Multiple Chronic Conditions

Transcription

1 Managing Patients with Multiple Chronic Conditions Sponsored by AMGA and Merck & Co., Inc. 1 Group Pre-work Wenatchee Valley Medical Center Best Practices in Managing Patients with Multiple Chronic Conditions

2 2 Medical Group Profile Established in satellite sites 200 physicians and mid-level practitioners 24 different specialties 150,000 active patients 750,000 annual visits EPIC Electronic Medical Record Located in the center of Washington state with an agricultural/rural base that serves North Central Washington from Yakima to the Canadian border.

3 3 Team Composition Dr Rutherford CEO Medical Director of HB Richard Bennett RN Assistant Administation Casey Brown RN Manager Quality and Education Lori Smet MN RN CCM Case Manager Coordinator Lori Van Winkle RN CDE Case Manager Moses Lake Roxana Martin RN CDE Case Manager Omak Jill Milner MN CRRN Case Manager Kelly Morrow RN Case Manager Bernie Stanfield RN BSN Case Manager

4 4 Chronic Care Goals & Objectives Improve care for chronically ill patients enrolled in Medicare with DM, COPD, HF Intervene with exacerbations to prevent hospitalizations, ER visits Provide case management services Oversight for evidence based care Transition of care Referral to community resources Education of disease process and health coaching

5 Chronic Care Goals & Objectives Where are we now? Analysis of the first 3 years has been completed and published by Medicare Improved Mortality rate Reduction in all cause hospitalization Decreased growth of Medicare costs Next step is to expand this model of chronic care to other physician practices within the clinic.

6 Chronic Care Intervention & Population Baseline Patients were chosen with chronic disease (DM, COPD, HF) with HCC score (as scored by Medicare) > 2.0 Average age: 79 yrs Female: 47% Male 53% We have a Diabetic registry in place and now have a HF registry Development of model of care, outreach to engage patients, dissemination to physicians and staff, As this was separate from clinic staff and daily workflow there were no changes to practice initially 6

7 Chronic Care Intervention & Population Baseline Real time communications between case managers and physicians through our electronic medical record system and use of the record by case managers to keep up to date with current plan for patient and diagnostic data. Case managers were involved on daily basis with physicians and office staff as needed when patients were sent to the office Credibility that was developed over time with staff and physicians as a result of the ability to communicate with EMR, trend reports that gave data to the physician about patient progress or medication effect

8 8 Self Efficacy Patient receives ongoing feedback about their health behavior from the case manager and the telehealth device Patient learns about diagnosis from physician, case manager and telehealth device and takes ownership of diagnosis Patients begin to care about diagnosis Patient learns self management Patient learns accountability for self monitoring

9 Self Efficacy Health indicators (A1c) have shown improvement We have increased outpatient visits We have decreased 90 day readmission rates Improved mortality rates Show slower growth of Medicare costs Plan is to continue to monitor these rates Next target is to impact 30 day readmission rates.

10 10 Improvement Interventions Early identification of exacerbation Timely intervention by case manager with use of algorithms, education, escalate to MD as needed, psychosocial concerns, oversight for evidence based standards Improving access to healthcare with case manager contacts Relationships and credibility with patients and physicians

11 11 Measures Used Hedis guidelines were used for monitoring management Admission data: ED/OB and inpatient Mortality rates Data on utilization, mortality and costs came from Medicare. Not always accessible or timely except that we were a Demonstration Project. Data for Hedis measures is taken from the medical record and our billing records. Not always easily accessible.

12 Payment Reform There currently are no external incentives and physicians are on a production based reimbursement. In 2011 the salary model has changed include quality and outcome metrics. We anticipate changes in payment models for the future and we want to be prepared for that change whether that be Capitated Care, ACO, Pay for Performance or Medical Home Model. In the search for other reimbursement we plan to approach insurance providers with our model as well as apply for an innovation grant from CMS. 12

13 13 Challenges or Obstacles Outreach and enrollment Keeping patients engaged for the entire 3 years Physician buy in Medicare selection of population false positives Program Dialogue

14 14 Outcomes and Successes Psychosocial outcomes Social needs addressed Depression component recognized Behavioral Change Medication adherence Self management and use of preventative services Clinical and Health status Continuity between PCP and Specialist Outcomes specific to chronic conditions (labs,meds) Productivity, Satisfaction, Quality of Life Improved health status and function Satisfaction with program and healthcare Financial Outcomes Improved utilization with cost savings realized for patient, payer, and physician

15 15 Future Steps Expand case management within our clinic system to include other at risk populations Continue to investigate strategies to improve quality of life for patients, the quality of care that we provide and help control costs.

16 16 Lessons Learned Issues around engagement Outreach and enrollment Keeping patients engaged Develop a relationship with patients Patients move along a continuum of high and low risk and are not always in need of acute monitoring

17 17 Questions How do other groups deal with the enrollment and engagement issues? What other diagnoses are other groups actively dealing with? How are other groups doing risk stratification along a continuum to identify target members? Besides HEDIS measures what other metrics are being monitored? As we are all dealing with chronic disease issues the experiences that we bring to this collaborative can give us a perspective on best practices that might be applied in our own situations.