Transcript Document

Sutter Care Coordination Program
(SCCP)
Supporting Patients
and Practitioners
in Optimizing Health
Care Coordination and Population Risk
Complexity
2
10% of the Population
Utilizes 60% of the Resources
Sutter Care Coordination Program: Focus
HIGH RISK PATIENTS
Transitions of
Care
Behavioral
Health
&
&
Medication
Complexity
AIM
3
TOP 2%
Social
Determinants
of Health
Impacted
SCCP Background & Purpose:
Current State
Reactive
SW Case
Manager
Non
Targeted
Diffuse
Doctor
RN Case
Manager
Patient
Loose Team
Work
Passive Pt
Health
Care
Coord.
70%
• Episodic Care
30%
• Longitudinal Care
SCCP Background & Purpose:
Future State
Proactive
RN Case
Manager
Targeted
Precise
Physician
Pharmacist
Tight Team
Work
Patient
Activated Pt
LCSW
Health Care
Coord.
30%
• Episodic Care
70%
• Longitudinal Care
Sutter Care Coordination Program: Structure
6 Geographic Teams & 1 Specialized Team
250 Primary Care Physicians
260,000 Patients
6
SCCP Metrics
1.
2.
3.
4.
5.
6.
MEASURE
Percent of patients with advance care planning
discussion within 90 days of enrollment
Percent of patients with patient developed goal
within 90 days of enrollment
Percent of high risk patients with transitions of
care call (TOC) within 48 hours of discharge
Percent of SCCP patients meeting at-risk criteria
per targeted At-Risk patients
% of high risk patients with medication
reconciliation by pharmacist within 72 hours of
discharge
Percent of discharged patients assisted by SCCP
with TCM codes billed
GOAL
95%
90%
100%
70%
100%
100%
SCCP: Focus & Portals of Entry
Transitions
of
Physician
Referral
AIM
Care
Risk
Profile
Activation
Program Admission
8
Targeted At-Risk Population vs. SCCP
% SCCP At Risk Enrolled per Targeted At-Risk
7000
20.0%
17.3%
6000
18.0%
18.2%
18.0%
Targeted At-Risk
16.0%
14.7%
5000
14.0%
12.9%
12.0%
4000
10.0%
3000
8.0%
6.0%
2000
4.0%
1000
2.0%
0
201403
201404
201405
201406
201407
At-Risk Enrolled
911
1031
1216
1263
1242
Targeted At-Risk
7036
7036
7036
7036
6834
Percent Enrolled
12.9%
14.7%
17.3%
18.0%
18.2%
201408
201409
201410
201411
201412
0.0%
Common Interventions
– Provides integrated care planning and coordination of
care
– Assists with complex psychosocial conditions
– Assist with referrals to Sutter services and community
resources
– Assists patients with end of life issues and advance
directives.
– Provide complex medication review and
reconciliation
– Coordinate alternate patient placement such as SNF
and assisted living.
Readmission Prevention
• Management of patients at times of transitions
– Discharge from Hospital setting
– Discharge from SNF
– Discharge from Home Health
• Communication regarding shared patients
– Acute case managers to Ambulatory case managers
– Ambulatory case managers to Acute case managers
• Phone
• Midas
Daily Acute and SNF Census Review to Identify
patients for follow-up
• SMG or SIP physician
• Discharge to home without home health
• High Risk patients identified for follow up
– Unplanned readmission within 30 days
– ≥ 2 admissions/year
– ≥ 2 ED visits/year
– ≥ 3 Chronic Conditions
– CMS Targeted Readmission diagnosis
• COPD, pneumonia, stroke, AMI
– Polypharmacy ≥ 7 medications
Transition of Care Process
• Select Patients
• Conduct post discharge
home/telephonic visits
– Medication Reconciliation
– Review “red flags,
medications and warning
symptoms
– Ensure follow up visits are
arranged
– Assess patient treatment
adherence
– Support systems in place
Acute / SNF
Census
High Risk
Identified
EPIC Roster
1st Day Phone
Follow Up
by Care
Coordinator
On-going
Documentation in
EPIC
2nd Day Phone
Follow up by R.N.
or Pharmacist
7th Day Phone
Follow Up by R.N./
SW/HCC
Case Review
Meetings
Physician
DC Follow Up
Appointment
Optional
14th
Day Phone
Follow Up by R.N./
SW/HCC
Long-term
Follow up
NO
Long-Term
Stable
YES
Close
On-going
Documentation in
EPIC
Transitions of Care Follow up
Transitions of Care Call (TOC) within 48 hrs of discharge
TOC Calls/48 Hrs. of Discharge
250
100.0%
87.7%
200
94.7%
92.4%
88.7%
90.0%
80.0%
78.2%
70.0%
150
60.0%
50.0%
100
40.0%
30.0%
50
20.0%
10.0%
0
201403
201404
201405
201406
201407
Num48Hr
61
142
180
110
126
Discharges
78
162
203
119
133
78.2%
87.7%
88.7%
92.4%
94.7%
Percent_TOC_Call
201408
201409
201410
201411
201412
0.0%
Transitions of Care Reduces Readmissions
Year
2013
First Qtr
2014
TOC Pts
973
Phone
Calls
3063
Readmitted
Pts
62
Readmission
Rate
6.4
241
826
14
5.8
The historical Medicare 30Day readmission rate
was at 15% and above.
Pharmacist Role
1.
Team Integration:
•
Serve multiple teams vs. single
•
Broad geographic area
•
2 PharmD cover Sacto/ Placer/ Yolo
•
EPIC / EMR coordination
2.
Transition of Care:
•
PharmD second pt call (48-72hrs)
•
EPIC / huddle hand off to RNCM (total vs.
shared)
•
Medication Reconciliation & follow up calls
day 7-14
•
Capacity: 4-6 med rec./ day
•
F2F FU with complex pts at office visit
Pharmacist Role
3.
Lessons Learned:
•
Benefit of LEAN to integrate
•
•
•
•
•
4.
Prior habits/ PCMH hangover (Pilot evolution)
Complexity of med rec when done correctly =
energy expended
How to do telephonic work (cold call).
Importance of provider relationships.
MD & PharmD working in PCP practice
Next Steps
•
•
Continue program roll out
Monitor & adjust
Pharmacy Medication Reconciliation
Pharmacist Med Rec w/in 72 hrs of Discharge
90
100.0%
95.0%
91.7%
80
92.9%
90.0%
Med Rec/Discharges
84.0%
80.0%
70
70.0%
60
60.0%
50
50.0%
40
40.0%
30
33.3%
30.0%
20
20.0%
10
0
10.0%
201403
201404
201405
201406
201407
72 hr Med Rec
1
11
19
13
68
Discharges
3
12
20
14
81
33.3%
91.7%
95.0%
92.9%
84.0%
Percent 72hr
201408
201409
201410
201411
201412
0.0%
19