Transcript Slide 1

Reducing Readmits Using
Patient
Navigation!
“Welcome to the Real World”
About MedStar…
• Governmental authority serving Ft. Worth and 14 Cities
o 880,000 residents
o Exclusive provider for all emergency and non
emergency EMS
• 110,000 responses annually
• 375 employees
• Medical Control from 14 member physician medical board
o Physician Medical Directors from all emergency
departments in service area + Tarrant County Medical
Society
Global Issues
• Today, 40 million people > 65
o 70 million in next 20 years
• 2010 20,000 docs short
o By 2025 = 140,000 to 214,000 short
• By 2015, 33% of hospital payments will be
based on patient satisfaction (PPACA)
• EMS controls 25% of downstream health
expenditures
• 50% of health expenditures occur in last 2
years of life
Global Issues
• Catalyst for Payment Reform (Yes, CPR)
o Coalition of employers (Walmart, Intel, GE for
example)
o Pushing for value oriented payments to
providers (20% by 2020)
o Aetna – Now paying the same for c-section or
vaginal birth – eliminate incentive for c-section
(H&HN)
o $1,250 for screening colonoscopies – regardless
of in or out of the hospital (H&HN)
Global Issues
• AHRQ = 1% of patients accounting for 1/5 of
healthcare expenditures (H&HN)
o There are 4.6 million Medicare beneficiaries with
CHF (AHRQ)
o One CHF admission cost CMS $17,500 (AHRQ)
o 30-day readmission rate for CHF = 24.7% (AHRQ)
o 52% of CHF patients readmitted within 30 days did
not see their doc between discharge and readmit
(NEJM)
• MedPAC = $12 billion CMS expenditures for
PPR
Emergency
Medical
Services?
Unscheduled
Medical
Services!
Current State of Unscheduled Care
• 9-1-1 safety net access for non-urgent healthcare
o 32.8% of 9-1-1 requests are non-emergent/non-urgent
• May 2012 Priority 3 calls
• Problems with uncontrolled and unmanaged access
o Emergency department the source of primary care
Current State of Unscheduled Care
• Incentivized to use the highest cost transport to
highest cost care setting
o And it’s the easiest…
o Same with hospital admissions
Current State of Unscheduled Care
• Reasons people use emergency services
o To see if they needed to
o It’s what we’ve taught them to do
o Because their doctors tell them to
o It’s the only option
• Many patients using ED have payer source…
Frequent Users of Emergency Departments:
The Myths, the Data, and the Policy Implications
Results
Frequent users comprise 4.5% to 8% of all ED patients but account for 21%
to 28% of all visits. Most frequent ED users are white and insured; public
insurance is overrepresented. Age is bimodal, with peaks in the group aged
25 to 44 years and older than 65 years. On average, these patients have
higher acuity complaints and are at greater risk for hospitalization than
occasional ED users. However, the opposite may be true of the highestfrequency ED users. Frequent users are also heavy users of other parts of
the health care system. Only a minority of frequent ED users remain in this
group long term.
Why is this important?
Annals of Emergency Medicine
Volume 56, Issue 1 , Pages 42-48, July 2010
New EMS Role!
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Right Resource
Right Time
Right Patient
Right Outcome
Programmatic Solutions
• Community Health Program
o “EMS Loyalty Program” members enrolled
• Proactive home visits
o Educated on health care and alternate resources
o Enrolled in available programs
o Flagged in computer-aided dispatch system
• Co-response on 9-1-1 calls
• Ambulance and CHP medic
o Non-Compliant enrollees moved to “system abuser”
status
• No home visits – transport may be denied by Medical
Director in consult with on-scene CHP medic
CHP Program Outcomes
• For patients with 12 month data pre and post
enrollment as of August 31, 2012…
o During enrollment
• 52.2% reduction in 9-1-1 use to the emergency
department
o Post Graduation
• 76.3% reduction in 9-1-1 use to the emergency
department
Programmatic Solutions
• CHF Program
o At-Risk for readmission
• As referred by cardiac case managers
o Routine home visits
• In-home education!
