Transcript Patient-Centered Medical Home at the CHDs

Presented to Florida Hospital Association Webinar
February 18, 2010
By
Wally Plosky, Program Director HERAP
Duval County Health Department
HERAP Focus

Uninsured and low income populations.
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Patients without a family physician.
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Patients requiring case and disease
management assistance (for diabetes,
cardiovascular, pulmonary and other chronic
conditions).
Patients who have trouble filling
prescriptions.
Zip codes with high hospital use for
Ambulatory Care Sensitive conditions.
HERAP Components

Coordination of hospital ER and inpatient referrals.
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Primary care medical homes.
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Multi-disciplinary disease management services.
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Free walk-in medical condition management
centers (MCMCs).
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Neighborhood community living rooms (CLRs).
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Medication assistance program (MAP).
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Expanded clinic hours – evenings and Saturdays.
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Stanford Medical School’s Chronic Disease Self
Management Program (CDSMP) - Living Healthy.
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Regional health information exchange (JHIN).
HERAP Staffing
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RN disease managers
Financial eligibility specialists
Clinical pharmacologists/pharmacists
Registered dietitians/certified diabetic
educators
Health educators
Mental health counselors
Patient navigators
2009 HERAP Accomplishments
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Received 2,697 client referrals from hospitals and
community partners.
Connected 70% of hospital-referred patients with
medical homes in the community.
Reduced emergency room utilization of HERAP-enrolled
clients by 55.4%.
Reduced hospitalization of HERAP-enrolled clients by
89.8%.
Coordinated with hospitals to recoup over $1M in
billable Medicaid dollars.
Helped hospitals in accessing over $75,000 in billable
Medicaid under the Medically Needy Share of Cost
program.
2009 HERAP Accomplishments (cont’d)
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Submitted 264 medication assistance applications totaling
$83,841.
Provided chronic disease management services for an
average of 200 patients monthly
Conducted three 6-week Stanford Medical School Chronic
Disease Self Management Programs (CDSMP), graduating
30 participants
Held 28 CLR outreach events, attended by 1007
participants, resulting in 227 HERAP enrollments
Implemented innovative technology to streamline financial
eligibility for hospital-referred clients needing access to
medical homes within 72 hours
Provided office space and IT support for the Duval County
WE CARE program and a volunteer Project Dentists Care
Key HERAP Partners
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Baptist Health (BMC – Baptist South)
Memorial Hospital (HCA)
St. Vincent’s Medical Center (includes St.
Luke’s)
Jacksonville Health Information Network
(JHIN)
DCHD Institute for Public Health
Informatics and Research (IPHIR)
Agape Community Health Center Network
(Co-Applicant public entity FQHC with
DCHD)
WE CARE, Inc.
HERAP Referral Sources
Hospitals/
ERs
Community
partners
Volunteers in
Medicine
Community
physicians
Self referral
Agape CHC
Network
We Care
HERAP
DCHD
programs
Community
outreach
I M Sulzbacher
HERAP Referrals by ZIP Codes
>40
30-39
24-29
10-23
<10
Duval County HERAP Cost
Effectiveness Review

Objectives

Evaluate the impact of HERAP’s comprehensive
multi-disciplinary disease management and medical
home program on:
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Emergency room utilization
In-patient hospital admissions/stays
Evaluate the effectiveness of a health information
exchange in monitoring HERAP effectiveness
(Jacksonville Health Information Network – JHIN)
Measure the effectiveness of a multi-hospital
partnership model with individual hospital-specific
program elements
Duval County HERAP Impact Analysis

Methods/Procedures

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Data set stratification
 521 uninsured patients formally enrolled in
HERAP’s disease management program with
at least one emergency room visit or one inpatient admission
 January 1, 2009 – September 30, 2009
“Before and after” utilization rate comparison
 Time bounded: 180 days immediately prior to
and following HERAP admission
Duval County
Hospital Emergency Room Alternatives
Program (HERAP) Impact Analysis
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Emergency room visits
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Reduction: 55.5%
Projected six month savings:
 $176,490
Hospital in-patient admissions
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Reduction: 89.8%
Projected six month savings:
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$4,324,260
Resources Our Partner Hospitals
Want for Their Discharged Patients
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Assistance with non-compliant clients.
Primary care medical home.
Prescription access.
Chronic disease care and case
management.
Knowledge of available community
resources and how to connect clients to
those resources.
Dental access.
Behavioral health and substance abuse
services.
HERAP Contact Information
Hospital Emergency Room Alternatives Program
Duval County Health Department MC-92
900 University Blvd. N., Suite 202
Jacksonville, FL 32211
Tel: (904) 253-1444
Fax: (904) 745-3005
http://www.dchd.net/herap.htm
Wallace B. Plosky, MBA, Program Administrator
[email protected]
Brenda Bernardez, MSN, Project Director
[email protected]