Appendix 4 of the NCQA document), each of which has multiple
elements.
Major principles of the Patient-Centered Medical Home
• Personal MD for each patient
• Physician directed, interdisciplinary teams of care
• Whole person orientation – acute care, chronic care, preventive, end of life
• Coordinated and Integrated Care – across all elements of health care system and community
• Quality and Safety
• Enhanced Access to Care
• Reimbursement for added value provided to patients
*Drawback of PCMH is that it is NOT patient centered
*Very heavy focus on EMR
Extending PCPs reach via IPiCC Pilot
Faulkner Primary Care
Rehab
Opt. 1
Opt. 2
Complex Care Management
Supporting patients between PCP visits
Transition Services
Supporting patients following discharge
[month 1]
[month 1]
APN led (in-home assessment);
focus on chronic illnesses mgt.
and red flag awareness
education.
PharmD led (in-home
assessment); focus on medication
optimization and red flag
awareness education
[months 2-4]
Ongoing RN and PCC support;
PharmD support as needed
Questions:
How to measure outcomes (e.g. admits avoided)?
Ongoing RN and PCC support;
PharmD support as needed
Ongoing RN and PCC support;
PharmD support as needed
Questions:
How to know when a patient is admitted?
Does the practice have enough admits to
support project ramp up?
Why Lead Transitions with PharmD?
Dovetail outcomes (pharmacy intervention)
Dovetail's focus on medications has reduced readmissions to less than 10% (N=100)
Reconciliation Issues
Med Adherence Issues
75% of Dovetail clients have medication
reconciliation issues identified during initial
pharmacy assessment
94% of Dovetail clients have
medication adherence issues
identified during initial pharmacy
assessment
Med Omission,
4%
ex. med was left off
discharge summary
Syst emic Issue,
40%
ex. Discharged
with med but no
Rx
Dose Specif ic,
26%
ex. dosage
was
changed
Drug Specif ic,
70%
ex. warfarin
and coumadin
Int ent ional, 56%
ex. Did not fill
Rx, refuses to
take med
Non-Int ent ional,
4%
ex. instructions not
understood, can't afford
meds
Project goals
•
Reduce overall healthcare expenses by focusing on the most common cost
drivers (admissions and readmissions and chronic illness)
•
Increase patient satisfaction by offering personalized, targeted interventions
to improve overall health from a consistent team of healthcare providers
•
Increase PCP satisfaction with their job overall as well as their ability to care
for complex patients
•
Help primary care practices take steps toward Patient-Centered Medical
Home accreditation by providing specific services identified in NCQA
guidelines
Project Timeline and Ramp-Up Schedule
Concept and operations development
Outcomes measures and tracking
systems
Staff hiring and training
Implementation strategy
Sep. 08
Kick-off
Jan. 09
Patient data collection
Data analysis / program
evaluation
Service delivery
Outcomes and recommendations
Feb. 09
Sep. 09
May 10
Patient Ramp-Up Schedule
Feb.
Mar.
Apr.
May
Jun.
Jul.
Aug.
Sep.
5
5
5
5
-
-
-
-
-
10
10
10
10
-
-
-
-
-
10
10
10
10
-
-
-
-
-
10
10
10
10
-
-
-
-
-
5
5
5
5
Monthly Total
5
15
25
35
35
25
15
5
Unique Total
5
15
25
35
40
40
40
40
Measuring clinical outcomes
Measure
Source
Collected By
Frequency
Patient perception of health
SF-36
(patient)
Dovetail RN
Initial and final visits
Patient satisfaction
Dovetail survey
(patient)
Dovetail PCC
Prior to initial visit and within 30
days after final visit
Physician satisfaction
Dovetail survey
(physician)
Project Assistant
Prior to initial visit and within 30
days after final visit
Utilization (hospitalization, ED
visits, PCP visits, specialty care,
VNA, Falls, Dovetail interactions,
etc)
Patient/family/RN report; medical
record review
Dovetail RN
With each patient interaction
Healthcare costs
Estimated based on average
utilization costs; SF-36 analysis
Project Assistant
At end of project
IT utilization (use by MD, client,
Dovetail)
Gateway System
Project Director
Monthly review
NCQA PCMH Standards Met
NCQA PCMH Standards
Project Director
Prior to Program/Post
The clinical centered tool (CCT)
•
Collects interventions as well as outcomes
•
Embedded SF-36 for pre and post intervention data
•
TTM evaluation
•
Incorporates all areas of geriatric domain concerns
•
Has report functionality
•
Guides clinicians in using a strength based approach to in home coaching (“Framing the visit in
the positive”)
•
Client centered
•
Excel spreadsheet database which allows for great flexibility in data collection and interpretations
Value proposition: selling complex patient management to payer and
provider groups under risk contracts
40,000 Medicare Advantage members
Patient Identification
Top 5% of highest cost / highest risk patients
2,000 patients qualify for services
50% accept services
1,000 patients enrolled in program
2000 admissions / 1,000 among patient group per year
Size of Problem
1,000 patients in program will have 2000 admissions ($10,000 each-AHRQ)
$20M problem ($41.66 pmpm)
1,000 patients enrolled for 4 months each ($450 per month)
Program Cost
$1.8M program cost ($3.75 pmpm)
12% reduction in admissions = $2.4 M avoided cost [+600K)
ROI
15% reduction in admissions = $2.25M avoided cost [+$3M]
25% reduction in admissions = $3.75M avoided cost [+$5M]
Questions / Discussion