Transcript Increasing Scope of Primary Care

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PROVIDER PRACTICE REDESIGN
USING A MULTI-FACETED STRATEGY
11/02/2009
Jennifer Abraham MD, FACP
Medical Director, Kern Medical Center Health Plan
Specialty Care Challenges in Kern
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3rd largest county in CA spanning over 8,000 square miles
Widely dispersed population of ~800,000
Lack of specialty care providers who see uninsured and
under-insured patients
Kern Medical Center is the only county hospital in Kern
County
For many specialties, KMC is the sole provider in the county
of specialty services for unfunded and underfunded patients
Neighboring county was also using some of Kern’s specialty
clinics on a contractual basis.
Wait times to be seen in some specialty clinics were
unacceptably long
11/02/2009
Kern County Selected Health Outcomes
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Mortality Rate per
100,000 population
Rank out 58 Counties
in California
All Cancers
183.3
47
Heart Disease
232.4
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Stroke
51.3
47
Diabetes
34.2
56
Chronic Lower Respiratory Disease
69.6
55
Chronic Liver Disease and Cirrhosis
15.4
49
Influenza/Pneumonia
28.4
57
Alzheimer’s Disease
37.4
56
Cause Of Mortality
Source: 2009 County Health Status Profiles, California Department of Public Health
11/02/2009
Coverage Initiative
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A five-year section 1115 Medicaid
Demonstration
Approved 9/1/05 for 3-year implementation
 Section
1115 Research & Demonstration
Projects: Provides the Secretary of Health and
Human Services broad authority to approve
projects that test policy innovations likely to
further the objectives of the Medicaid program.
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The Demonstration provides $180 million in
federal funds
11/02/2009
Coverage Initiative Goals
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Expand the number of Californians who have health
care coverage
Strengthen and build upon the local health care
safety net system
Improve access to high quality health care and
health outcomes for individuals
Create efficiencies in the delivery of health services
that could lead to savings in health care costs
Provide grounds for long-term sustainability of the
programs funded under the Coverage Initiative
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Coverage Initiative
Kern Medical Center Health Plan
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The Coverage Initiative Program in Kern County
Manage care of 5,000 patients
Community clinics contract with KMC to provide
primary care for KMCHP patients
Components of KMCHP:
Primary care home assignment
 Intensive care management for frequent hospital
users
 Provider Practice Redesign: expanding the scope of
Primary care providers
 Information sharing between community clinics and
KMC
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11/02/2009
Coverage Initiative
Kern Medical Center Health Plan
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Manage care of 5,000 patients
Components of KMCHP:
Primary care home
assignment
• Contracting with community clinics to
increase access to primary care
Decreasing Avoidable
admissions and ED use
• Intensive care management for frequent
hospital users
Expanding the scope of
Primary care providers
• Kaiser Specialty Care Access Grant:
Provider Practice Redesign
Information sharing
• Community clinic access to County hospital
between community clinics
records via Portal
and KMC
11/02/2009
Provider Practice Redesign
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Objectives
Strategy
Expand Access to Specialty Care
Services
Decrease denied and deferred
referrals
Allow specialists to focus on most
severe cases
Build consensus about guidelines
for delivery of care
Mini
Fellowships
Consensus
Care
Guidelines
Phone/
Chart
Consults
Information
Exchange
Community
Grand
Rounds
11/02/2009
Provider Practice Redesign
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Model originally implemented for the
LAC+USC Camino de Salud Network in LA in
2007
Model started with Rheumatology and later
expanded to Cardiology
Outcomes:
 444
patients screened by the Cardiology and
Rheumatology Champions
 2/3 of patients managed in their primary care
home rather than being referred to specialty
care
11/02/2009
Creating Guidelines
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Targeted specialties chosen by analyzing referral center data
for specialties with highest referrals and longest wait times:
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Cardiology
Endocrinology
Orthopedics
Neurology
Rheumatology
Primary care providers and specialists attend “Grand Rounds
Meetings” to discuss specific challenges within those
specialties
Guidelines created by pulling together evidence-based
guidelines and data from published resources
Guidelines are reviewed by all providers and modified to
meet needs of specialist and limitations of safety net clinics
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Guidelines
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Guidelines are disease-specific
Delineate management roles for primary care
provider vs. champion vs. specialist  dependent
on acuity
Outlines diagnostics needed before consult
Allows for more management within the primary
care setting
Allows referrals to be appropriate and more focused
on most severe cases
Reduces number of denied and deferred specialty
referrals
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10/26/2009
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11/02/2009
Champion Process
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Mini-fellowships: Community clinic providers complete
curriculum and undergo training under specialist working at
KMC
Mini-fellowship Curriculum
Incentives to complete curriculum
Pre- and Post- tests
10 CME credits
Reading Materials
Increased reimbursement through KMC
Lecture by the specialist and clinic
shadow day(s)
Access to specialists for phone
consults & chart reviews
Process:
Mini-Fellowship
Curriculum &
Training
PCP becomes a
Champion with clinical
confidence to adhere to
guidelines
Champion can manage
higher acuity patients by
having access to specialist
for chart reviews and
phone consultations
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Reimbursements
