Accountable Community of Health. Billie Lynn Allard MS, RN Administrative Director of Nursing for Community Health & Putnam Medical Group

Transcription

1 Accountable Community of Health Billie Lynn Allard MS, RN Administrative Director of Nursing for Community Health & Putnam Medical Group

2 Sout hwester n Vermont Healthcare ME NY VT NH MA SVMC FAST FACTS Vermont 75,000 3 Dependent High 2nd oldest state Total Service Area States Ser ved (VT, NY, MA) Medicare Medicaid Population

3 The Medical Home is a model in which individuals receive accessible, continuous, and comprehensive care. The Medical Home provides the individual preventive and disease care, over a period of time and coordinates all of the care delivered. Individuals are actively engaged in the decisions and planning of their health care. Active PCMH = 128 Unique Providers = 783 Community Health Team Staff = FTEs

4 Population Health in Bennington... WHY County health ranked 12 th out of 14 28% of adults are obese Adult Obesity Rate in Vermont % diagnosed with diabetes 25% are regular smokers 35% of moms smoked during pregnancy Obesity on the rise 18% had at least one tooth removed Drinking water contamination in three communities 38% higher teen pregnancy rate than across Vermont

5 OneCare Vermont and Medicaid Contract OneCare Ver mont- statewide Accountable Care Organization (ACO) Launched by UVM and Dartmouth-Hitchcock Health System Most VT hospitals are participants SVMC has been in up-side risk only, shared savings plans for 4 years SVMC agreed to Medicaid capitated payment for 2018 Si ngl e payment amount for the whole year regardless of whether the member seeks a lot of care or a little care

6 Shift in the Location of Services Inpatient & Obser vation Admissions Primar y Care Visits

7 Mary D. Naylor, PhD, RN, FAAN

8 Village Primary Care Full Spectrum of Health Care Services (Including Pediatrics, Adolescent, And Adult Medicine) 8

9 Support for Primary Care Providers

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11 Safe transition to home from hospital

12 Individual Choice Meani ngful Goal Setting Identifying Soci al Needs Meeting patients where they are S

13 Who really Controls Outcomes? 100 Patient/Family The majority of health care occurs at the low-acuity end of the scale, where outcomes are controlled not by physicians or the system but by the everyday choices of individuals and families. The largest opportunity clinical staff have to influence health outcomes is to influence choices by partnering over time. Control 0 Low Acuity The System High Source: Gottlieb, Sylvester and Eby. Transforming Your Practice: What Matters Most. Family Practice Management. January 2008.

14 Social Determinants Drive Health... HOW Majority of spending is focused on Health Care 10% 4% 15% Most influential driver of health status is Behavioral Patterns 40% Contributions to Premature Death 30% Social Circumstances Genetic Predisposition Behavioral Patterns Health Care Environmental Exposure

15 Population Health is a Paradigm Shift Patient Person Medical Services Population Health Hierarchy Partnerships

16 Transitional Care Visit Difference Days Number of vi sits % less ED visits 6 months after TCN inter vention % l ess I NPT/ OBS visits 6 months after TCN inter vention ED Visits I NPT/OBS Admi ssi ons Visit Type 6 Months Pr e TCN I nter venti on 6 Months Post TCN Intervention N = 787

17 Reduced i npati ent/obser vati on vi si ts 49.7%

18 Integrated Social Work Lack of insurance/coverage Inability to pay for basic necessities (ex. medications) Homeless/safe housing Psychosocial support (connect with community resources) Substance abuse or mental illness Advance Directives

19 Working with the CFO Fee for Service Value Based

20 How we paid for it... Sour ce Funding Cardinal Health Grant $50,000 for Clinical Pharmacist Pilot Vermont Health Care Innovation Project $400,000 for TCN, CCT, & INTERACT Magnet Prize $50,000 from the Cerner Corporation Community Benefit Expenditures Uncompensated Care Investment in the future from health system value based payment model preparation

21 Reduced emer gency depar tment vi si ts by 44%

22 Community Care Team Targeted patients frequenting the Emergency Department with substance use and mental health disorders Health promotion advocate is stationed in the ED to meet with clients and develop a relationship Monthly meeting with community partners & agencies to create integrated care plans Emergency Department Visits Emergency Department Vi si ts 44% less ED visits 6 months after CCT inter vention 6 Months Pre-Intervention 6 Months Post-Intervention N = 46

23 I mpr ovi ng chr oni c di sease management

24 Maslow s Hi er ar chy of Needs Transcendence Sel f - Actualization Aesthetic Needs Cognitive Needs Ready to Learn Esteem Needs Belongi ngness & Love Needs Where Most Patients Are Safety Needs Biological & Physiological Needs

