Transcript Social or Care Complexity

Session # D5b in Period 5
October 17, 2015
Beyond PCMH Walls:
Wedding Community-based, High-Utilizer approaches to
Integrated Primary Care
Macaran A. Baird, MD, MS
Barry J. Jacobs, Psy.D.
Collaborative Family Healthcare Association 17th Annual Conference
October 15-17, 2015 Portland, Oregon U.S.A.
Faculty Disclosure
The presenters of this session
• currently have the following relevant financial
relationships (in any amount) during the past 12
months:
• 20% of Barry Jacobs’ salary is covered by a proofof-concept grant from Independence Blue Cross of
Philadelphia for his work on the Crozer-IBC
Medicare Advantage Super-Utilizer Program
Learning Objectives
At the conclusion of this session, the participant will be able to:
• 1. Describe the 3 major shifts required to get past habits of
thinking of the PCMH as a location
• 2. Describe actions and options already being implemented
outside the walls of the PCMH for the “high-utilizer”
population.
• 3. Reflect on what it takes to restore a sense of satisfaction
and professionalism in working with complex, high-utilizing
portion of our primary care population—and in teaching
young clinicians to value this as part of their jobs.
Bibliography / References
--Baird MA. (2014). Primary Care in the Age of Reform – Not a Time
for Complacency. Family Medicine, 46(1)7-10.
--Baird M, Peek CJ, Gunn W & Valeras A. (2013). Approaches to
complexity care. Chapter in The Landscape of Collaborative
Healthcare: Evaluating the Evidence, Identifying the Essentials. M
Talen & AB Valeras (Eds), Springer Science & Business Media
--Coburn, K. et al. (2012). Effects of a community-based nursing
intervention on chronically ill older adults: a randomized control trial.
PLoS Medicine , 9(7)
--Gawande, A. (2011). The hot-spotters—can we lower medical
costs by give the neediest patients better care?, The New Yorker,
January 24.
--Pratt R, Hibberd C, Cameron IM, Maxwell M. The Patient
Centered Assessment Method (PCAM): integrating the social
dimensions of health into primary care. Journal of Comorbidity.
2015;5:110-119.
--”Working with the Super-Utilizer Population: The Experience and
Recommendations of Five Pennsylvania Programs,” 2015, available
at http://www.aligning4healthpa.org/pdf/High_Utilizer_Report.pdf
Learning Assessment
• A learning assessment is required for CE
credit.
• A question and answer period will be
conducted at the end of this presentation.
Goals
1. Review why clinical care systems are
concerned about a small group of very
complex patients who fail to improve.
2. Understand what we can do to help these
patients more effectively?
3. Learn from current clinics designed
specifically for “High-Utilizer” patients
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Why Transform?
•
•
•
•
New
delivery/payment
systems
Population health
Capacity (teambased care)
Triple Aim (Quad
Aim)
The market for medical services is
shifting
• Clinical practices are becoming responsible for
reaching the “Triple Aim” & must achieve a 4th
“Quadruple Aim”-an improved clinical team
experience
• “Total cost of care” savings depend upon
reaching those who use many resources, or
“high utilizer” / “Priority Patients”
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The fulcrum is moving
Your leverage and net value to the system is
larger through managing a panel
Fee for
service
Pay for
performance
Bundled care
mgmt fees
Total cost of
care contracts
Global
budgets
If you don’t address the expense and misery accompanying patient
complexity, someone else will.
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Avoiding complacency with PCMH:
4 steps
• Improve assessment & interventions for
social and health system complexity
• Regard primary care as a way of operating,
not as a geographic place
• Incorporate/integrate with “hot spotters”
and other mobile providers
• Improve leadership competence
– Baird, Family Medicine, 2013.
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Who becomes a “high utilizer” and therefore,
a “high priority” patient?
Whom do we see most often but not really
help?
Do some just demonstrate the “reversion to
the mean” concept?
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High-Priority patients?