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Specialty Care Champions can bill for a higher
reimbursement through the KMCHP to
compensate for increased time and
management
Specialists can bill for a phone consultation
and patient review
Billing Codes:
 Outpatient
Consultation Code: 99241-99245
 Phone consultation Code: 99358
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Methods of Consultation
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Advantages
Disadvantages
Telephone
Calls
•Easy to implement
•Less security concerns
•Both parties need to be available
at the same time
E-Referral
System
•Secure system
•Referrals and consults can
be sent over the same system
•Requires a system that has the
appropriate capabilities
•May require significant investment
E-mail
•Almost everybody has email
•Can respond at own
convenience
•Security problems
•Requires implementing encryption
method
Pager
•Can reach providers even if
they are not by their phones
•PCPs may find it inconvenient
because call back can be delayed
Fax
•Easy to implement
•Doesn’t require anybody to
learn a new program
•Faxes can get lost or be difficult to
read
•Would need a secure fax site
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Expectations of the Champion
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Expectation of the Champion
Stronger understanding of managing
and treating patients for specific
disease
Adherence to referral guidelines
Method of Monitoring
Pre- and post test scores
Regular chart audits
Documentation of all Champion visits Champion codes required for
higher reimbursement
Gradually be able to manage
Number of referrals over time to
increasingly complex patients
the specialist
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Information Sharing
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E-referral system
Referral Process improvement
 Updating, training, and expansion to more clinics
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Expanding KMC records viewing systems
to the community clinics
Will improve coordination of care and require less
reliance on faxing of results and consult notes
 Decreases duplication of labs and other services
 Improve patient safety and point of service quality of
care
 Outpatient and Inpatient records, Labs, Radiology
(including digitized pictures)
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Implementing PPR in LA vs Kern
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More clinics and providers in the CDSN service area
Specialty departments in LA vs 0.1 providers at KMC
In Kern, some rural clinics are 2-3 hours from county
hospital and are staffed only with NP/PA’s most days
Adaptations in the Model for Kern County
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Guideline development without champion
Clinic referral guidelines that are problem-based to
decrease misdirected referrals
Webinar use for Grand Rounds
Travel to clinic sites
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Conclusion
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Provider practice redesign
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Increasing scope of primary care physicians
Improving compensation to primary care physicians
Developing guidelines for referral to clinics
Expanding e-referral use
Evaluation measures
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Improve access to specialists
Decrease wait times
Improving communication between specialists and primary
care
Improving information exchange
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Decrease duplication of services
Decrease overall cost of care
11/02/2009
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Questions?
11/02/2009
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FULLER SCOPE OF PRACTICE:
UTILIZING CLINICAL PHARMACISTS IN
CHRONIC DISEASE STATE MANAGEMENT
Ryan Gates, Pharm.D.
Senior Clinical Pharmacist
November 2,2009
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Expanding Access to Care
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Background at Kern Medical Center:
Physician Managed Specialty Care and General
Practice Resident clinics are overwhelmed
 Same day and urgent appointments not available
 Clinical pharmacists have played an integral role in
expanding access to care and coordinating care
between primary care clinics and specialty care clinics
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11/02/2009
The Value of Clinical
Pharmacy Services
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314+ studies confirm that pharmacists1 add value to the health care
system by improving care and decreasing cost
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$1 spent on Clinical Pharmacy = $16 of savings2
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Avoidance of ADR’s & Prescribing Errors
Risk reduction of medication related lawsuits
Increased formulary compliance
Improved patient care and outcomes
$219,000 per year were saved by pharmacists
providing
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pharmaceutical care services to diabetic patients
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400 lives and $5.1 billion in health care costs were
saved by
pharmacists providing pharmaceutical care in 1000
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hospitals
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Rijdt TD, et al. Economic effects of clinical pharmacy interventions: A literature review. AJHP 2008;65:1161-1171
Schumock GT, et al. Economic evaluations of clinical pharmacy service 1980-1995. Pharmacotherapy 1996;16:1188-208
Finchman JE, et al. Pharmacist Care for Diabetes Patients. America’s Pharmacist 1998;120(3):49-52
Bond CA, et al. Health care professional staffing, hospital characteristics, and hospital mortality rates. Pharmacotherapy 2000;20(6):609-621
11/02/2009
KMC Pharmacy Clinics
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Anticoagulation
Diabetes
Smoking Cessation
Pharmacotherapy/Refill
Blood Pressure
Oncology
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Patient Management
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Access to clinics
 Referral
by their primary care provider
 Walk-in patients for medication refills
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Clinical pharmacist functions under protocols
and policy for defined disease states
Pharmacist has prescriptive authority and has
privileges to order labs and tests by policy.
