Transcript Reducing Medical Costs and Improving Clinical Care, Coordination

Session #D5b
Saturday, October 12, 2013
Reducing Medical Costs and Improving Clinical Care,
Coordination & Outcomes by Reducing Admissions for
High Utilizers of Emergency Care Services
Sara Tracy, MSPH
Senior Manager, Emergency Services & South Hospital Operations,
Kaiser Foundation Health Plan of Colorado
Kevin Vanderveen, MD
Colorado Permanente Medical Group Assistant Regional Department Chief,
Emergency Services Physician Director, Telephone Medicine Center
Joanne Whalen, PsyD
Licensed Clinical Psychologist & Behavioral Medicine Specialist,
Kaiser Permanente of Colorado
Collaborative Family Healthcare Association 15th Annual Conference
October 10-12, 2013
Broomfield, Colorado U.S.A.
Faculty Disclosure
We have not had any relevant financial relationships
during the past 12 months.
Objectives
• Identify one model of using integrated care teams to
reduce emergency room admission rates and
• Recommendations for replication in other health
care settings.
• Identify key players in a health care organization
needed to implement such a program.
• Identify critical components for successful
implementation of care conferences.
“High” utilizers w/ 6 or more visits in one year
• 2010 ED spend alone = $3.8 million
• Average visits = 8.7 per 12 months
• Average yearly spend per member:
 Commercial: $16,500
 Medicare: $8,200
• 7.8% connected w/ Chem Dep
• 35% connected w/ Mental Health
• Remaining 57% not connected w/ either
Type of patients
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Isolated medical issue that results in several ED visits and then
resolves (ex: acute MI, trauma, surgical abdomen etc.)
Chronic pain issues
Misuse of controlled substances
Other chemical dependency issues – i.e. alcohol dependency
Behavioral health issues that manifest as physical complaints (i.e.
anxiety leading to chest pain)
Patients with challenging social issues & possible placement needs
– may be becoming unable to care for self in current situation
Patients with complex medical issues & emergency needs
Why intervene?
• Improve quality of life for patient and improve quality of care
patient is receiving
• Improving coordination of care within integrated care system
• Reduce cost to patient and organization
• Partner w/ local ED’s to help them care for these patients
• Reduce unnecessary (& potentially harmful) diagnostic testing &
treatment
• Provide support to Primary Care Physician & care teams for
patient
Why Primary Care Interventions
• Everything mentioned on previous slide!
• Primary care in most cases has strongest
relationship with patient
• Enhance and strengthen the “medical
home”
How we identify ED high utilizing members
• Real time report from many local ED’s on
admissions of KP patients – patients with 6 or
more visits/year are flagged
• Local Emergency Depts will call KP and notify of
frequency of ED visits and/or drug seeking
behavior
• Local provider may notice frequency of ED visits
Once patient is identified, what do we do?
• Chart review to identify trends
• Convene all providers critical to patient’s care for care
conference
• PCP
• Nursing team
• Behavioral Health/Chem Dependency
• Emergency Care Providers
• Clinical Pharmacist
• Social work/care coordination services
• Include outside providers as needed
Purpose of care conference, cont.
• Identify drivers of ED visits
• Identify any other support/outreach needed &
who will do it
• Review medications if needed & make
changes
• Identify interventions
Purpose of care conference
• Notify appropriate outside entities that a care
plan is in place (i.e. emergency departments that
patient visits)
• Establish plan going forward for future ED visits
• Determine next steps & any further follow up or
review needed
Controlled Substance Issues & Solutions
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Ensure there is a written opioid agreement
Explicitly stipulate that controlled substances MUST
be obtained from a single source for chronic pain—
verify with state controlled substance database
Continued receipt of controlled substances tied to
certain behaviors—i.e. regular follow-up with
behavioral health, evaluation by chemical
dependence
28 Day refills
Provision for notification of other providers – i.e.
dentists
Behavioral Health
• Reviewing EMR for relevant mental health
history
• Outreaching patients to get connected to BH
• Educate & support medical staff on dealing
with BH/CD patients
• Education & skill building for patients related
to coping w/ pain & BH/CD issues
Barriers
• Financial – patient unable to afford cost
of recommended treatment
• Patient willingness and/or ability to
participate in recommended treatment
plan
• Social and/or family issues
• Transportation
Challenges, roadblock, & obstacles
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Buy in from primary care
Practice variation/lack of consistency
Varying financial incentives in different care settings
Documentation of care plan
Perceived loss of physician autonomy
Perceived liability issues
Perceived patient satisfaction issues
Lack of accountability & incentive
Critical Components to successful
implementation
• Chart etiquette & standardized documentation of
plan
• Key providers involved & invested in care
conference
• Buy in from organization leadership
• External & internal communication
• Consistency in practice & willingness to follow
through w/ plan
Success of the intervention
• Pre and post (12 months each) data from institution of
the program in 2010 shows 55% reduction in ED costs
and 40% reduction in visits.
• Several patients have completely detoxed off of
narcotics completely
• Will not be able to impact all patients
2011 Results
Case Example: Megan
19 year old Caucasian female college student
Frequent ER visit for believed allergic reaction
for prior 4 years (one required intubation)
50+ epi pen injections in the last 4 years
# ER visits
12 months
Pre-intervention
Pre-intervention ER
costs
12 months prior
# ER visits
12 months
Post intervention
ER Costs
12 months
Post intervention
8
$19,912
1
$974
Megan – Intervention
Allergist recommended test to take in the ER to confirm
(dispute) reaction
Confirmation that not having reaction allowed room to
work on anxiety
Brief CBT treatment with Behavioral Medicine Specialist
(exposure with response prevention, relaxation
exercises, challenging irrational thoughts)
Significant improvement in quality of life
Case Example - Susan
48 y/o disabled Caucasian female
Frequent ED & clinic visits over 10 years for
migraine headaches – treated with IM
cocktail including narcotics
# ER visits
12 months
Pre-intervention
Pre-intervention
ER costs
12 months prior
# ER visits
12 months
Post intervention
ER Costs
12 months
Post intervention
29
$11,879
4
$2,526
Susan - Intervention
Departure of previous PCP opened the door for
new treatment plan
Discussed with patient weaning her off of narcotics
Initial reaction in first six weeks from patient was
anger at providers
Two months post intervention, patient reported
only “mild” headaches and had not been back
to ED
Case Example - Amy
54 year old female office employee
Known CAD, multiple visits to the ED over the
years for chest pain
Co-morbidities of anxiety disorder, breast CA
# ER visits
12 months
Pre-intervention
Pre-intervention
ER costs
12 months prior
# ER visits
12 months
Post intervention
ER Costs
12 months
Post intervention
20
$48,431
6
$13,840
Amy - intervention
Care conference included cardiology team who
saw Amy often in the office
Added Rx for anxiety when Amy experiences chest
pain
Connection with behavioral health provider and
teaching re: mindful eating, stress reduction,
anxiety management
Patient able to wean off of home oxygen soon after
intervention after two years on oxygen
Learning Assessment
Audience Question & Answer
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor before
leaving this session.
Thank you!