5/5/2014. A National Best Practice Overview May Lauran Hardin MSN, RN CNL
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1 A National Best Practice Overview May 2014 Lauran Hardin MSN, RN CNL Disclosure Lauran Hardin I have no financial relationships with commercial interests with products or services relevant to today s presentation. I will not be discussing unapproved or investigational uses of products or devices. 1
2 The Situation Robert Wood Johnson Foundation reports 5% of the population uses nearly half of total healthcare spending ( topic areas/health policy/health carecosts/healthcarecostsfastfacts.html Recent analysis identifies High frequency Patients or Super Utilizers who they are is poorly understood Successful Population Health strategies include management of these high cost patients Shift in Payment Strategy Old Model=VOLUME New Model=VALUE Rewards Unit Cost (FFS) Minimal focus on care efficiency and patient centeredness Limited alignment with quality Care delivered based on preference Silos of Care Rewards for Volume Rewards health outcomes and population health (GPS) Focus on decreased cost and improved patient experience Alignment with quality & safety Consistent Evidence based practice Integrated networks of care Rewards for Value 4 2
3 Our Challenge The Burning Platform and Nobile Mission Young Man Complex Medical Disease Gastroparesis Substance Dependence In a PCMH High frequency: 10 ED visits, 8 IP admissions, 65 day LOS in 12 months Outcomes Trust and Engagement Shared Plan Cross Continuum Evidence Based Intervention Tools for patient, family and staff 2 ED, 2 Inpatient admissions 8 day LOS in 12 months 3
4 Who are the High Frequency Patients? Definition Dr. Jeffrey Brenner Executive Director/Medical Director, Camden Coalition of Healthcare Providers, MacArthur Genius Award Super Utilizer = Patients who accumulate large numbers of ED visits and hospital admissions which might have been prevented by relatively inexpensive early interventions and primary care. (Brenner, 2013; Mann, 2013 CMMS) 8 4
5 A Population View Source: Healthcare Risk Adjustment and Predictive Modeling by Ian Duncan 9 Risk Stratification Playbook for Population Health, The Advisory Board Company 5
6 6
7 What is root cause of high frequency access? 7
8 Patient with COPD and Kidney Disease with Insurance Transition Coordinator Pulmonology Equipment Company Dialysis Nurse Navigator PCMH/ Complex Care Mgr Hospital Homecare CM Insurance CM Patient with COPD and Diabetes and no Insurance: ED = PCP Community Agencies ED=PCP Equipment Company 8
9 Significant Root Cause Issues Psychiatric Illness Substance Use Disorder Alcohol, Prescription Drugs Homelessness Access Cultural Preference Domestic Violence/Abuse/Trauma Electronic Health Record Challenges System Competency Challenges 17 5/5/2014 Mental Health and Substance Use Disorder 8.9 Million persons have co occurring disorders Only 7.4 percent of individuals receive treatment for both conditions with 55.8 percent receiving no treatment at all. Untreated mental illness and substance use disorders lead to more deaths than traffic accidents, HIV/AIDS, and breast cancer combined Centers for Medicare and Medicaid Services (CMS) data show nearly one in four people with mental or substance use disorders lack health insurance. For those with both mental illness and substance use issues the figure is 30 percent 18 (SAMHSA retrieved January 7, 2014 from occurring/topics/data/disorders.aspx) 9
10 National Best Practice Camden Coalition of Healthcare Providers Bending the Cost Curve Founder of Hot Spotting Community Coalition Community HIE Care Intervention Teams Train Camden Residents to participate in decision making over healthcare resources Community Transformation Research and Training Center Dr Jeffrey Brenner Executive Director/Medical Director, Camden Coalition of Healthcare Providers, MacArthur Genius Award 10
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13 For a Wealth of Information sitelearning/resources/care intervetions/ 13
14 Health Quality Partners The Fountain of Youth Dr Advance Preventive Care Home Based Nurse Case Management Evidence Based Intervention Frail Medicare Patients Ken Coburn MD MPH President Health Quality Partners 10 Year RCT Death Rate decreased 24% Hospitalization decreased 33% Cost decreased 22% For More Information Ezra Klein Article
15 Center for Integrative Medicine Ambulatory ICU R. Corey Waller MD, MS, FACEP, ABAM Director, Center for Integrative Medicine Medical Staff Chief, Division of Pain Management Comprehensive Bio Psycho Social Model Clinic MD/PA/MSW >10 ED Visits for >2 years Follow for 6 9 months and transition to PCP Pregnant Substance Dependent patients and Super Utilizers Spectrum Health has shown a 3.2 million year over year decrease in charges for patients seen in CIM For More Information how.htm?doc_id= Waller.pdf 15
