Transcript Slide 1

CARE COORDINATION
An Approach for High Risk Patients
Goals for Today
• Discuss unique heath care needs of individuals with
disabilities and the frail elderly.
• Learn about two models of care delivery targeted at
high risk patients
• Understand how health reform affects the
development of care coordination models
• Describe provider engagement and it’s importance
• Define “relevant response” and “life geography” in
the context of care coordination.
Changing Landscape
• Health care reform is driving new models of care
– Lessons learned in case management and MSHO
care coordination are being replicated in the
broader Medicare and commercial settings.
• Face to face assessments
• Community based services
• Care giver support
Health Care Reform
Continuum
Delegated Care
Coordination
Heath Care
Home/Capitated
Models
Quality Based
TCOC
Making the Transition
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Care on the Continuum
Patient Population
Risk/Frailty and High Cost
Patients with Chronic Disease
and Acute Episodes
>50% medical spend
Care on the Continuum
Patient Population
Risk/Frailty and High Cost
High Utilization
87%
Patients with Chronic Disease
and Acute Episodes
>50% medical spend
13%
Year 1
Care on the Continuum
Patient Population
Risk/Frailty and High Cost
High Utilization
Patients with Chronic Disease
and Acute Episodes
87%
>50% medical spend
13%
Year 1
Year 2
Care on the Continuum
Patient Population
Risk/Frailty and High Cost
Clinic Medical Home
High Utilization
Regression to mean
-acute episodes
-well-managed
chronic disease
87%
13%
Year 1
Year 2
Patients with Chronic Disease
and Acute Episodes
>50% medical spend
Care on the Continuum
Patient Population
Risk/Frailty and High Cost
Clinic Medical Home
High Utilization
Patients with Chronic Disease
and Acute Episodes
87%
>50% medical spend
Bluestone population
13%
Year 1
Year 2
Complex social/behavioral/medical
Chronic High Spend
Higher % on public programs
Frail/elderly/vulnerable
High incidence dementia
Underserved
Care on the Continuum
Patient Population
Risk/Frailty and High Cost
Clinic Medical Home
High Utilization
Patients with Chronic Disease
and Acute Episodes
87%
>50% medical spend
Bluestone population
13%
Year 1
Year 2
Complex social/behavioral/medical
Chronic High Spend
Higher % on public programs
Frail/elderly/vulnerable
High incidence dementia
Underserved
Care on the Continuum
Patient Population
Risk/Frailty and High Cost
Facility Partners
Clinic Medical Home
Assisted Living and
Group Homes
NP/PA Services
MD Services
Care Coordination Services
Social Support
High Risk Care Coordination
Care Coordination PLUS
On-site Primary Care
Bluestone Vista
Bluestone Physician Services was
established in 2006 in Stillwater, MN
to meet the needs of patients who
were not being well serviced in the
traditional medical system.
Bluestone Physician Services is the
largest provider to Assisted Living
Facilities in Minnesota,
• Provides primary care and care
coordination to 4,500 residents in
over 150 assisted living communities,
group homes and in their own homes.
• The first Geriatric Certified Health
Care Home in the country.
• 17 providers, 26 nurses including a
full time psychiatrist.
• Designed customized technology
including online orders, family email
and monitoring systems.
Bluestone
Bluestone
Solutions
Bluestone
Physician
Services
Bluestone
Consulting
Care Coordination
Bluestone
Technologies
Bluestone Care Coordination
High Risk as Organizing Principle
• MSHO/SNBC
– MSHO-Primary care model-Residential Care
– SNBC-Community Model-Disability/income
• Health Care Home-Residential Care
– Integration with Primary Care
– Integration with facilities
• Medicare Advantage/At risk contracting
– Predictive modeling
Patient Identification-Who’s in?
• High Risk Patients
– Life Geography-HCH
• Where they live-Residential Care
• Life events
• Socio-economic
• Diagnosis- i.e. Dementia
– Assignment by payer-MSHO/SNBC
– Self selected-all
– Claims/predictive modeling-Risk contracts
Care Coordination Across Systems
• Residential Care
– Facility based
• Engage the true decision maker
– One care coordinator across facility
• Staff education
• Waiver and HCH services
• Community Based
– Coordination with “external” case management
• How to find other care coordinators
Medical-Behavioral
Integration
• Interdisciplinary Team Meetings (IDT)
– Based on hospice model
• “assure” primary care
– Regularly scheduled case consultation meetings
• Best practice
• Medical advice-follow up at next IDT
• Triggers
– Population specific
Patient Engagement
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Timely communication
Accurate communication
Trust built on “small” accomplishments
Realistic expectations
Role clarity
Persistence
Care Coordination Plus Model
Self-care
Care Plan
Optimized
Empowerment
Pt. and family
WellnessBehavioral
Change
Life skills/Education
Chronic Care NeedsPhysician Engagement
DM/MH/MTM/Care Team
Pt Engagement through basic
needs(rarely medical)
Trust/Housing/Safety/Equipment
Needs Hierarchy
Action Hierarchy
Optimized Care Plan
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Comprehensive
Medically sound
Realistic
Relevant
Accessible
Transferable
Integrated
Health Care Home
• Bluestone Physician Services was certified as HCH in
2010.