• Comprise from 1% – 3% of most primary
care populations
• May use 10-20% of population budget
• Usually have complex medical, psychosocial and behavioral health problems
• Often fail to respond to routine care plans
delivered within clinics & hospitals
• Some improve and become near normal
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What types of issues do High
Utilizer patients face?
• Serious medical and end-of-life illness
• Acute injuries and serious illnesses from
which they will eventually recover
• Co-morbid and entangled medical and
psychiatric problems
• Medically unexplained symptoms (MUS)
• Social determinants of health- barriers
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Alternative definitions
• Clinician reaction: “difficult,” “not responsive,” “I don’t
have anything else to offer”
• Patterns of healthcare use: Overuse, misuse, cost,
ineffective use – “high utilizer,” abusing the system
• Mental health: Distress vs. disease; code-able vs.
meaningful diagnoses
Cumulative complexity: Imbalance between patient
workload and patient capacity (Schipee et al, 2012)
•
•
Workload: All everyday tasks plus demands of patient-hood
Capacity: All abilities, resources, readiness to address demands—physical,
mental, socioeconomic, support, literacy, attitudes, beliefs
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Commonplace “wishful thinking” in the face of
unnamed and unmanaged complexity
Clinician
Maybe the next dx
The next consultant
The next test or scan
The next medication / tx
A new Dr. (better than me)
Maybe P.T. or other
Mental Health (if all else fails)
Maybe they will N.S.
(Your own wish here)
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Payer / health plan?
Maybe a different provider group?
Remote disease management ?
Part II: Complex patients -risk becoming high utilizers?
Definitional: Co-morbidity vs. interference with care
Two Axes of Patient Complexity
Medical Complexity
• How many diseases
• How chronic
• How severe
• How challenging
Social or Care Complexity: Interference with usual care and decision-making
• Distress and distraction
• Lack of social safety and support
• Disorganization of care
• Lack of resources for care
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Axes of patient complexity
Hypothesis: Total care challenge = size of shaded area
Medical Complexity
Patient A
• High medical complexity
• Low social/care complexity
Patient B
• Low medical complexity
• High social/care complexity
Social / Care Complexity
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Patient C
• High medical complexity
• High social/care complexity
Total care challenge = size of shaded area
Medical
Complexity
Social or Care Complexity
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Complexity:
A Property of what exactly?
A property of…..
• ….The patient as a person or partner in care?
(patient complexity)
• ….The patient’s diagnoses?
(medical complexity)
• ….The patient’s situation?
(social complexity)
• ….The organization of care and team?
complexity)
Most or all of these?
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(care
Part III: What do they need?
Complex patients need….
• Clinician and system willingness to accept social and care
complexity as part of the job—a culture shift
• Respectful clinicians & teams using a systematic and nonpejorative vocabulary for “complexity”
• Care plans connecting the dots among relevant “outside”
factors—that often lead outside the clinic
• Acceptance that “non-adherence” may be more a
property of the intervention than of the patient
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Example: Tool with questions
Patient-Centered Assessment Method (PCAM)
1. Health and well-being
• Physical symptoms to investigate further?
• Physical symptoms affecting mental well-being?
• Lifestyle affecting physical or mental well-being?
• Other concerns about mental well-being?
2. Social environment
• Home safety & stability?
• Daily activities & well-being?
• Participation in social network?
• Financial resources?
Maxwell, Hibberd, Pratt, Mercer, &
Cameron (2013); Scotland
www.pcamonline.org
3. Health literacy & communication
• Present understanding of health & well-being?
• Capability to engage in discussions regarding health and care?
4. Service coordination
• Other services needed?
• Are services well coordinated?
