Transcript RMCCMSA 2014 presentation 10-3
Hotspotting in Aurora
Angela Green, PsyD Director of Behavioral Health Heather Logan, MSW Director of Accountable Care & Bridges to Care Erin Loskutoff, MPH, MSN, AGNP-C B2C Nurse Practitioner
MCPN
Every touch, every time.
MCPN
Every touch, every time.
MEDICAL REPORT
THE HOTSPOTTERS
Can we lower medical costs by giving the neediest patients better care?
by Atul Gawande
JANUARY 24, 2011
The Round Table: Aligning the Partnerships
What are we trying to accomplish here?
• • • Identify WHY patients over-utilize the hospital: Build a model around the WHY Stabilize, Coordinate, Improve Care, Reduce Cost Reduce ER visits and Inpatient stays through a community intervention
The Bridges to Care Vision
Helping people one at a time to empower themselves with tools, knowledge, and confidence to take responsibility for their own physical and psychological health.
• • • • • • •
Bridges to Care Model
Hybrid of the Hospital Discharge, ED, Home, and Community Based Models Intervention begins at bedside 60 day model: Patient graduates from the program 8 visits minimum Collect information at each step to evaluate/improve program Inclusion/Exclusion Criteria MCPN’s model includes 2 unique components
Medical Providers
Behavioral Health Providers
Criteria
INCLUSION
• • • •
Live in Aurora 3 Hospital Visits (ER & IP) in last 6 months Adults Non-violent offenders, homeless, BH are all ok EXCLUSION
• • • • • • • • • • •
Acute visits (?) Pregnancy HIV (?) Malignancies Primary dx of personality disorder Post-surgical Primary diagnoses of substance abuse Diminished capacity Pediatrics Violent offenders/sex offenders Care giver as primary decision maker or Power of Attorney
Enrollment
24-72hrs post d/c
CHW/CCC
Present giveaways and B2C contact info
Complete Enrollment forms B2C Home Visit Timeline 60 day model (Minimum of 8 visits) More home visits may be needed to graduate the patient from the program NOT ALL PATIENTS WILL FOLLOW THIS TIMELINE EXACTLY.
Any combination of NP/BHP/CCC/PNP/ HC Any combination of NP/BHP/CCC/PNP/ HC
Pre-Graduation Visit – HC Review graduation checklist - Teach-back Opportunities
Pre-enrollment 333333# Complete pre-enrollment forms (Track Via) - CHW Schedule:
1 st Home Visit (Enrollment w/CCC) 2 nd Home Visit - NP visit Updated8/5/13 SA
#1 #2
Medical Visit w/ NP (w/in a week of hospital d/c- if possible)
#3 #4 30 days Assessment HC Complete 30 day assessment and Outcome forms #5 #6
Any combination of NP/BHP/CCC/PNP /HC
#7 #8 Graduation Celebration
–
CCC
Present giveaways and home clinic contact information
Complete -60 day assessment and Outcome forms
Behavioral Health: An Essential Component
• SDAC data revealed nearly 80% of Medicaid patients in this data set had a behavioral health component to condition
AIM-C Approach
• • •
A
ssess – SBIRT, PHQ, initial visit, CPCQ, risk stratification, enrollment evaluation, CCC assessment •
I
ntervene – brief counseling, meds, referrals, coaching E
M
power – educate, activate, validate, participate, motivate
C
onnect – relationship, resources, referrals
Outcomes/Deliverables
• • • • • • • 1. Enroll our 689 patients 2. Demonstrate cost savings - Reduce re-hospitalizations - Decrease Illness Burden 3. Transition patients from home visits to clinic visits 4. Establish health homes for patients 5. Demonstrate sustainability/develop a sustainability plan
Demographics
Demographics
Demographics
Transitional 1% Street 2%
B2C Homeless Status
Unknown 1% Homeless Shelter 1% Doublin g Up 7% Other 21% None 13% Not Homeless 54%
Encounters By Type & Team Member Encounters by Type & Provider
BH 4% Psych NP 5% MA 6% CHW 26% Health Coach 15% Med 16% CCC 28%
40 20 0 120 100 80 60
Physically Unhealthy Days
107 94
80% 71%
65 38
29%
30
23% 49%
After 30 days 23
17%
16
12%
Increase After 60 Days Unchanged Decrease 14
11%
12
12%
After 180 days
N = 133
Chronic Diagnoses
B2C Status Active Graduated Lost to Follow Total More than 1 Chronic DX
36 239 83 358
Frequency
38 244 106 388
Percentage
95% 98% 78% 92% • An overwhelming proportion of B2C patients suffer from chronic illnesses (92%)
17 18 19 20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 ICD9
401.9
305.1
311 300.00
250.00
272.4
493.90
300.4
530.81
278.00
309.81
250.02
496 300.01
296.80
244.9
428.0
305.00
296.32
346.90
Description Top 20 Chronic Diagnoses (All statuses)
Unspecified essential hypertension Nondependent tobacco use disorder Depressive disorder, not elsewhere classified Anxiety state, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other and unspecified hyperlipidemia Asthma, unspecified, unspecified Dysthymic disorder Esophageal reflux Obesity, unspecified Posttraumatic stress disorder C Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Chronic airway obstruction, not elsewhere classified Panic disorder without agoraphobia Bipolar disorder, unspecified Unspecified hypothyroidism Congestive heart failure, unspecified Nondependent alcohol abuse, unspecified drunkenness Major depressive disorder, recurrent episode, moderate Unspecified migraine without mention of intractable migraine
Freq
183 141 103 95 90 88 79 60 58 56 50 42 40 38 37 36 33 31 28 27
B2C Patients with BH Diagnoses
78% of Active patients 86 % of Graduates 81% of All B2C Patients 69% of Lost to Follow
10 0 30 20 90 80 50 40 70 60
Mentally Unhealthy Days
79 70 63
59% 53%
37 33
25% 28% 47%
33 30
25% 23%
39
29%
15
11%
After 30 days Increase After 60 Days Unchanged Decrease After 180 days
N = 133
Current B2C – Utilization Trend Data
Current B2C – Utilization Trend Data
What We Already Know About Cost Savings “Health centers save $1,263 per person per year, lowering costs across the delivery system‒from ambulatory care settings to the emergency department to hospital stays”
Source: NACHC analysis based on Ku L et al. Using Primary Care to Bend the Curve: Estimating the Impact of a Health Center Expansion on Health Care Costs.
GWU Department of Health Policy. Policy Research Brief No. 14. September 2009.
Lessons Learned
• • • • • • You need good people to do hard work!
Systems are not designed for innovative work!
Chances are no one has gotten this far before!
Sometimes being a gardner is all you can do!
Be realistic about what change means!
Buy in is crucial, it just may not always come from the top or look the way you envisioned!
Constantly Evolving: Don’t use pen!
Achieving the Triple Aim
“The integrator’s role includes at least five components: 1. Partnership with individuals and families, 2. Redesign of primary care, 3. Population health management, 4. Financial management, and 5. Macro system integration.
“ Health Aff May 2008 vol. 27 no. 3 759-769