The Cleveland Super-Utilizer Project: Red Carpet Care
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1 The Cleveland Super-Utilizer Project: Red Carpet Care Alice Stollenwerk Petrulis, MD The MetroHealth System Cleveland, OH Bernadette Yohe, RN Buckeye Community Health Plan
2 Picture of MH
3 MetroHealth 750 bed facility includes rehab, SNF Link to Case Western Reserve School of Medicine 500 employed physicians Level l Trauma, burn center, spinal and rehab, regional LifeFlight, 100k visit-ed 53% of county s uninsured/ Medicaid
4 Background
5 IMPROVE Statewide Medicaid effort to decrease avoidable ED visits-2010 NEO: Non-mental health ultra-utilizers Care plans devised by MH Medical Director in cooperation with PCP, Case Managers at payor Care Plans in EMR (EPIC) Ready identification by ED
6 IMPROVE Payor case managers Assisted in making appointments Appointment reminders Arranged transportation Educate about medications Accompanied patients on visits Offer free pre programmed phones Monthly review of plans
7 IMPROVE Outcomes Decrease in ED visits at MH by 44% in a year Increased communication with payor Effective education of patients Coordinated patient care Reduction in nonclinical work for provider Development of patient self-management and responsible behavior Program continues into 3rd year.
8 An Important Lesson In a FFS environment: MetroHealth lost revenue due to decrease in ED visits and hospitalization Medicaid plans saved Going forward: Shared savings PMPM Payor-funded case managers
9 Methodology Partnered with: Medical Mutual of Ohio- commercial plan Buckeye Community Health Plan- Medicaid Innovative financial model: Payor funded APNs PMPM Shared savings
10 Steering Committee Data: Methodology Chaired by Randy Cebul. MD, Metro Epidemiologists from Metro Finance representation from each plan Intervention Chaired by Alice Petrulis, MD, Metro Representation from each health plan Case managers- medical and behavioral health
11 Methodology-cont d Lists of possible recruits Criteria: DM, HTN, HF High cost due to ED and hospitalizations Exclusion criteria CA ESRD Pregnancy Goal- 150 recruits 75 from each plan
12 Focus Groups 2 sets of patients identified from prior IMPROVE project Lunch/transportation Results Want to see same provider every time Desire for provider to like them and want to take care of them
13 APNs Methodology-cont d Two Prescriptive authority 2 different delivery models One as PCP One as case manager with other PCPs Sites Main campus- FP Urban satellite
14 EMR: EPIC Registry Tools Reminders about next appt Post discharge phone calls EMR alert if patient in ED or hospital Weekly meetings with CMs at plans Avoid duplication Journals- patients and APNs
15 Community Resources West Side Catholic Center University Settlement Providers of food, housing support, notaries, clothing, counseling
16 Tools Surveys- experience of care Phones for APN Avoid patient wait on call tree Phones for patients Criteria Relieved concern re minute limits Ready ID of call from APN Direct access to APN
17 Tools Notepad, pedometers, water bottles, pillboxes APN business cards Patient toolkit- bag, calendar with note pg
18 Activities of APNs Recruitment Success of ED and hospital visits Intake form Camden Coalition Depression screening Questions re education/literacy, legal issues Mobility, Transportation needs, food, pain Home visits
19 Activities, cont d Appt reminders Medication reconciliation Urgent phone calls Urgent visits Care plans in EPIC
20 Metrics Quality metrics DM, blood pressure, lipids, CA screen, immunization ED visits and hospitalization reduction Show rates Medication refills Surveys
21 Success and Testimonials Home visit aborted ED visit Interaction in ED prevented readmission Meds, shoes Cart Pulse oximeter Rehabilitated drug abuser Senior Advantage
22 Key to Success Collaboration with health plans Access to provider same provider Integration of BH and nutrition Group clinic availability Identification of all patient needs Housing Transportation Community resources
23 Questions
24 Thank you Contact information: MetroHealth: Alice Stollenwerk Petrulis, MD Buckeye Community Health Plan: Bernadette Yohe
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