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The product is action:
In common across 3 complexity checklists:
Any question that lights up requires action within the care plan (not
just a threshold sum across questions)
Choose level of action needed on complexity:
•
•
•
•
Routine care (little or no complexity detected)
Active monitoring (potentially need to act on complexity)
Plan action for complexity (commence planning)
Act immediately (urgent action on complexity is needed today)
Plan of action—written & shared by team in record:
• Goals for care–both medical and social complexity
• Specific actions to accomplish goals—who does what (incl pt. and family)
• What the clinician / team will do today—how urgent such action is
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MCAM: Peek, Baird, & Coleman (2009)
PCAM: Maxwell, Hibberd, Mercer, & Cameron (2013--Scotland)
INTERMED: deJong, Huyse, & Stiefel (2006-The Netherlands)
Complexity items & action areas
Item
Action areas
Impairment--sx severity Mitigate functional limitations; self-regulation
Diagnostic
uncertainty
Review, 2nd opinion, find out patient’s
theory, motivational interviewing,
build trust
Distress & distraction
Identify & help mitigate social / personal stress
with peer support, groups, self-care
Social isolation, risk
Build social connections and safety, connect
with social services
Disorganization
of care
Clarify roles & plan, engage patient,
build trust
No common language
Professional interpreters, cultural bridging
Un- or under-insured
Financial counseling, seek public health plan
Adapted from Peek, Baird, & Coleman, 2009
Example: Care coordinator assessing medical and care complexity
in a MN Health Care Home
Medical Complexity (MN HCH tiers*)
• How many conditions in what dx groups?
• Chronic?
• How severe?
• If chronic & severe—need a major team?
Coordinated plan—who does what
• Findings and goals on each axis
• What matters to pt & family
• Team roles, incl patient / family
• What level of urgency to act
*Based on MN Health Care Home
complexity tiering V. 1.0
www.health.state.mn.us/healthreform/homes/paym
ent/HCHComplexityTierTool_March2010.pdf
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Social or Care Complexity: Interference
• Distress and distraction
• Lack of social safety and support
• Disorganization of care
• Lack of resources for care
New methods of approaching High
Priority patients
• Assess for social and behavioral complexity
• Reach out beyond the clinic with specific
staff- “Hot Spotters”
• Connect to other community resources
• Continue to survey patients in clinic for
becoming “high-utilizers” and engage them
with the new outreach efforts
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References
•
Baird MA. Primary Care in the Age of Reform – Not a Time for Complacency. Family Medicine.
2014;46(1)7-10.
Baird M, Peek CJ, Gunn W & Valeras A. (2013). Approaches to complexity care. Chapter in The
Landscape of Collaborative Healthcare: Evaluating the Evidence, Identifying the Essentials. M
Talen & AB Valeras (Eds), Springer Science & Business Media.
Browning D. Listening to elderly cuts use of costly medications. Star Tribune. Dec 20, 2013.
Brownlee S. Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer, New York:
Bloomsbury USA 2007.
de Jonge, P., Huyse, F., & Stiefel, F. (2006). Case and care complexity in the medically ill.
Medical Clinics of North America, Volume 90, #4. Elsevier
Horwitz AV, Wakefield JC. The loss of sadness: how psychiatry transformed normal sorrow
into depressive disorder. New York, Oxford University Press, 2007.
Kuehn BM. Health Reform, Research Pave Way for Collaborative Care for Mental Illness.
JAMA. 2013; 309(23):2425-2426.
Kuehn BM. Studies shed light on risks and trends in pediatric antipsychotic prescribing. JAMA.
2009; 303:1901-1903.
Maxwell M, Hibberd C, Pratt R, Cameron I, Mercer S. (2011). Development and initial
validation of the Minnesota Edinburgh Complexity Assessment Method (MECAM) for use
within the Keep Well Health Check. Scotland National Health Service. Available at:
www.pcamonline.org
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•
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References (con’t)
•
Peek, CJ. (2010). Building the medical home around the patient: What does it mean for behavior?
Families, Systems and Health Vol. 28, No. 4, 322-333
Peek CJ, Baird MA & Coleman E. Primary Care for Patient Complexity, not only disease. Families,
Systems, & Health, Dec 2009
Peek, CJ. (2008). Integrating care for persons, not only diseases. Journal of Clinical Psychology in
Medical Settings. Vol 16, No. 1. Springer, New York.