• Care Coordination-”A function not a person”
• RN care coordination added 2012
• Use of technology for care team communication
across systems
– Bluestone Bridge
Health Care Home in the
Geriatric Setting
• Unique residential model brings unique care
coordination challenges.
– Facility based
– Responsible parties
– Complex health issues
– Quality measures do not consistently apply
Positive Changes in
Geriatric/Disability care
• MAPCP Demonstration
• Resource Toolkit
• MNCM
– Upcoming care coordination measures-an
opportunity for collaboration!
• Follow up after hospital discharge
• Advance Care Planning
Bluestone Measurement
Framework
• Quality indicators:
-advanced care plan completion
-appropriate chronic disease management
-optimal medication management
• Cost indicators:
-ED/Hospital utilization
Aging in place:
-Days out of home (AL) setting
-%deaths in home (AL) setting
Utilization Management
• Acute/ER Reduction
– Action Plans
– Contracts
– Accompanied visits
– Scheduled primary care visits
• Pharmacy
– Internal med reviews
• Advance Care Planning
– POLST
Residential Care Utilization
Facility
ER Visits
Hospital days
Length of Service
Number of Beds
with addition of
nursing service
78%
reduction
72%
reduction
1 years
39
1
90% reduction
96% reduction
5 years
15
2
50% reduction
NA
5 years
40 /MC
100/AL
3
10 visits
0
5 years
62
( psych beds)
4
0
0
5 years
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Care Coordination Utilization
Bluestone-next steps
• Assist other health systems implement residential
care models
– Fairview
• Continue to develop dementia care model
– Identification
End of life care.
• Residential care forums
– Targeted to entire residential care community
• High risk care coordination provision/consulting
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.
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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
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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
Cost of Care for Individuals with
Disabilities
• 16%
of people reporting a disability
accounted for
• Nearly half of all hospital discharges
• 62% of hospital days
• 34% of all adult physician visits
• 41% of all adult drug prescriptions (Anderson, et
al., 2011)
• This population is expensive, but does not
experience good health.
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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
Why do this at Courage?
• Co-locate primary care with physiatry and
psychiatry, which are the two common
specialties seen by this population
• “Reverse engineer” primary care into a setting
designed for this population, and where
medical and social supports are already
present, rather than trying to take an existing
primary care clinic and add social supports
Percentage of Clients with Charge
60%
53%
50%
40%
30%
20%
10%
0%
28%
26%
18%
14%
13%
Percentage of Clients with
Charge
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
Other things we knew
• Using the model put forth by DHS for
reimbursement (FFS with care coordination
fee calculated on complexity of clients), this
clinic will never break even
• We would need some kind of shared savings to
make the clinic self-sufficient
• We needed to include new payment methods
as we built the clinic
Clinic Staffing
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We serve a relatively small population
Primary care physician .4 FTE
Nurse Practitioners 2 FTE
RN Care Coordinators 3 FTE
LSW Care Coordinator 1 FTE
CMAs 3 FTE
Care Coordination
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Each client is assigned a care coordinator
Care coordinator develops care plan with client
Care coordinators make quarterly contacts
Assist clients with managing day to day conditions
Care coordinators are first contact if there are
problems, although they can also call triage line
• Providers available 24/7 through office number
• We encourage clients to stop by when they are at
Courage for other reasons
Different kinds of Care
Coordination
• Extended Primary Care – care coordination to
provide coordinated care, connect with social
supports
• SNBC Care Coordination – contracts with private
insurers to manage their SNBC clients – puts all care
coordination in one spot, although they may still have
other coordinators/case managers
• We provide both types of care coordination at
Courage, and one doesn’t look much different than
the other, except SNBC has documentation for the
insurance company
Designing the Clinic
• The clinic is fully accessible
– Fully accessible facility
– Exam rooms have a full turning radius for a power
wheelchair
– 6X8 high/low matts for exam tables
– Accessible OB/Gyn high low table
– Hoyer lifts
– Accessible scale
Care pathways
• Developed pathways prior to bringing on
physicians or nurse practitioners
• The care pathways have undergone revision
– Pneumonia as an example
– Seizures as another example
• Included Patient Activation Scores as part of
the care pathways
Healthy Days
• Now thinking about your physical health,
which includes physical illness and injury, for
how many days during the past 30 days was
your physical health not good?
