Navigating the Care Gap

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1 Navigating the Care Gap O C T O B E R Melissa Walls, RN Director of Disease Management West Tennessee Healthcare

2 Learning Outcomes Ways to decrease readmission rates Decrease unnecessary ED utilization Evidence based multi-disciplinary clinics

3 Challenge Multiple rural hospital closures Poor access to primary care Inpatient capacity strain and ED overutilization Disproportionately high rates of patients with chronic disease Excessive readmissions

4 TN Department of Health- Hospital Closures all within primary/secondary market: Gibson General Hospital 2014 Humboldt General Hospital 2014-(converted to ED) Haywood Park Community Hospital 2014 Methodist Healthcare-Fayette Hospital 2015 McNairy Regional Hospital 2016 Inpatient capacity strain led to the opening of two new acute care floors in the flagship hospital site Average 105,000 ED visits/year 28,000 inpatient discharges per year *>30% of all patients have diagnosis of Diabetes

5 Program Goals Teach patients how to manage chronic diseases to reduce morbidity and mortality (and improve quality of life) Reduce unnecessary ED visits and hospitalizations, especially for safety net population Improve coordination of care after hospital discharge, especially between primary care, specialists Decrease readmission rates in CHF, Diabetes, and COPD Expand access to primary care and behavioral health Address social determinants of health by assisting with social needs (transportation, affordable meds, etc.)

6 Timeline of System Efforts 2011 CHF QIT 2012 Diabetes Intercept 2013 LIFT Wellness Center 2014 Disease Management (CHF/DM) 2015 Disease Management (COPD)

7 Jackson Madison County General Hospital-West Tennessee Healthcare Lift Wellness Center-downtown Jackson

8 Workflow Process Discharge from acute care/ed Algorithmic management based on disease severity & goals Deficiencies/ gaps in care management Callback in 24 hrs or direct mailer Active engagement for 12 months Physician follow-up Multidisciplinary clinic visit (preferred initial contact) Scheduled clinic visits or remote management (phone/text) Outcomes tracking compliance, HEDIS, utilization

9 Sample Questions

10 Multi-Disciplinary Approach Registered Nurse Pharmacist Dietitian Social Worker Respiratory Therapist Nurse Practitioner Behavioral Health Counselor A nurse-directed, multidisciplinary intervention can improve quality of life and reduce hospital use and medical costs for elderly patients with congestive heart failure (Rich, et. al., The New England Journal of Medicine, 1995).

11 CareGap Consumer Path Participant Identification Evaluation Stratification Communication/ Evaluation Stratification Claims Data Health Risk Assessment Clinician Enters Patient Data Into CIMS Enrollment Maintenance: Clinic every 8-12 weeks Low Risk: Clinic every 4-6 weeks Survey Questions: Understanding Disease & Physician Orders Pharmacy Consult Transportation Logistics Nutrition/Exercise Lifestyle Choices Testing Supplies Glucose/HbA1c BP, Cholesterol & Weight Activities of Daily Living Treatments/Procedures Maintenance: Clinic every 12 weeks Low Risk: Clinic every 6 weeks Community/ Self-Referral Discharge Assessment Coaching Moderate Risk: Clinic every 2-4 weeks Work Queue: Foot Exam Eye Exam PCP/Specialist Visits Medications Educational Classes Next Clinic Visit Meet with Social Worker Diagnostic Tests Moderate Risk: Clinic every 4 weeks PCP Referral High Risk: Clinic every 1-2 weeks Notifications: Reminders Follow-up Surveys Educational Materials Physician Communication High Risk: Clinic every 2 weeks 6 months

12 Community Partnerships INTERNAL Medical Clinic of Jackson primary care Dispensary of Hope pharmacy Medical Center Lab/Quest bloodwork monitoring LIFT Wellness medical fitness* Pathways HealthLink* MCMP diabetic shoes* MCHH chronic disease home health visits* EXTERNAL Dr. Brian Sellers (Walmart), Lions Club, MidSouth Retina Associates eye exams and glasses West TN Regional Health Department dental exams Wound clinic diabetic wound care Area Relief Ministries & RIFA food boxes and utilities support *generates downstream revenue

13 Deficiencies Management Gaps in Care Patient outcomes, including: Glycemic control: HbA1c, blood glucose Micro- or macro-vascular complications: nephropathy, retinopathy, neuropathy, cardiovascular diseases, amputations Cardiovascular risk factors: weight, cholesterol, triglycerides, albumin, serum creatinine, blood pressure, BMI Hospital admissions Mortality (Renders, et. al., Diabetes Care, 2001)

14 Patient Education

15 Program Volumes CY16 Callbacks/Consults Diabetes 4,729 CHF 8,429 COPD/Asthma 8,324 Clinic/Face-to-Face Visits Diabetes 1,502 CHF 500 COPD/Asthma 414

16 Staff Mix RN case managers (3 FTE) Disease-specific RN s (2 FTE) Social worker (1 FTE) CRS (3 FTE) Pharmacist Respiratory therapist Certified diabetes educator Dietitian Family nurse practitioner Interpreter Behavioral health specialist FY17 budget Personnel costs $850,000 Administrative costs $225,000 TOTAL EXPENSES $1,075,000

17 Outcomes

18 Readmissions and Cost Savings CY16

19 Effective chronic illness interventions generally rely on multidisciplinary care teams -Edward Wagner, BMJ: British Medical Journal, 2000

20 References Cheung, Paul T., et al. "National Study of Barriers to Timely Primary Care and Emergency Department Utilization Among Medicaid Beneficiaries." Annals of Emergency Medicine 60.1 (2012): 4-10.e2. Renders, Carry, et al. "Interventions to Improve the Management of Diabetes in Primary Care, Outpatient and Community Settings: A Systematic Review." Diabetes care (2001): Wagner, Edward H. The Role of Patient Care Teams in Chronic Disease Management. BMJ : British Medical Journal (2000): Rich, Michael W., et al. "A Multidisciplinary Intervention to Prevent the Readmission of Elderly Patients with Congestive Heart Failure." The New England Journal of Medicine (1995):

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