Referral back to primary care when specific
goals are achieved
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Pharmacist Involvement
in Anticoagulation
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Anticoagulation (AC):
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AC Clinic vs PMD1
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Meta-analysis of 63 studies (n=50,208)
Time INR in Therapeutic Range:
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Poor AC Management = Poor Outcomes and Higher
Downstream Costs2
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AC clinics (65.6%)
PMD (56.7%)
Meta-analysis of 45 studies (n=71,065)
44% hemorrhages occurred when INR> goal
48% thromboembolisms occurred when INR <goal
Conclusion: Nearly 50% of bleeds and clots could be prevented
with improved anticoagulation control
Van Walraven, et al. Effect of study setting on anticoagulation control. CHEST 2006;129;1155-1166
Oakie, et al. Frequency of Adverse Events in patients with poor anticoagulation. CMAJ 2007;176:1589-1594
11/02/2009
KMC Anticoagulation Clinic
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1272 patients per year
Decrease in LOS of 2.45 days
Decrease Readmission rates by 19%
39.68% reduction in drug-drug interactions
68% Therapeutic INR at first clinic visit vs
16.1%
Time INR in Therapeutic Range
= 79.91% (+/- 0.2)
- National Benchmark ranges 61-68%1
1) Circulation 2007;116;449-455
11/02/2009
Diabetes Clinic: Background
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History:
 Demand for endocrinologist managed diabetes
clinic has outgrown its capacity
 Longer and longer delays in availability are seen
 Growing complexity of medication management
in diabetes care
 Addition of a Pharm.D. with specialized
residency training in diabetes
 Clinical Pharmacy services were expanded in
2006 to include Diabetes
11/02/2009
Pharmacist Managed
DM Clinic: QA Data at KMC
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78.9% Reduction in Hospital Admissions/ER
visits for diabetes related indications
Mean A1c at initial visit = 10.1%
Mean A1c after treatment = 7.7%
A1c < 7.0 after treatment = 43.2%
 A1c < 6.5 after treatment = 29.7%
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Mean Fasting BG at initial visit = 206.1 mg/dl
Mean Fasting BG after treatment = 135.7 mg/dl
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Fasting BG < 120 mg/dl after treatment = 51.5%
Mean Days of Treatment = 216
11/02/2009
Smoking Cessation Clinic:
Background
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History:
 In 2000 the smoking cessation services created
after an identified patient care need was unmet by
current practice
 It serves nicotine dependent patients while
increasing effectiveness of pharmacotherapy and
reducing drug costs as well as providing necessary
intensive treatment that is unavailable through
current clinic structure
 Smoking Cessation Clinic is a positive point in
cancer prevention:
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Looked favorably upon by the American College of
Surgery for accreditation of KMC’s Oncology Program
11/02/2009
Smoking Cessation Clinic:
Quality Assurance Data at KMC
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Average age of 50 years old
Average 31 years of smoking at 1.2 packs/per
day
Over 40% tried to quit in past using ONLY
medications
75% quit rate at end of 8 week intensive
course
3
times the national average quit rate
11/02/2009
Blood Pressure Clinic:
Background
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Improved outcomes in Anticoagulation Clinic
growing complexity of medications
decreasing access to physician care
Clinical Pharmacy services were expanded to
include the treatment of
 Hypertension,
 Pharmacotherapy
 Refill
clinics
11/02/2009
Pharmacist Involvement in
Blood Pressure Management
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Managed Care Setting
(PharmD vs MD BP Management)
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 PharmD
Managed Group had:
 Significantly
better blood pressure control
 Drastically lower cost effectiveness ratios/BP reading
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$27 vs $193 / mm Hg for systolic BP reading
$48 vs $151 / mm Hg for diastolic BP reading
 Significantly
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better patient satisfaction
Many more studies available
Pharmacotherapy. 2001 Nov;21(11):1337-44.
11/02/2009
Pharmacotherapy /
Refill Clinic: Background
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History:
 Clinical
Pharmacy services were expanded to
address:
 Growing
complexity of pharmacotherapy issues in the
outpatient setting (pain medications, renal dosing, EPO,
etc.)
 Increased ER visits for medication refills
 Long durations between PMD visits where
medications/disease states needed monitoring in order to
safely refill medications
 Medicine residents and Attendings do not have the
time/resources to clinically evaluate all refill requests
11/02/2009
Oncology Clinic:
Clinical Pharmacist Duties
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Provide daily over-site of chemotherapy clinic
Write orders for daily Chemotherapy & electrolyte
infusions
Create protocols for chemotherapy regimens based on
most up to date data
Precept Medical and Pharmacy Students
Monitoring patients for their cancer care
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Order labs, tumor markers, CT scans, Bone scans
Schedule chemotherapy for patients, post surgery, post
Radiation
Write 6 month plan for case management for self pay
patients
Identify patients to enroll in patient assistant programs
11/02/2009
Overview of
Pharmacy Clinics
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Total Clinic Volume:
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7000 clinic visits/year
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32% of afternoon medicine clinic volume M-Th
6000 phone call follow ups/year
QA Data of Clinical Pharmacy Services:
Decrease down stream costs
 Decrease length of Hospital Stay
 Decrease hospital admissions/ER visits
 Achieve Outcomes Superior to Standard of Care
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INR Time in Therapeutic Range 79%
Avg. A1c 7.36 after treatment (Avg. pre-treatment A1c 10.1)
Blood Pressure: 37% DM patients at goal BP (60% < Stage1)
Smoking Cessation quit rates 3x national average
11/02/2009
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Questions
11/02/2009