• Now thinking about your mental health, which
includes stress, depression, and problems with
emotions, for how many days during the past
30 days was your mental health not good?
Patient Activation
Measure
• Measure of the knowledge, skills, and
confidence a patient has that allows them to
become engaged in their care
• Assessment of patient activation is a way to
structure the interaction of team members with
the patient, to provide the “just right” amount
of support for patients experiencing
exacerbations in health conditions.
Patient Activation Measure
• Patients with high levels of activation are four
times more likely to get care when they need it
as patients with low levels of activation
(AARP, 2009).
• Patients with low levels of activation are also
twice as likely to experience a medical error,
and twice as likely to experience a hospital readmission within 30 days of discharge.
Patient Activation Levels
• Level 1 – individuals are starting to take a role, but don’t feel
confident, and tend to be passive recipients of care
• Level 2 – individuals are building knowledge and confidence,
but lack understanding of their health or recommended
changes
• Level 3 – individuals have the key facts and are beginning to
take action but need support to implement and maintain
behaviors
• Level 4 – individuals have adopted new behaviors, but may
need help to maintain them in times of stress or illness
Patient Activation Measure
• A change of 1 point is associated with
– 1.7% decline in hospitalizations
– 1.8% gain in A1c control
– 3.4% gain in A1c testing or LDL testing
• We see an average of 12 point improvement
over the first 6 months of enrollment in the
clinic
Utilization Data
• High hospital utilizers
– We have access to DHS encounter data with a
three year baseline for hospital and ED utilization
– 10.8 days per year during 3 year baseline period
– Most common cause of hospitalization is UTI
– ED utilization not that high, probably because they
always got admitted
Key Components
• Extended clinic visits – 60 minute evals, 30 minute
clinic visits
• ~25% of visits are same day or next day
• Clinical Pathways for 5 conditions
• Disability knowledgeable providers and nurses
• Work around transportation whenever possible telemedicine, UTI plan
• Providers available 24/7
• Use Patient Activation Measure to identify those
patients who need the most support
• Each patient has an individualized care plan
Our goals for the clinic were
the triple aim
• Improve population health
• Reduce health costs
• Improve client experience
Goal
Measure
Better Health Improve patient’s perception Center for Disease Control
of health
and Prevention Healthy Days
Decreased
Cost
Decrease the complexity of
dealing with health
conditions
Secondary Conditions
Surveillance Instrument
Decrease severity of
depression
Patient Health Questionnaire
- 9 (depression measure)
Decrease the rate of
hospitalizations
Per member Year
hospitalization days
Better
Improved patient
Experience of engagement in their health
care
care
Satisfaction Surveys
Patient Activation Measure
Courage Center Patient
Satisfaction Surveys
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)
Better
Health
Goal
Measure
Pilot Outcomes
Improve patient’s
perception of health
CDC Healthy
Days
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 the
Secondary
complexity of health Conditions
conditions
Surveillance
Instrument
Decrease severity of
depression
PHQ-9
Decrease in depression score in first
year of enrollment
Decreased
Cost
Decrease the rate of
hospitalizations
PMPY
hospitalization
days
Better
Experience
of care
Improved patient
engagement
Reduced hospital days by 75% after
admission to HCH.
Saved $19,100 per person per year,
$3.4 million a year on 177 clients
Increased PAM scores by 5 points in
first year.
Patient
Activation
Measure
Satisfaction Surveys Courage Center 97% of clients would recommend
Patient
Courage Center Primary Care Clinic to
Satisfaction
others.
Surveys
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 on-going
monitoring of chronic conditions
• Implement Payment Reform to make the clinic viable
Relevant Response
• Key to impacting cost and quality
• Requires care team identified in care
plan/health record
• The right person at the right time with the right
information.
– Physician
– Care Coordinator
– Decision makers
Provider Engagement
• Coordination with clinic HCH Care
Coordinator
• Identify common goals/pain points
• Provide information
• Empower client
• Empower care coordinator
– Specialized knowledge
– Influence
Questions
Thank You!
Nancy A. Flinn
[email protected]
Dr. Dave Moen
[email protected]
Sarah Keenan
[email protected]