Transcript Title of Presentation Arial 50pt Bold
Community-based Chronic Illness Management:
Strategies and Tools to Reduce Costs and Improve Outcomes
April 5, 2010 Steve H. Landers MD, MPH Director, Cleveland Clinic Center for Home Care and Community Rehabilitation [email protected]
Brent T. Feorene, MBA President, House Call Solutions [email protected]
Today’s Agenda
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Welcome and Introduction Current trends What is on the table?
Future tense Programs that hold promise CCF: Today and Tomorrow Q&A
Powerful Trends Impact Medical Practice
Technology Aging Population Chronic Illness Consumer Expectations Economic Pressures
Demographic Imperative
Administration on Aging. A Profile of Older Americans: 2007. Accessed at www.aoa.gov
Activity Limitations
Administration on Aging. A Profile of Older Americans: 2007. Accessed at www.aoa.gov
Chronic Illness Epidemic
Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update
Aging + Chronic Illness
Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update
Costly
Congressional Budget Office
“High Risk”
Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update 2005 MCR FFS stats from MedPAC DataBook June 2008
Readmissions
Jencks SF et al. N Engl J Med 2009;360:1418-1428
Half of Medicare Patients Rehospitalized Without Seeing Doctor After Discharge ~60% of Rehospitalized HF patients hospitalized due to another problem
Physician Frustration
“Train Wrecks” “Gomers” Frustration with the complexity, communication barriers, and administrative burdens… Adams WL, McIlvain HE, Lacy NL, et al. Primary Care for Elderly People: Why Do Doctors Find it So Hard? The Gerontologist. 2002;42(6):835-42.
Adams WL, McIlvain HE, Geske JA, et al. Physicians’ Perspectives on Carring for Cognitively Impaired Elders. The Gerontologist. 2005;45(2):231-9.
Quality Concerns
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“suffering in spite of spending” “silo care” “no care zone” avoidable readmissions hospital acquired conditions the “hidden patient” frustration
What’s On the Table?
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Patient Centered Medical Home
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Bundled Payments
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Penalties for Re-hospitalizations
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“Accountable Care Organizations”
Chronic Care is Different
• • •
Engaging community Self-management support Advanced information systems/ tracking
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. Jama 2002;288(15):1909-14.
‘New Model’ Primary Care
• • • • •
Practice “Redesign” Team Approach Advanced Information Systems “Patient-Centered” “Healing Relationships”
14.
Martin JC, Avant RF, Bowman MA, et al. The Future of Family Medicine: a collaborative project of the family medicine community. Ann Fam Med 2004;2 Suppl 1:S3-32.
Patient-Centered Medical Home
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Whole-Person Team Based Accessible Advanced Information Systems NCQA Certification Process
Kellerman R, Kirk L. Principles of the patient-centered medical home. Am Fam Physician 2007;76(6):774-5.
The Case of Mrs. Jones
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82 year old woman, h/o HF and OOP “Tired and weak and swollen ankles x 5 days” Walker, Oxygen, Son’s Assistance
Bringing Home Medical Home?
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Highest risk patients may not be able to access offices
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Permanent
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During time of vulnerability Accessibility and whole person approach enhanced when care is done at home Scalability of team
Landers SH. The other Medical Home. Jama 2009;301(1):97-9.
“Secret Weapons”
Enhances view of patient and caregivers Reduces barriers to care Strengthens patient relationships Avoids hazards of hospitalization Costs less Desired more Enabling technology emerging
Workforce Estimates
• • • • •
Annual FFS MCR HHA Visits > 110,000,000 Medicare Home Health FTEs >250,000 Annual FFS MCR Physician Visits < 2,000,000 Home Care Physician and Mid Level FTE’s ?
Total Primary Care Physician FTEs ~270,000
Role for Home Health
Home health is likely the (only) truly scalable infrastructure for improving quality and access for the low-mobility, high risk Medicare beneficiaries who drive the majority of program expenditures and suffer the most---1 st step in impacting quality for this group may be conceptualizing home health as THE central architecture/ platform to deliver transitional, post-acute, and primary care/ chronic care management for these individuals
Programs that hold promise
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Transitional Care
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Multi-level targeting patients with the right provider at the right time House call programs
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Reserved for the frailest, most complex patients
Technology in the form of EMR/EHR and telehealth among others is not an absolute necessity, but has proven itself to be an excellent enabler to improve productivity, reduce costs and enhance outcomes.
A Role for Chronic Care Management
Adapted from, “The Glide Path” Kyle R. Allen, DO Medical Director, Post-Acute and Senior Services Summa Health System
Public Health Primary Care Acute Care Long-term Care
High
Health Capacity Normal Aging Accelerated Loss of Health Disability
Disease Management Chronic Care Management
Acute Event
Death
Time
Risk Factors
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Obesity Tobacco and
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alcohol Environmental
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Hypertension Rapid weight
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gain/loss Hyperglycemia
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Hip fracture Stroke CHF COPD
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Incontinence Dementia Caregiver burnout IADL/ADL decline Cumulative, inter-related risk factors require ongoing, coordinated care interventions.
Transitional Care
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Goal
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Ensuring a smooth transition for the patient from one site or level of care to another that meets goals of care Why?
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Limits of traditional disease and case management in preventing adverse events and unnecessary utilization/costs
Rates of Rehospitalization within 30 Days after Hospital Discharge Jencks SF et al. N Engl J Med 2009;360:1418-1428
Who to target?