Peek CJ, and Heinrich RL (1995) Building a collaborative healthcare organization: From idea to
invention to innovation. Family Systems Medicine, Vol. 13, No. 3/4, pp. 327-342.
Pratt R, Hibberd C, Cameron IM, Maxwell M. The Patient Centered Assessment Method (PCAM):
integrating the social dimensions of health into primary care. Journal of Comorbidity. 2015;5:110119.
Rasmussen NH1, Furst JW, Swenson-Dravis DM, Agerter DC, Smith AJ, Baird MA, Cha SS. Innovative
reflecting interview: effect on high-utilizing patients with medically unexplained symptoms. Disease
Management. 2006 Dec;9(6):349-59
Salazar-Fraile J et al. “Doctor, I just can’t go on.’ Cultural constructions of depression and the
prescription of antidepressants to users who are not clinically depressed. International Journal of
Mental Health, 2010, 39:29-67.
Schwarz A. Report Says Medication Use Is Rising for Adults With Attention Disorder. New York
Times. March 12, 2014.
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References (con’t)
•
•
•
•
•
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Singer N. Selling That New-Man Feeling. New York Times. November 23, 2013.
Stipp D. Trouble in Prozac Nation. Fortune. November 28, 2005.
Tracy L. Johnson, Deborah J. Rinehart, Josh Durfee, Daniel Brewer, Holly Batal, Joshua Blum,
Carlos I. Oronce, Paul Melinkovich and Patricia Gabow. For Many Patients Who Use Large
Amounts Of Health Care Services, The Need Is Intense Yet Temporary. Health Affairs. Aug 2015;
No. 8: Tracy L. Johnson, Deborah J. Rinehart, Josh Durfee, Daniel Brewer, Holly Batal, Joshua
Blum, Carlos I. Oronce, Paul Melinkovich and Patricia Gabow. For Many Patients Who Use Large
Amounts Of Health Care Services, The Need Is Intense Yet Temporary. Health Affairs. Aug 2015;
No. 8: 1312-1319.
Tiefer L and Witczak K. A call to challenge the “Selling of Sickness.” BMJ 2013:346-12809.
Watters E. The Americanization of mental illness. New York Times. January 8, 2010.
Weiss, K. (2007); Managing Complexity in Chronic Care: An overview of the VA State-of-the-Art
Conference, GJIM 22 (Suppl 3): 374-8, 12/07
Extending Beyond PCMH Walls
• There are many examples of interventions for
high-complexity patients, including telephonic
case management
• But high-complexity pts require more
intensive interventions and, what Dr. Baird has
termed, “mobile health teams”
• “Super-Utilizer” care, originally developed by
Jeff Brenner, MD
Who is Jeff Brenner, MD?
• Frustrated family MD
• Closed solo practice in
Camden, NJ
• Began looking at data
about city’s healthcare
trends
Brenner (cont.)
• Formed Camden Coalition of Healthcare
Providers in 2002
• Developed Camden Healthcare Database
• Formed relationships with outpatient and
inpatient providers, as well as social service
agencies, throughout city and state
• Promulgated “hot-spotting” or “super-utilizer”
model of collaborative intervention
Key SU Components
• Continuous, real-time utilization data across health
systems to identify high-utilizers
• Assessment procedures and outcome measures
• Intensive, community-based care coordination (as
overlay to PCMH), conducted by interprofessional
teams (nurses, social services, community health
workers)
• Home visits; medical visit accompaniments
• Relationship-based, trauma-informed care
Crozer-Keystone SU Program
• Part of 5-hospital
system in Philly suburb
• 10-10-10 family
medicine residency
• PCMH III (since 2009)
• Launched first SU pilot
in 2011
• Started Crozer-Camden
Super-Utilizer
Fellowship in 2012
Initial PCMH-Based SU Program
• 14 hospital- and ER-SU pts
from our PCMH practice
• Dxs: CHF, CVA, anxiety, SA
• Close coordination between
primary physician and SU
team (fellow, psychology,
pharmacy, social work,
volunteer)
• Spectacular successes and
failures
