UPMC & UPMC HEALTH PLAN. UPMC CENTER FOR WELLNESS For individuals with spina bifida and spinal cord injury

Transcription

1 Thursday, August 16, :00 PM-4:30 PM EDT UPMC & UPMC HEALTH PLAN Add your company logo here UPMC CENTER FOR WELLNESS For individuals with spina bifida and spinal cord injury Sponsored by AMGA and Merck & Co., Inc.

2 UPMC: integrated global health enterprise one of the leading nonprofit health systems 20 hospitals 400 doctors offices and outpatient sites long-term care facilities major health insurance services division (UPMC Health Plan) 2

3 UPMC Dept. of PM&R established in clinical sites 40 faculty (clinical and research) physiatrists (adult and pediatric), neuropsychologists and pain management specialties 23,000 annual outpatient visits EMR EpicCare 3

4 John Lovelace, President UPMC for You Brad E. Dicianno, MD, Director UPMC Adult Spina Bifida Clinic, UPP Physical Medicine and Rehabilitation Chris Fassinger, RN, Wellness Practitioner, UPMC Health Plan Debra Smyers, Sr. Director Program Development, UPMC Health Plan Melissa Halgas, Project Manager, UPMC Health Plan 4

5 Improved outcomes related to: Home and community function Psychological symptoms Medical complications Health care utilization ED visits, unplanned acute admissions and length of stay Unplanned medical expenses and overall cost of care Quality measures Program began Feb 2012 results will be evaluated following the end of year 1 5

6 Fits into strategic plan Specialty medical home Incorporation of patient advocates/care coordinators Quality metrics stress value of care rather than volume

7 Target Population: Primary diagnosis of spinabifida cystica, congenital spinal cord anomaly or spinal cord injury Age 18 or older Active member of UPMC Health Plan Live in one of the following Pennsylvania counties: Allegheny, Armstrong, Butler, Beaver, Washington, Westmoreland Active patient of the physician group or a new patient recently discharged from an inpatient rehabilitation unit. Exclusions: primary diagnosis of spinabifida occulta, history of severe mental illness requiring hospitalization, and/or currently living in a skilled nursing facility. 7

8 Collaborative approach to program development Project team included representatives from both a specialty provider group and a health insurance company. The team was comprised of a physician, clinical director, project manager and support staff Program planning milestones: Trained registered nurse to function as Wellness Practitioner Developed clinical algorithms and educational materials Developed data collection tools Determined modifications to work flow between UPMC Health Plan care management staff, physician practice staff and the new Wellness Practitioner. Trained staff 8

9 Enrollment: Population identified by physician group, however patient must agree to enroll into program. Patient registry of enrolled participants maintained in addition to patient performance along key measures. Intervention Add Wellness Practitioner role to existing physician visit/standard of care. Wellness Practitioner has at least four interactions with patient annually, practicing within 10 care modules. Identifies and addresses clinical needs and barriers. Collaborates with physicians (PCP and specialist) on treatment plan. Interactions can include office visits, home visits, and telephone calls. 9

10 Intervention (continued) Wellness Practitioner provides intervention Wellness Practitioner collaborates with hospital staff when patient is admitted. Follows up with patient to ensure optimal transition post-discharge. Wellness Practitioner supports patient as needed by providing education and acute clinical interventions. Goal is to avoid unplanned care emergency department visits and admissions for conditions that could be prevented*. *Preventable conditions for this population are defined as: pneumonia, post-surgical complications, septicemia, urinary tract infections, bone infections, pressure ulcers and other similar infections. 10

11 Module Quantitative Outcome Measure or screening tool Clinical Outcome Measure Bladder Management Bowel logs Incontinent episodes GFR Bowel Management Bladder logs Incontinent episodes Preventable Diagnoses (Utilization and cost) UTI bladder catheter infections sepsis - bladder infections Patient Education Skin Integrity Salzberg tool Incontinent episodes Wounds Sepsis - wounds Infective arthritis or osteo Behavioral Health Quality of Life and Functional Independence BDI-II CAGE DAST CHART-SF WHOQOL-BREF Hours performing self care Time lost from work/school Depression Knowledge Survey Body Mass Index BMI Obesity Medications and supplies Medication log Medication possession ratio General Health Maintenance Nutrition PACIC Routine PCP visits Pneumonia/Flu Surgical/Medical complications Nutrition contract Exercise Exercise contract Time spent exercising/wk 11

12 Outcome Measure Home and Community Function Physicaland cognitive independence, mobility, social integration, activity and employment outcomes Total paid and unpaid caregiver hours # hours spent doing own self-care Psychological symptoms Medical Complications Frequency of self-reported incontinent episodes BMI Time lost from work/school # of preventable conditions Data CollectionTool or Source CHART-SF 1 Internally developed assessment Beck Depression Inventory II 2 Internally developed assessment 12

13 Outcome Measure Health Care Utilization Emergency department utilization Inpatient utilization Medication possession ratio Expenditures by financial categories Quality Measures Lifesatisfaction environment, physical health, psychological, social Receipt of services that are patient-centered, proactive and planned KnowledgeAssessment exercise, behavioral health, bladder, bowel, nutrition, BMI, health care, QOL and function, skin integrity, medications Data CollectionTool or Source UPMC Health Plan claims data WHOQOL-BREF 3 PACIC 4 Internally developed assessment 13

14 Established a gain share incentive program for patients, sharing savings with the program or patients Legal issues with direct patient incentives are challenging 14

15 Identification of a financial model to support fixed program costs (e.g., educational materials, administrative support). Administrative management of program through health insurance company opened the door for additional regulatory limitations (e.g., state/federal approval of patient communication/educational materials). Collaboration across organizations required formal business agreements and delineation of responsibilities. Recruitment of CRNP 15

16 40/120 enrolled Collaboration across organizations allowed for significant stakeholder involvement in a program well-suited to participant needs. Patients are eager to take part in this new initiative. Nominated for an award at the Annual Best Practices Compendium held by Medicaid Health Plans of America 16

17 Planning to incorporate telemedicine delivery of the program Addition of other diagnoses and care algorithms 17

18 Fundamental to success: Good Project management Choice of skill set for Wellness Practitioner Social work support Unique collaboration between Payer and Providers 18

19 Is anyone integrating social work as a key component of their model?