25 Standardized Education Interdisciplinar y team Refrigerator magnets for easy access COPD & CHF Action Plans Providers sign off Shared wi t h: Primary Care Providers Home Care Agencies SNF s Hospital Pill boxes, scales, journals

26 Empowering patients to manage their medications

27 Clinical Pharmacist Program Pilot in one office Stationed in hospital Education for patients on high risk meds Goals: Reduce poly-pharmacy by de-prescribing Find lower cost alternatives Improve knowledge about medications Increase medication compliance Home Health Primar y Care Sub Acute Care Hospi tal Care

28 Medication Therapy Management 1,187 patients documented to have face to face time with Clinical Pharmacists since 2014 Patients Identified on High Alert Medications by MTM Average face to face time spent with patient is 20 minutes Pharmacist education accepted 91.7% of the time (N = 1170) 44.2% 55.8% High Alert Medication Non-High Alert Medication N = 807

29 Interdisciplinary Team Dai ly rounds & Interdisciplinary discharge planning for all hospitali zed pati ents

30 Reduced our SNF s readmi ssi on r ate by 15.5%

31 Reducing 30-Day Readmissions from SNF s All Payer, All Cause 30-Day Readmission Rate Long-Term Care 30-Day Readmission Rate 14.0% 14.0% 12.0% 10.0% 13.3% 11.2% 12.0% 10.0% 12.1% 8.0% 8.0% 6.0% 6.0% 4.0% 4.0% 5.0% 2.0% 2.0% 0.0% 0.0% Pre-INTERACT Post-I NTERACT Pre-INTERACT Post-I NTERACT

32 Reducing All Payer, All Cause Readmission Rate 25 Pre-implementation 20 Post-implementation Corporate Goal 5 0 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17

33 Pulmonary Rehabilitation Goal: Improve quality of life, ability to manage illness & health status, and restore patient to highest functional ability 71% of participants completed the program Individuals who stayed in the Maintenance Program had a 0% readmission rate for the 3 months after graduation. Readmission Rate (%) Day Readmission Rate Hospital Wide COPD Cohort Hospital Wide COPD Cohort 2.56 Pulmonary Rehab COPD Cohort Pulmonary Rehab COPD Cohort N = 77

34 Measuring Improvements 63.6% Improvement with dyspnea 67.3% 65.5% 67.3% Improved quality of life Improvement in functional ability to walk 10 meters Improvement in functional ability to walk for 6 minutes

35 Reduced average A1C by 15.7%

36 Integrated Diabetes Education Hemoglobin A1C Average A1C Pre I ntervention 5.5 Post I ntervention 15.7% reduction in average A1C after Integrated Diabetes Education N = 63

37 Physical Therapy assessments in the ED to increase access to care

38 Physical Therap ist in ED 163 patient encounters from October 2016 February minutes spent on average with each patient while in the ED 49.7% of patients evaluated left with independent home exercises (17.8%) or a recommendation for outpatient physical therapy (30.1%) 88.4% of patients surveyed reported very good when asked what their overall experience was with the physical therapist

39 Bennington Community Collaborative Building a Healthy Bennington BENNINGTON COLLEGE

40 Food Insecurity Grateful Heart Project Healthcare Shares Meals on Wheels voucher Leftovers to Food Pantr y Summer Meal Program VT Food Bank drop site SVMC Campus garden Food donated to the TCN Program

41 Mission to enhance community health while revitalizing the downtown region Renovating distressed or vacant homes and facilitating home ownership SV M C is a key sponsor of this program and is dedicated to providing opportunities for families

42 Healthcare System of the Future Focus on Population Health: Bennington Redevelopment SVMC is lead investor in $40M downtown revitalization project SV M C Wound Care Restaurants SV M C Dialysis Market Independent and Assisted Living 42

43 EPODE (Prevenous I obesite des enfants) Epode-international-network.com

44 Opportunity Costs 1 Emergency Department visit 1 months rent 2 hospitalizations 1 year of child care 20 MRIs 1 social worker for a year 60 echocardiograms 1 public school teach for a year

45 80% Health Behaviors Physical Environment Social & Economic Factors 20% Clinical Care

46 Meeting the Quadruple Aim Source:

47 Partnership is Powerful Longitudinal Care Delivery Wellness Curriculum in Schools Patient Centered Discharge Plan Smoking Cessation Counseling Transportation System Integrated Care Planning Partnership is Powerful

48 Contact Information Billie Lynn Allard, MS, RN Administrative Director of Nursing for Community Health & Putnam Medical Group