Transcript The One Care Program - UNM Health Sciences Center

The Care One Program
Douglas Binder, M.D., Medical Director
The Care One Program
University of New Mexico Hospital
March 7, 2008
What is Care One?
• An innovative program that targets high risk
patients and actively manages their care
• Based on models tested and validated at other
institutions
• Involves intensive outpatient case management
• An exchange of case management hours for bed days
• Making an individualized care plan that can be
carried out effectively
The Care One Patient
• At highest statistical risk of clinical
deterioration within the near term
• Can be predicted
• Interventions can be made
• Can be potentially prevented
The Care One Patient
• One or more serious medical issues
• Episodically attended to
• Usually requires admission to sort out
• Falls through cracks again following discharge
• Challenging social situation
• Uninsured
• Marginal housing
• Mental Health issues
• Depression
• Anxiety
• Psychosis
• Substance abuse issues
• Drugs
• Alcohol
Stabilizing these patients makes
sense for the Health Science
Center!
Care One patients represent 1% of the
total UNMH population but consume about
20% of the resources
• Average cost to UNMH: > $100,000/year
• Average bed days at UNMH: 27
What we are doing
• We provide services and oversight
• These are our patients
• It makes sense to manage these patients
• It makes sense to have ongoing UNM HSC oversight
• We maintain an ongoing active partnership
• With the patient
• With community health resources
Care One today
• Started in Spring, 2004
• Put on hold for variety of reasons
• Program resurrected and fully operational as of
February, 2006
• 4 health care professionals
• Medical assessments
– Douglas Binder
• Coordination of services
– Duly Arenivar
• Case Management
– Daniel Nagera
• Psychosocial assessments
– Cynthia Goldblatt
What is Care One doing?
• Patient A
• Patient B
• Patient C
Patient A
• 69-year-old female
• DM, CHF, in wheelchair from stroke, on
dialysis, recent gallbladder operation
• Housing situation
•
•
•
•
Came from Zapoteca with husband 8 years ago
Legal residents
4 children here, some US citizens
Move from house to house, every few weeks or few
months
Patient A
•
•
•
•
•
•
Gets dialysis at the DCI every other day
Husband wheels her home afterwards
No PCP
No money
No social services
Episodic involvement with various social
workers and various clinics over the years
Patient A
• Potential eligibility
•
•
•
•
•
•
•
•
Disabled and Elderly Waiver
Medicaid
Medicare
SSI
Food stamps
General Assistance
American Kidney Foundation funds
Transportation
• Needs PCP
• Needs constant monitoring
Patient A
• PCP
• Spanish speaker at Senior Health
• Connections with various social services,
and follow through
• Home visits
• Her care is being managed so that she
does not come to UNMH in crisis
Patient B
• 72-year-old male from Cuba
• Living and working here since 1960s
• Bad heart disease, with <20% EF
• Valve replacement
• Pacemaker
• On multiple medications
• Loosely affiliated with FP and Cardiology
clinics
Patient B
•
•
•
•
Living in a car
No medicines
No appointments at UNMH clinics
No papers at all
• Residency status unclear
Patient B
• Housing
• Emergency temporary housing
• Permanent housing
•
•
•
•
•
Reliable transportation to and from UNMH
Medications
Clinic appointments
Citizenship
Medicare
Patient C
• 45-year-old gentleman with diabetes
• Multiple admissions to UNMH
• Diabetes
• Infections
• Admitted November, 2007
• Diabetes out of control
• Bone infection
• Amputation and prolonged antibiotic treatment
• Discharged with excellent plan
• Transportation arranged
• Medications arranged
• Good follow-up
Patient C
• Winds up on Care One list
• We schedule an appointment
• Patient does not show
• We schedule an appointment
• Patient does not show
• We schedule an appointment
• Patient does not show
One definition of mental illness
Doing the same thing over and over again
and expecting a different result
Patient C--the home visit
• Small trailer on the outskirts of town
• Multiple family members
– Some with multiple amputations
• Past the bus lines
• No car
• Rely on friend in the East Mtns for transportation
• No medicines
• No social services
• Unaware of any follow-up appointments
The “plugging in” of Patient C
• Transportation
• Social services
• Not just for patient, but for other household members
• Medications
• Follow-up appointments
•
•
•
•
Diabetes education
Diabetes clinic
Wound care
Primary Care
Patient C
• Despite our very best efforts…….
