Congestive Heart Failure (CHF) Improvement

Transcription

1 Congestive Heart Failure (CHF) Improvement December 3, 2015 Beth Averbeck, MD Senior Medical Director, HPMG Primary Care

2 HealthPartners Health Plan 1.5 million members Medical Clinics 1,700 physicians 50 primary care locations 55+ medical specialties Dental Clinics 70 dentists across 22 clinics 6 dental specialties Hospitals 6 hospitals Level 1 trauma and tertiary center Acute care hospitals Critical access hospitals Consumer-governed, non-profit Integrated health and financing 22,500 team members

3 Overview CHF Improvement 1 Improvement Approach 2 Outpatient Model 3 Care Coordination 4 End of Life Care 5 Successes/Barriers

4 Improvement Approach: Engaging stakeholders Capacity assessment Stay patient focused Leadership sponsored Project managed Engage physicians and other members of the care team in design Design for good enough Make it easy to do the right thing

5 Improvement Approach: Structure and Process Expert Panel Cross-sectional Hospital/primary care/cardiology Pilot in 3 clinics Spread to all Redesign based on successes and barriers

6 Outpatient Model: Care Model Process Before The Visit During the Visit After the Visit Between Visits Visit Scheduling Pre-visit Planning Check-in Visit Follow-up Between Visits Reception Insurance verification Check-in Scheduling Message triage Forms CMA/LPN Registry Message triage LPN standing orders Test results Immunization RN s Phone triage Protocol driven care Warfarin management Medication refill Abnormal test triage Care Coordination Action Plan Physician / Clinician Leader of care team Diagnosis and treatment Engaging patients in their care Directing members of care team Care plans

7 CHF EHR Support Practice alerts ECHO Labs for monitoring Problem list Diagnoses Care plan Action plan

8 CHF Measures Ambulatory ACE/ARB use Patient education Ventricular function Advanced directives

9 Care Coordination Consistent approach across clinics & hospitals: Identify those most at risk Proactive outreach Care Plans Shared visits (MD & RN) Access for mental health Link to health plan and community resources % of Population 9% % of Total Healthcare Expense 1% 29% 39% 20% 70% 21% 11% Data Source: Thomson Reuters Market Scan Database National Sample of 21 million insured Americans,

10 Care Coordination Activities Transitional Care Social Workers Careline Hospice Primary Care Discharge Care Coordinators Nurse Educators Specialty Care Community Resources Hospitals Medication Therapy Management Pharmacist Emergency Room Inpatient Case Management Home Care Behavioral Health Disease & Case Management

11 Care Coordination: Identify, stratify, support Configured a predictive model leveraging our integrated capabilities to identify and stratify 1. Electronic Health Record (EHR) data is the sole input into the model 2. Electronic Health Record (EHR) data is supplemented with the claims data EHR predicts risk and supplemented for more complete picture by claims data when available Severity of condition (labs, assessments, etc.) Social history Problem List Diagnoses Prescriptions Surgical and procedure history Tier

12 Tier 4 patient registry example Name/ Age/ Gender Hospitalization Risk Last Hospitalization Case Manager? Next Primary Care Visit John Smith 45 M Paula Brown 87 F Sally Adams 63 F 12/30/2014 Yes 4/8/2015 1/15/2015 No 2/15/2015 2/23/2014 Yes 5/2/2015

13 Care Plans & Action Plans Plan of care Includes the full scope of patient centered care including the action plan and care plan. Care Plan Patient specific strategies designed to guide health care professionals involved with the patient s care. Includes brief pertinent history and recommendations/goals for care Action Plan A written plan that contains patient centered/driven goals, specific tasks or actions to be completed, timelines, identifies resources and builds on successes

14 Plan of Care example Date: 4/14/15 Signed: J.Smith, MD Care Coordination Contact Name Phone Number Role in Care Comments HealthPartners Brooklyn Center Clinic Sherry Johnson, RN & Dr. Smith Assessing symptoms and concerns Monday-Friday 8am- 5pm HealthPartners Careline RN-Triage Nurse Assessing symptoms and concerns Complex Case Management James Brown, RN Supporting patient in their home After hours and on weekends Benefit & self management Care Plan: He will weigh himself daily and if weight is up by over 5 lbs should take an added 40 mg of Lasix Action Plan Raymond will work on a low salt diet and weigh himself daily and call if weight is up over 5 pounds Patient Instructions Raymond will follow the low salt, low fat and cholesterol diet Raymond will take his medication as prescribed Follow-up Sherry will follow-up with Raymond by phone by June 2015

15 Care Coordination Examples Primary Care and Specialty Care Co-management (CHF clinic and primary care) Hotline for urgent Non-urgent e-opinion Urgent Care and ED to Primary Care Scheduled orders for follow-up Pro-active outreach to patients Home to Hospital Physician notified of admission Hospital or TCU to Home RN outreach Firefighters/paramedics

16 Linked RN Visit 20 Minutes 20 Minutes 20 Minutes Patient and Nurse: Pre-Assessment Initial history Patient and Physician: Diagnosis Care Plan Patient and Nurse: Close the loop Action Plan Link to resources Modeled after The Everett Clinic

17 Fire Department/Paramedic Partnerships Home visit the day after hospital discharge. Key elements of the visit: Physical exam Vital signs Home safety/food security evaluation Patient education Physician orders Resource referrals Medication checks and reconciliation

18 Medication Reconciliation

19 End of Life Care Shared Committees: Hospital Long-Term Care Specialty Primary Care Advanced Care Planning Advanced directives Honoring Choices MN ( Provider orders for life sustaining treatment (POLST) Palliative Care Hospice Measurement (advance directives): Primary care, Hospital, Cardiology, Nephrology, Pulmonary, Oncology

20 Honoring Choices (MN) Shared development and updating of educational materials - Multicultural and interpreter best practices - Sharing background, content, learnings (and videos) Support for Honoring Choices Minnesota (HCM) to receive state grant funding Community collaboration - National Healthcare Decisions Day (NHDD) events - Support Honoring Choices Minnesota s (HCM) First Annual Run/Walk Provide yearly data for Honoring Choices Minnesota (HCM) collectively; ongoing resource to HCM for questions from developing programs

21 Successes/Barriers Successes: Cross functional improvement teams Test small, spread fast Those doing the work design the work Transparent measurement Barriers: Coordinating the coordinators Comfort with end of life discussions EHR capability Documenting CHF class/stage

22 Questions & Discussion