16 Complex Care Portal Rapid Cycle Care Transformation Lauran Hardin MSN, RN CNL Director Complex Care Portal Program Population Analysis, risk stratification and financial modeling for CIN Expert Intervention Center Mentor/Potentiate Existing Resources Build Infrastructure in system Embed Evidence Based Tools Build Community Partnerships Portal Structure 2.0 RN FTEs Virtual Team built around the patient with all other disciplines >700 patients served in one year 5 10 new patients added weekly Significant reduction in ED/UC, Inpatient/Observation admissions, LOS Quality/Safety works whether patient engages or not Entry Criteria: Complex = high frequency, extended LOS, complicated issues 16
17 Seeing Beyond the Acute Episode of Care (Aggregate Patient Story/Stock Photo) Young 30 year old Woman Chronic Pain & Dependent on legally prescribed Narcotics (overuse) Pregnant and Hiding it from Providers Accessing multiple EDs for narcotics Multiple CT Scans Outcome Cross Continuum/ED Plan of Care Decreased Overtesting Referral to Comprehensive Clinic 33 5/5/2014 Meeting the Needs of Vulnerable Populations (Aggregate Patient Story/Stock Photo) Male 48 years old Alcoholism and Substance Use Disorder Significant Psychiatric Issues Fragile life circumstances Lives with a friend Outcome Safe plan for patient and staff Link to CPI techniques Reminder to see the whole person 34 5/5/
18 Coordinating Across Systems (Aggregate Patient Story/Stock Photo) Female 78 years old Dementia with Agitation Lives in Long Term Care Frequent UTIs Outcome Safe plan for patient and staff Evidence Based Pathway Cross Continuum Agency Collaboration 35 5/5/2014 Maine Quality Counts Collaborative Community Care Helena Peterson RN, MPH, CPHQ Program Manager, Community Care Teams Maine Quality Counts 16 Association Dr, P.O. Box 16 Manchester, ME (cell) (fax) For More Information: ycounts.org/ 18
19 Community Care Teams Multi disciplinary, community based, practiceintegrated care teams Build on successful models (NC, VT, NJ) Support patients & practices in Pilot sites, helping patients overcome barriers to care, improve outcomes Receive PMPM payments from Medicaid, Medicare, commercial payers Key element of cost reduction strategy, targeting high cost patients to reduce avoidable costs (ED use, admits) Maine PCMH Pilot Community Care Teams Environment Schools Transportation Workplace Housing Care Mgt Outpatient Services Family Food Systems High need Individual PCMH Practice Med Mgt Specialists Shopping Coaching Income Behav. Health & Sub Abuse Hospital Services Heat Faith Community Literacy Physical Therapy 38 19
20 Maine Community Care Team Referral Process Alignment of CM Resources (Pre-referral) Identify Patients & Respond Engage Patients CCT Interventions - Graduation CCT develops report capacity: portals, hospital data, HIN CCT identifies patient from data Pt referred to CCT CCT develops workflows & comm systems w/cm resources & practices Practice aware of CCT & other CM options Practice enables EHR access for CCT. Practice identifies point person to make CM referrals Payer/ external CM identifies pt Practice identifies pt Yes CM accepts pt Meets criteri a? Other appropriat e CM? Notify practice Notify pt No No Yes Engage pt: face to face, call or letter Notify practice Outreach successful? No 1st pass, 2 nd pass & disch letter Yes No, plateau or lost to followup Meet pt Set goals, expectations, disch plan Home visit Further visits/referrals: health educator, telehealth, transportation, hospice etc) Goals met? Yes Discharge Graduate DRAFT H. Peterson 01/22/2014 Notify practice Monitor utilization Additional Resources Southcentral Foundation Nuka Model of Care Community Centered, Team Based Model Anchorage, Alaska Nuka_Model_of_Care_Provides_Career_Growth_for_Frontline_Staff.pdf Commonwealth Care Alliance Model of care for Dual Eligible Patients Boston, Massachusetts program/our model of care Project RED (re engineered discharge ) 20
21 Roles in an Interdisciplinary Team Interdisciplinary Team Physician Case Manager MSW Pharmacist Psychiatrist Community Health Worker/Health Coach Resource Coordinator Financial Services Support 21
22 Key Functions Chronic Disease/Medical Management Medication Reconciliation Care Transitions Navigation Health Promotion & Education Mental Health/Trauma Informed Care Access to Resources Preventive Care Shared Plan Cross Systems Building Trust Next Steps in Hot Spotting 22
23 Promising Practices Research and Core Competency Development Open Source Development Telemedicine Group Visits Same Day Appointments/Call Center Approach PCMH and Practice Redesign Paramedicine Trauma Informed Care For More Information Lauran Hardin MSN, RN CNL Complex Care CNL Mercy Health Saint Mary s 200 Jefferson SE Grand Rapids MI lauran@octoberday.com hardinlj@mercyhealth.com 23
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