Transcript Hospital-Medical Home Demonstration Weill Cornell Chiefs

The Affordable Care Act is Transforming
Health Care in our Community:
The Washington Heights-Inwood Regional Health
Collaborative
18th Annual NHMA Conference
J. Emilio Carrillo MD, MPH
March 29, 2014
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NYP Regional Health Collaborative
DRAFT
Health Reform is transforming the
care we provide patients in the
Washington Heights-Inwood
Community
Goals
 Provide Better Care
 Measurably Improve Health
 Contain and Reduce Costs
WHI Regional Health Collaborative
Community Health Needs
Assessment
NYP
Columbia
VNSNY
NYSPI
(WH)
Community
MDs
ISABELLA
HEBREW
Columbia
Doctors
HOME
Outcomes Evaluation
4
Setting the Framework:
Washington Heights-Inwood Demographics
Population: 205,000
Foreign Born: >50% born outside US
Poverty Level: 31%
Education: Residents aged 25 and older have
completed fewer years of education than NYC
overall
Race / Ethnicity:
71% Hispanic
14% Black
11% White
2% Asian
2% Other
Setting the Framework: Insurance
Gaps in NYC
Map represents children in NYC community
districts who are “EPHINE”: “Eligible
for Public Health Insurance but NOT
Enrolled
Washington Heights / Inwood is among the
worst according to this measure
Nov 24 2009
Setting the Framework: Detailed Health Needs Assessment of our Community
 Overall Health: 1/3 adults consider themselves to be in poor health
 PCP: 1/3 adults have no PCP
 Insurance: 1 in 3 adults is uninsured or had no insurance year before
 Heart Disease: hospitalization rate has increased
 Obesity: 1 in 5 adults is obese
 Diabetes: 11% of adults have diabetes
 Mental Health: more than 1 in 20 adults suffer from depression
 Asthma: hospitalization rates higher than NYC overall
Pediatric Asthma
National prevalence 8%
Local prevalence 18%-22%
Leading chronic illness in children
Health disparities in minority populations
NHLBI 2007 Guidelines –
– Control and risk
The NYP Patient Centered Medical Home: The Centerpiece of the
Washington Heights Regional Health Collaborative
Team Based
Care
IT Tools for
Patient Care
and
Population
Health
Targeted Care
Management
Cultural
Competency
and
Community
Health
Workers
Diabetes, Asthma, Heart Failure, Depression, COPD, Children Special Health Needs
Care Management and Redesign
Before – Silos
After – Care Team
Transitions of Care Initiative
Supporting the Patients after they leave the Hospital
Engagement of the Patient
with a Medical Home
Comprehensive Discharge
Planning and Education
Disease Registries
Care Management
Beginning on Day of Admission
IT Enabled
Ambulatory Care begins
Cultural Competency
Patient
Management of
Transitions of Care
Emergency Department-to-Home
Hospital-to-Home
The Team
Weekly Interdisciplinary Meeting, Daily Huddles
PFA (Patient Financial Analyst– NYP Title)
- Front desk Registrar; greets and
signs- out all patients.
- Provides visit tallies ahead of time to
Nurses and Providers
-Participate in Pre-Visit Planning Process
and discussion.
Medical Assistant (MA)
-Participates in Pre-Visit Planning
Process and discussion
-Document Pre-Visit Planning on
Flowsheet
-Execute traditional MA clinical functions
Physician
Primary Nurse
RN Care Manager
Community Health Worker
(CHW)
- Peer to peer outreach, education and
support that includes home visits
- Focused on Diabetes and Pediatric Asthma
- Subcontracted position from collaborating
Community Based Organizations.
Diabetes Educators
- AADE based curriculum, certification
- Dietitians, nurses, or pharmacists
- 1:1 Assessments and follow up visits
- Group classes
- Refer patients to PCMH supporting
programs
PCMH October 2010 Cohort: 2-Year Results
• Reduced Emergency Department Utilization by 23.8%
• Reduced Inpatient Admissions by 18.0%
• Reduced 30-Day Readmission by 23.3%
• Length of Stay reduced by 13.6%
• Lowered Hemoglobin A1C Levels (0.32; 3.96%) n= 2,795
n = 5,857
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Outcome Measures
2009
2012
Percent
Change
Patients with
asthma
2000
3539
+77%
MS-CHONY
Admissions
70
52
- 57%
MS-CHONY
ED visits
200
156
-60%
Targeted Care Intervention - TCI
• Study is based on 580 patients (TCI=290; Control=290) who have been in care
management for at least 3 months. (all payers)
• Admissions reduced by 63%
• ED utilization reduced by 35%
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NYS Medicaid “Health Home”
•
Care management service model across a continuum of medical,
behavioral care and social services.
•
Health Home services are provided through a network of organizations –
providers, health plans and CBOs. (26 Collaborators with MOUs)
•
The care manager oversees and coordinates access to the services and
promotes communication among providers.
•
Health records are shared among providers so that services are not
duplicated or neglected.
•
Aim to reduce ED, Admissions and improve health outcomes and patient
experience
NYP Health Home Network
* Care Management Agencies for Health Home Provider Contract
AIDS Service Center of NY*
AIDS Service Center Queens
Assn for Rehab Case Management (BH and
Hsg)*
Bailey House (COBRA HIV)
Brooklyn AIDS Task Force
Coram Healthcare
CUCS (BH)
FEGS
Hebrew Home*
Iris House (Social Services and Housing)
Isabella Geriatric Center*
LGBT Community Center
Little Sisters of Assumption Family Health
Svce
Manhattan Psychiatric Center*
Metropolitan Center for Mental Health
National Alliance on Mental Illness
Narco Freedom*
NYPI - Washington Hts Community Service Unit
Palladia (Substance Abuse, BH, Hsg)*
Postgraduate Center for Mental Health*
Project Renewal
Puerto Rican Family Institute*
Realization Center
Salvation Army
Upper Manhattan Mental Health Center*
Village Care*
Hospital-Medical Home Demonstration
•
Transform outpatient continuity
training sites to high quality
Patient Centered Medical Homes
•
Improve the level of integrated,
coordinated, and culturally
appropriate care in the
participating outpatient settings
•
Extend/expand the continuity
training experience for their
primary care residents
•
Implement inpatient safety
improvements
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The Patient Centered Medical Home and Medical Village
Targeted Care Intervention
PCMH Patients in Registries
(Diabetes, Asthma, CHF, Depression,
Complex and High Risk)
21,000
NYP Ambulatory Care
population
120,000
240,000
All Washington Heights & Inwood
Community
NYP Regional Health Collaborative
Medical Village
Health Information Exchange
and Exchange
Collaboration
Care Providers
Integration
& Coordination
of in the Region
J. Emilio Carrillo MD, MPH
Community-basedPrograms
Programsand
andServices
Services
Community-based
Targeted Care
Management
– Care Transitions
Transitions
of Care
Initiative (TCI)
Patient Centered Medical Homes
Population Health
Infrastructure / Capability
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