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Courage Center Primary Care Clinic: Health Care Home for Persons with Disabilities Courage Center Guided by the vision that one day, all people will live, work, learn and play in a community based on abilities, not disabilities. 2 Courage Center • A comprehensive rehabilitation and resource center for persons with disabilities service individuals with lifelong and newly acquired conditions at every point in the life cycle since 1928 • Largest nonprofit provider of rehabilitation services in Minnesota 3 Courage Center • Serves 12,500 people with disabilities and complex health conditions annually at 4 sites in the Minneapolis and St. Paul metropolitan area • Has long recognized the unmet need for primary care for our patients • Research staff are located within the Public Affairs and Research Department, a unique linkage to advocacy and public affairs. Target Population Identified for our HCH • Persons with disabilities or complex health conditions • Require combination of medical and social services to live successfully and participate fully in their home communities • Require multiple services that span the continuum from acute to long-term medical care 30 Health Care Costs Across the Population Percent of the Population 25 20 15 10 The 50% of the population that costs the least. The 5% of the population that costs the most. 5 0 Low Cost High Cost Health Care Costs Planning for the Clinic Per Member Month Costs by Number of Conditions Cost per Member Month $60,000 $49,701 $50,000 $40,000 $30,000 $24,097 $20,000 $10,000 $12,710 $3,570 $4,833 $5,893 $9,055 $0 0 1 2 3 4 5 Number of Targeted Conditions 6 Our goals for the clinic were the triple aim • Improve population health • Reduce health costs • Improve client experience Better Health Goal Measure Improve patient’s perception of health Center for Disease Control and Prevention Healthy Days Decrease the complexity of dealing with health conditions Secondary Conditions Surveillance Instrument Decrease severity of depression Patient Health Questionnaire - 9 (depression measure) Per member Year hospitalization days Decreased Cost Decrease the rate of hospitalizations Better Experience of care Patient Activation Measure Improved patient engagement in their health care Satisfaction Surveys Courage Center Patient Satisfaction Surveys Measures • • • • • Healthy Days PHQ-9 Hospital Days Emergency Room Visits Secondary Conditions Surveillance Instrument After 36 months • After 3 years, we have served 278 patients, with 207 active members in the clinic • Chart review on 50 patients found – Average of 12.5 health conditions – 80% of patients also have a major mental health diagnosis – Average of 12.4 medications (including OTC) Goal Measure Pilot Outcomes Improve patient’s perception of health CDC Healthy Days Decrease the complexity of health conditions Secondary Conditions Surveillance Instrument 45% of clients entered with 0/30 healthy days. After one year, average client had increased from 7 healthy days a month to 14 healthy days. No significant decrease in the number of secondary conditions, slight decrease in severity of conditions. Decrease severity of depression PHQ-9 Decreased Cost Decrease the rate of hospitalizations Better Experience of care Improved patient engagement PMPY Reduced hospital days by 75% hospitalization after admission to HCH. days Saved $19,100 per person per year, $3.4 million a year on 177 clients Patient Increased PAM scores by 5 points in first year. Activation Measure Courage 97% of clients would recommend Center Patient Courage Center Primary Care Clinic to others. Satisfaction Surveys Better Health Satisfaction Surveys Decrease in depression score in first year of enrollment Components of the CMS Grant • Expand the clinic from 200 to 500 clients • Implement a Chronic Disease Self-Management Program with our population • Develop low-cost in-home support for clients in the clinic who don’t qualify for waiver services (similar to Independent Living Skills) • Expand telemedicine program to provide ongoing monitoring of chronic conditions • Implement Payment Reform to make the clinic viable Questions Nancy A. Flinn [email protected]