• • • •
Community dwelling Admitted for ambulatory sensitive conditions, such as COPD, CHF, Diabetes, Pneumonia and Dementia Frequent flyers – two or more admissions in the past six months to one year Individuals currently enrolled in case management
Patient Factors Contributing to Poor Post-Discharge Outcomes • • • • • • • •
Multiple conditions/therapies* Functional deficits Emotional problems Poor general health behaviors Poor subjective health rating* Lack of support Cognitive impairment** Language, literacy and culture
Level I
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A health coaching model using RNs
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25 – 30 patients per coach
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Not a “doing” model Lowest-intensity, lowest-cost model Target thirty day duration Enroll patients who are able to be “coached” to effectively self-manage through the transition
Level I
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Five Principals
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Medication self-management
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Nutrition management
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Patient health record
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Physician follow-up
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Red flag awareness
Level I
Process
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Health coach visits while I/P
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Introduce the program and gain acceptance Prepare patient and family for follow-up Home visit
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One visit within 48 – 72 hours of discharge
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Structured
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Review the program in detail Environmental scan Medication reconciliation Review discharge instructions Introduce PHR Discuss physician follow-up Educate on red flags
Level I
Process
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Key follow-up phone calls
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2 – 3 calls as needed
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Ensures compliance and continuity Modify plan Plan to call after major post-acute events
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Physician visit
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Home health/therapy
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Change in Rx regimen Graduation
Level II
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Use RNs in a more active model of care RN must balance “coach” and “do”
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Patient capabilities
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Support systems More extended time frames up to 6 months Criteria are the same as Level I, but add
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Significant ADLs/IADLs
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Psycho-social concerns
Level II
Process
• • • •
Builds on Level I activities
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RN visits while I/P Initial home visit within 48 – 72 hours of discharge
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Key follow-up phone calls Coaches and provides care May need additional home visit(s) Graduation date can be extended based on situation
Level III
• • • • •
Highest level of intensity and care provision using NPs and/or PAs A hybrid model, but weighted more toward medical than nursing SNF-level patient able to remain community dwelling
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Geriatric syndromes
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ADLs/IADLs Polypharmacy Risk loss of functionality and/or exacerbation of chronic condition(s) Most likely to bridge “at-risk” period successfully with effective, coordinated care
Level III
Process
• • • •
Builds on concept of Levels I & II Initial visit within 48-72 hours of discharge from SNF or hospital Key follow-up phone call(s) Typical 30 days enrollment to graduation
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Back to office-based practice Enrollment in house call program
House Call Program
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Provide a patient-centered medical home to frail, low-mobility elderly Physician and NP serve as the patient’s in residence PCP
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Primary care house calls Urgent care visits Collaborate with hospitalists on IP care Coordinate specialty care, ancillaries and other health services, as needed Offer counseling and social service coordination for patient and family/caregivers
House Call Programs
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Typical profile
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Difficulty getting to/from the PCP office Have not seen PCP in 12 -18 months
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ED most likely access point for healthcare services 2+ deficiencies in ADLs Complicated, chronic medical conditions and polypharmacy not likely responsive to other programs Disruptive to PCP office flow
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Physical/facility issues
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Time and resource intensive Difficult to meet the full spectrum of patient’s needs
What are the outcomes?
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Community-based chronic illness management programs have demonstrated positive outcomes
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Reduced utilization
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Lower costs Improved outcomes
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Health
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Quality of life/Goals of care
Transitional Care
• • • •
Eric Coleman, MD Randomized controlled trial of a Level I program Outcomes
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Reduced readmissions Lower costs In use by over 135 health systems nationally
House Calls
Montefiore Medical Center
Results for Medicare Advantage Enrollees CMO HCP Patients Member Days Total Hospital Days Total Admits Hospital Admit PPPY Hospital Avg. LOS Total SNF Days Total SNF Admits SNF Admit PPPY SNF Avg. LOS
Pre-HCP
112 12,936 820.0
102.0
2.9
8.0
2,148.0
41.0
1.2
52.4
Initial Six Mos.
112 12,936 503.0
59.0
1.7
8.5
703.0
17.0
0.5
41.4
Absolute Change % Change
(317.0) (43.0) (1.2) 0.5
(1,445.0) (24.0) (0.7) (11.0) -38.7% -42.2% -42.2% 6.0% -67.3% -58.5% -58.5% -21.1%
How are these programs paid?
Managed Care/Payer Perspective
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The economic incentives are aligned and the programs produce positive ROI
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Montefiore
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Summa Health System
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Inspiris
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United
How are these programs paid?
Medicare FFS environment
• • •
Programs’ downstream benefits
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Capacity management
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Avoided admission
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Reduced ALOS
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Less pressure on ED Fewer re- admissions Increased market share Provider professional billings
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Partial contribution MDs, NP & PAs Community agencies
Cleveland Clinic
Center for Home Care and Community Rehab
Today: Gaining a beach head
• • •
System-wide recognition
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Oversight and Strategy Board
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Department of Home Care Physicians Services
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Mobile physician services
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Geriatric consults PCP
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Home care, hospice, home infusion, etc.
Expansion of MPS
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First to a specific CCF member hospital in development for 2010
Cleveland Clinic
Center for Home Care and Community Rehab
• • • •
The future: Strategic tool for CCF Seamless delivery and coordination of care
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Regardless of location
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Regardless of age/time in life Care transitions New roles for home care staff Use of telehealth and remote technologies
Transitional Care Resources
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Eric Coleman, MD
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www.caretransitions.org
National Transitions of Care Coalition
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www.NTOCC.org
Better Outcomes for Older adults through Safer Transitions (BOOST)
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www.hospitalmedicine.org/ResourceRoomR edesign/RR_CareTransitions/CT_Home.cfm
House Call Resources
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American Academy of Home Care Physicians
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www.aahcp.org
American Geriatrics Society
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http://www.americangeriatrics.org/pro ducts/positionpapers/housecall.shtml
Thank You
“The future belongs to those who believe in the beauty of their dreams”
- Eleanor Roosevelt