Change in UH charges
UNMH Charges for All Patients Activated Before 1/31/07
Before and After Intervention by Month
UNMH Charges for All Patients Activated Before 7/31/07
Before and After Intervention by Month
1,400,000.00
1,800,000.00
1,600,000.00
1,200,000.00
1,400,000.00
1,000,000.00
1,200,000.00
1,000,000.00
800,000.00
800,000.00
600,000.00
600,000.00
400,000.00
200,000.00
2
R = 0.7113
400,000.00
2
R = 0.5684
200,000.00
0.00
0.00
-12 -11 -10 -9
(200,000.00)
(400,000.00)
(200,000.00)
-8 -7
-6
-5
-4 -3
-2
-1
0
1
2
3
4
5
6
7
8
9
10 11 12
Change in UPA charges
UPA Charges for All Patients Activated Before 07/31/07
Before and After Intervention by Month
UPA Charges for All Patients Activated Before 1/31/07
Before and After Intervention by Month
450,000.00
250,000.00
400,000.00
200,000.00
350,000.00
300,000.00
150,000.00
250,000.00
200,000.00
100,000.00
150,000.00
R2 = 0.4599
100,000.00
2
R = 0.4169
50,000.00
50,000.00
0.00
0.00
-6
-5
-4
-3
-2
-1
0
1
2
3
4
5
6
-12 -11 -10 -9
-8
-7
-6
-5
-4
-3
-2
-1
0
1
2
3
4
5
6
7
8
9
10 11 12
Change in Admissions
Number of Inpatient Admissions for All Patients Activated Before 07/31/07
Before and After Intervention by Month
Number of Inpatient Admissions for All Patients Activated Before 1/31/07
Before and After Intervention by Month
30
45
40
25
35
20
30
15
25
20
10
2
R = 0.7216
15
R2 = 0.6532
10
5
0
5
-12 -11 -10
0
-6
-5
-4
-3
-2
-1
0
1
2
3
4
5
6
-5
-9
-8
-7
-6
-5
-4
-3
-2
-1
0
1
2
3
4
5
6
7
8
9
10
11
Change in ED Visits
Number of Emergency Room Visits for All Patients Activated Before 07/31/07
Before and After Intervention by Month
Number of Emergency Room Visits for All Patients Activated Before 1/31/07
Before and After Intervention by Month
35
45
40
30
35
25
30
20
25
20
15
2
R = 0.5423
2
R = 0.7285
15
10
10
5
5
0
0
-6
-5
-4
-3
-2
-1
0
1
2
3
4
5
6
-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3
4 5 6 7 8 9 10 11 12
How UNMH benefits from Care One
• Prevention of unnecessary hospitalizations
• Potential retro-billings of $3.6 million via
Medicaid and Medicare
• Collections tend to be about 1/3 of billings
• These are patients who are difficult to track down and
difficult to work with
• Huge expenditure of energy
• Need to work with business office more closely
The future of Care One
• Controlled expansion of the program
•
•
•
•
•
Expand patient population served by Care One
Expand our mental health services
Use community health workers for home visits
Pharmacy waivers
Transportation issues
#1 on our “wish list”
The Sunday NY Times
''Without Health Benefits, a Good Life Turns Fragile'’ (March 5, 2007)
To the Editor:
I am the medical director of a small program that focuses on uninsured and medically
fragile patients. Most of my patients are impoverished. Those who are not are
struggling. Some used to be what we refer to as middle-class.
When I ask, ''What is your most pressing problem?,'‘ I am invariably told that it is lack
of money. The illnesses come second.
My patients cannot afford their medications or the co-payments for doctor visits and
tests. They pick and choose among their options, and some do not choose wisely. I
work with a social worker, an assistant case manager and a mental health counselor
to try to repair the lives of these individuals and their families, and arrange things so
that they do not have to make these choices.
I am fortunate to be working for an organization that is committed to this goal. I
would like to think that we, as a society, are committed to this goal.
Douglas Binder, M.D.
Albuquerque, March 5, 2007
The writer is medical director of Care One, University of New Mexico Hospital.
Care One
end presentation