• Overall assessment, vital signs, weights, ‘environment’ check,
baseline 12L ECG
• Feedback to primary care physician (PCP)
o Non-emergency access number for episodic care
o Decompensating?
• Refer to PCP early
• In-home diuresis
Initial Assessment of Health Status
Patient/Provider Satisfaction
CHF Program Outcomes
• Admissions avoided:
o Patient-specific data provided by local hospitals
• For patients with 12 month data pre and post
enrollment (23 patients)
o 44 admissions prevented (46.8%)
• 94 admissions pre-enrollment and 50 post-enrollment
o Ambulance transports to ED avoided as of August 31, 2012:
• 44.1% reduction during enrollment
• 55.9% reduction post graduation
CHF Program:
Economic Results
Congestive Heart Failure
Average charge and cost for an inpatient stay for Congestive Heart Failure.
Discharge Dates between 10/01/2010 and 09/30/2011
X Y Z Health Network
The following ICD9 Codes were used to identify Congestive Heart Failure:
HEART FAILURE
428.*
Average Charge - $56,919.87
Cost
56,919.87
18,214.36
44 Admissions Prevented:
44 X $57,000 (Average Charge) =
$2,500,000 in Savings
Programmatic Solutions
• Hospice revocation avoidance
o Enroll patients “at risk” for revocation
o Visit at home
• Counsel – instruct – 10 digit access
o “Register” patient in CAD
• Co-respond with a “9-1-1” call
• Help family through process awaiting hospice RN
Hospice Program Outcomes
• 12 patients enrolled
• 1 family called 9-1-1
o Intervened prior to transport
o Still transported based on nature of illness
• 9 patients successful in the end
• 3 still enrolled
CHF Medicare Specific Savings
• Fort Worth Hospitals
o 12 Medicare patients with one 1 year pre and post
enrollment data
• Payments for EMS Transports
 126 fewer ambulance trips
 $66,241 CMS payment savings
• Hospital Admits
 6 fewer in-patient admissions (-33.3%)
• 9% increase in outpatient visits
 $111,726 in savings
• $177,967 Total payment savings
o $14,831 Medicare cost savings per patient
What about November 2012?
Observation Challenge
Study: Hospital 23 Hour Observation Stays
Increase 34 Percent In 2 Years
“Using Medicare enrollment and claims data nationwide, we
documented a rising trend in the prevalence and duration of
hospital observation services in the fee-for-service Medicare
population during 2007–09…
… the ratio of observation stays to inpatient admissions
increased 34 percent, from an average of 86.9 observation stay
events per 1,000 inpatient admissions per month in 2007 to
116.6 in 2009.”
Feng, Wright, and Mor: Sharp Rise In Medicare Enrollees Being Held In Hospitals For Observation Raises
Concerns About Causes And Consequences Health Aff June 2012 31:61251-1259
Programmatic Solutions
• ’23 hour observation’ Avoidance
o Partnership with IPA/ACO
o ED Physician identifies eligible patient
• Refer to MedStar Community Health Program
• Non-emergency contact number for episodic care given to
patient
o In-home care coordination with referring physician
o Assure attendance at PCP follow-up next business day
o Initiated August 1, 2012
• 5 patients enrolled
• No return ED visits prior to PCP appointment
Additional Resources
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http://www.medstar911.org/community-health-program
http://www.communityparamedic.org/
http://www.ircp.info/
http://www.hrsa.gov/ruralhealth/pdf/paramedicevaltool.pdf
http://www.wecadems.com/cp.html
http://www.dhhs.ne.gov/Documents/CommunityParamedicineReport
.pdf
• http://www.nytimes.com/2011/09/19/us/community-paramedicsseek-to-prevent-emergencies-too.html
Opportunities in Your System?