September, James Misak, M.D. Linda Stokes, MSPH The MetroHealth System

Transcription

1 Better Health Greater Cleveland relies on the presenter to obtain all rights to use and display copyright-protected information. Anyone claiming a right or interest in or to any posted information should contact Better Health immediately by calling Serving the Uninsured Population in Cuyahoga County Using a Patient-Centered Medical Home Model of Care Including Nurse Care Coordination September, 2012 James Misak, M.D. Linda Stokes, MSPH The MetroHealth System

2 Disclosure Presenters reported no financial interest relevant to this presentation

3 Objectives Review implementation of PCMH for Partners In Care including Care Coordination targeted topics Discuss patient utilization trends Discuss patient health outcomes

4 Partners in Care: MetroHealth s Patient-Centered Medical Home for the Uninsured Patient-Centered Medical Home model adopted in primary care Initiated in 2009 Encourage patients to establish permanent relationship with a primary care provider for continuity of care and to coordinate other care needs Partners in Care - program serving the uninsured population Patient-Centered Medical Home including on-site care coordinators Reduce episodic, acute care episodes Establish continuity of care for chronic disease patients Improve health outcomes in the uninsured population Reduce the cost to serve the uninsured population

5 Joint Principles of the Patient-Centered Medical Home Personal physician each patient has an ongoing relationship with a personal physician Physician directed medical practice - physician leads a team of individuals who collectively care for the patient Whole person orientation - taking responsibility for arranging for care from other providers for all stages of life Care is coordinated and/or integrated - assuring that patients get the indicated care when and where they need it Quality and safety hallmarks of the practice model Enhanced access with options such as open scheduling and new methods of communicating with patients Payment reform recognizing the added value provided to patients Reference: tmp/022107medicalhome.pdf

6 Team-based Care Team Roles Patient owns the care plan and seeks care through medical home RN / LPN Attending Physician Resident Physician (Optional) Care Coordinator is a new role held by an RN, who helps the patients navigate the system and/or manage chronic illnesses based on knowledge of their needs Attending Physician manages the team and focus on the more complex cases APN serves patients without physician intervention Care Coordinator Patient PSR RNs fully leverage their capability to deliver care and education and delegate admin tasks MTAs deliver care assistance and education MTA APN Social Worker Social Worker is tightly integrated into the care team, participating in chart reviews PSR engages Care Coordinator for higherrisk patients and for some appointment decisions Resident Physicians part of some teams

7 Care Coordination: Components Care Navigation Directing, educating and optimizing use of appropriate care setting, including Emergency Room Disease Management Proactive outreach to identified populations: Diabetes, Hypertension, Heart Failure & High Risk Case Management Continuous review and support of treatment plan adherence Assessment, planning, educating and evaluating progress

8 Patient Registry in EPIC

9 Tracking Cases in EPIC Tapestry

10 Tracking Patient Progress in Epic Tapestry

11 Partners in Care Population 2011 Demographics Total population size is 15,703 patients. Age: Majority of population is between 25 and 64. Gender: There are more females than males in the Partners In Care population.

12 Partners in Care Utilization 2010 Partners in Care utilization for 2010 used a patient comparison group defined based on similar demographics and primary care service sites. Higher utilization of primary care and specialty care outpatient services Lower utilization of emergency department and inpatient services Encounter Volume Encounter Volume Encounters per 1000 patients 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1, Primary Care Specialty Care Encounters per 1000 patients Inpatient Emergency Partners in Care Comparison Group Partners in Care Comparison Group 12

13 Partners in Care Utilization Comparison The rate of encounters decreased in 2011 for enrolled patients. Care Coordinators targeted ED usage for reduction in 2011 and saw a 14% decrease. Partners In Care Encounters (Rate per 1000) Partners In Care Encounters (Rate per 1000) IP ED OP-S 2289 OP-P

14 Partners in Care Cost Comparison PMPM overall cost decreased in 2011 for enrolled patients. Location of Care 2011 (vs. 2010) Outpatient Primary Outpatient - Specialty Emergency Room Inpatient Decreased Decreased Steady Decreased

15 Partners in Care Health Outcomes Partners in Care - Hypertension 54.2% 55.6% 60.0% 40.0% 20.0% 0.0% BP at Target (<140/90) 2010 (n=2097) 2011 (n=3216) Slight improvement in percent of Hypertensive patients with BP at Target.

16 Partners in Care Health Outcomes Partners in Care - Diabetes 80.0% 70.0% 73.5% 60.0% 40.0% 44.2% 44.4% 44.0% 37.3% 20.0% 0.0% HBA1c at Target (<9) BP at Target (<140/80) 2010 (n=2077) 2011 (n=1879) LDL at Target (<=100) Slight improvement in percent of Diabetic patients with HbA1c at Target.

17 Advancing the Model to Insured Populations at MetroHealth Preparing to expand Care Coordination model to Medicaid, Medicare and other insured patient populations Significant workforce expansion requires thorough and detailed workflow definition and procedures Information systems enhancements needed to expand the model beyond the pilot solution Additional management oversight to monitor workloads and flex staffing assignments for efficient operations

18 Thank You Questions?