• Overall decreased costs
A Frail Elderly SU Program
• In spring of 2013, the SU team at the CrozerKeystone Family Medicine Residency Program
was approached by a physician executive at
Independence Blue Cross, the largest
Philadelphia area insurer, to create a proof of
concept SU intensive care coordination
program for 10 IBC Medicare Advantage
patients with PCPs in the Crozer Keystone
Health System
• Launched January 2014;
renewed for 2nd year
• As of 8/15, team saw 20
patients; avg age=80
• Dxs: CHF, COPD, DM,
dementia
• 50% decrease in inpt
admissions, 80%
decrease in OBS
Crozer-IBC Model
• Based on work of Drs. Ken Coburn (“warm
spotting”; nurse as point person), Dave Moen
(home visit), and Dan Hoefer (palliative care)
• Hired nurse case manager as point person—
weekly home visits, medical accompaniment,
family meetings
• Interprofessional team of advisors/interveners—
family medicine, psychology, social work,
pharmacy, volunteer
• Weekly huddles; EMR
Camden-inspired SU vs. Elderly SU
• Greater numbers of chronic medical
morbidities (e.g., CHF, COPD)
• Fewer social problems; many behavioral
problems
• Patients more dependent on family and
community services; creates greater need for
intervening with family caregivers, local
agencies
• More frequent involvement with PCPs
Carmella, IBC PT
• 89 year old widow who
lives in a multigenerational rowhome.
• Co-morbidities include:
DM, CHF, HTN, CAD,
Obesity, Peripheral
Neuropathy & edema
• Chaotic home
environment;
boisterous ItalianAmerican family
Baseline utilization x 6 mos for CO
8
7
6
5
INPT
LOS 4
OBS
ER
3
Engagement
2
1
0
9/4/13






11/4/13
1/4/14
3/4/14
5/4/14
10/4/13 – Admitted for bilateral lower extremities cellulitis
11/20/13 – ER for Edema
11/24/13 – OBS for arm cellulitis
1/7/14 - Admitted pneumonia and CHF
2/5/14 – Admitted for change in mental status/Anemia/UTI
Enrolled in Crozer Connections to Health Team program 2/12/14
Challenges
• Busy household with diffusion of responsibility
among family members for C’s healthcare
• C’s insisted on sleeping in recliner in living
room that didn’t recline because she was
afraid to be alone (unsure of her place in
afterlife); chronic leg edema, cellulitis, UTIs
• C defied children by going up and down
rowhome steps on her own to sit on patio;
falls risk
Interventions
• Weekly RN visits (and frequent phone calls with
family members)
• Weekly Psy.D. student behavioral health visits
• Coordination of home PCP visit (through residency
program) and home lab draw
• Home medication reconciliation
• RN accompaniment to medical visits
• Team worked toward decreased family caregiver
burden/increased family organization
Outcomes
• Since 2/14, only 1 hospitalization for possible
CVA (later diagnosed Bell’s Palsy)
• More frequently sleeps upstairs
• Decreased edema
• Decreased blood sugars
• Ongoing psychological and spiritual counseling
still addressing fear to change sleep behaviors
• Family better coordinated and hopeful
Outcome Studies
• South Central Pennsylvania High-Utilizer
Learning Collaborative (Crozer-Keystone,
Lancaster, Neighborhood Health Centers of
the Lehigh Valley, Pinnacle, WellSpan):
• 2012-14: 446 pts, 21% decrease in ER admits;
52% decrease in hospital admits; 63%
decrease in patient-days in hospital
• Camden: In midst of RCT of 800 pts (run by
MIT’s Poverty Action Lab); results due 2017
Final Comments
• In conversations with Marci Nielsen, director
of the Patient Centered Primary Care
Collaborative at last year’s CFHA conference,
she said SU programs as part of the PCMH
• Not a question of either/or
• Mobile health teams extend the PCMH’s reach
and lower overall utilization and costs
Session Evaluation
Please complete and return the
evaluation form to the classroom
monitor before leaving this session.
Thank you!