Harvard Pilgrim Health Care Quality Grant Harvard Vanguard Medical Associates, Pediatrics Roster Review of our Medically Complex Patients Presentation to the Medical Directors Meeting, HPHC March 18, 2015 1
Our Team Central Pediatrics Dan Slater, MD Specialty Director Madeleine St. Denis, NP Nurse Leader Lani Evans, Specialty Administrator Elizabeth Driscoll Chelmsford Pediatrics Laura Lee, MD Sally Faggella, RN Claudia Scott, Care Facilitator Quincy Pediatrics Mike Whitner, MD Annette Grace, NP Kari Szumylo, Care Facilitator Care Improvement Laura Plum Case Management Denise Boure, RN John Dockrey, RN BSN 2
Roster Review of our Medically Complex Patients Proposal: Implement a new care facilitator role in our primary care departments to provide proactive highly integrated care Develop a multi-disciplinary roster review session focused on the needs of a cohort of medically complex patients. Inclusion: Medically or psychosocially complex patients identified by the Primary care team based on the presence of any of multiple dimensions: complex chronic disease, multiple specialist involvement, significant disability, time and/or resource intensive families, psychiatrically complex families. Roster includes 1300 patients roughly 1.4 % of HVMA Pediatrics Patients cross all Payers and all sites 3
High Risk Patient Strategic Model The Community Insurers Case Management Family School & Religious Institutions Ancillaries Skilled Nursing: - VNA, ECF Therapies : - OT, PT, Speech, ABA DME DCF Medically Complex Patient Specialists Hospital PCP Team Care Facilitator Dashboard Management Social Worker Assigned CM Assessment CM Enrolled BH Contact Roster Review Care Plan
Roster Review of Medically Complex Patients Roster Activities Prioritization Medical Need Cost Prevention Well Child Care With All Appropriate Screenings Immunizations WIC Integration Coordinate Specialty Care Referral Management Adherence Support Medication Reconciliation Clarify Problem List Identify and Assist in Overcoming Family Barriers Advocacy Identify & Address Family Goals Enhance Community Partnerships Close the Loop Develop Action Steps Ongoing Follow up with Family 5
Roster Review of our Medically Complex Patients Goals/Outcome Metrics Triple Aim Plus 1 Patient Experience Improvements Measurably Better Quality of Care Well Child Completion Rates ER & Admission Rates Enhanced care plans Decreased Cost of Care Staff Experience 6
Patient Experience Baseline Survey Data Thinking about the care your child has received from Harvard Vanguard s pediatric department over the past 12 months, please rate your experience in each of the following areas using a scale of very poor to very good. *16% response rate to 299 surveys sent Chelmsford + Quincy Combined Very poor Poor Fair Good Very good Response Count* Our sensitivity to you/your child s needs 0 0 1 (2.1%) 5 (10.6%) 41 (87.2%) 47 How well our office followed up on care and connected with you between visits (e.g., phone consultation, e-mail communication, outreach reminders) 1 (2.1%) 0 2 (4.2%) 16 (34.0%) 28 (59.6%) 47 How well the staff worked together to care for your child Concern the provider showed for your/your child s questions or worries Likelihood of your recommending your child s pediatrician to others 0 0 1 (2.2%) 11 (23.9%) 34 (73.9%) 46 0 0 0 6 (13.0%) 40 (87.0%) 46 0 0 0 8 (17.0%) 39 (83.0%) 47 answered question 47 skipped question 0 7
Patient & Staff Experience Claudia Scott, Care Facilitator, Chelmsford (Click Below to Play Video) 8
% Completed % Completed Quality Outcomes Well Child Visits: 3-6 Years 100.0 98.0 96.0 94.0 92.0 90.0 88.0 86.0 84.0 82.0 Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Goal 91.0 91.0 91.0 91.0 91.0 91.0 91.0 91.0 91.0 91.0 91.0 91.0 HVMA 90.1 89.5 89.4 89.2 89.1 89.4 89.5 89.7 90.2 90.4 90.6 91.2 CHE 89.3 88.5 88.9 87.6 86.5 86.8 86.0 85.7 86.5 87.3 88.1 89.5 Well Child Visits: 3-6 Years 100.0 98.0 96.0 94.0 92.0 90.0 88.0 86.0 84.0 82.0 Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Goal 91.0 91.0 91.0 91.0 91.0 91.0 91.0 91.0 91.0 91.0 91.0 91.0 HVMA 90.1 89.5 89.4 89.2 89.1 89.4 89.5 89.7 90.2 90.4 90.6 91.2 QCY 89.9 87.5 86.5 87.7 89.0 89.0 89.2 89.8 90.5 90.1 90.4 92.0 9
Quality Kari Szumylo, Care Facilitator, Quincy Since start date of 8/18/20, there have been 28 Medically complex roster reviews. As a result, we were able to: Make 6 referrals to a Payer based asthma program. This program provides advanced education, identifies home triggers and in some cases supports home improvements such as new carpeting, air purifiers, and in one case a new vacuum. Change durable medical equipment providers in 3 cases to preferred vendors, saving the company about $200/month/pt. Bring 4 patients pharmacy care in house. Create a plan for 3 patients that have a history of no shows both at HVMA and specialty visits. To date, 2 of those 3 have not missed a visit since their roster review. Collaborate with BH on a case connecting the patient s behavior and her medical condition. We have enhanced our relationship with our BH department supporting more timely consultation. Arrange an in-home behavioral health care team for a family that experienced a very traumatic event. The younger 2 of 4 siblings have autism and asthma. The family s utilization of the ER this year over last for asthma is less than half. I touch base with this family weekly to make sure they are all doing well. 10
Quality Kari Szumylo, Care Facilitator, Quincy Connect a patient with Trisomy 21 to therapies inside and outside the school setting. Refer the family to resources and support/play groups for other Trisomy children. Assist the family in obtaining SSDI benefits. This mother had made a comment to me that she felt like she fell through the cracks of the Harvard Vanguard System. After intervening, she thanked me during our next conversation and said that we have restored her faith in the Harvard Vanguard System. Collaborate with the Nurse Case Manager and the Social Worker to help families with getting housing issues resolved. Work with the Mass. Commission for the blind to get a legally blind child in to a horseback riding program. Collaborate with Early Intervention to make sure that a patient has an adequate plan for transition in to the public school. Touch 6 patients or more a day. Touches range from phone calls to roster review prep, to completing roster review action items and to face to face encounters. Appreciate that the patients and their families are thankful and relieved that they have someone they can call to help them when they feel like they can t help themselves. 11
Financial Impact Change in Risk Dollars for Subsets of MCP Cohort Jan 20 - Jan 2015 3 month claims lag in effect (Dollar values redacted for web posting) Chelmsford Jan- Jan-15 Change (%) risk pts 102 136 33 risk dollars XXXXXXX YYYYYYY -4 risk dollars/pt XXXXXXX YYYYYYY -28 all pts 175 218 25 all dollars XXXXXXX YYYYYYYY -1 all dollars/pt XXXXXXX YYYYYYYY -21 hphc pts 18 21 17 hphc dollars XXXXXXX YYYYYYY -15 hphc dollars/pt XXXXXXX YYYYYYY -27 Quincy Jan- Jan-15 Change (%) risk pts 54 85 57 risk dollars XXXXXX YYYYYYY 50 risk dollars/pt XXXXXX YYYYYYY -5 all pts 98 124 27 all dollars XXXXXX YYYYYYY 55 all dollars/pt XXXXXX YYYYYYY 22 hphc pts 10 9-10 hphc dollars XXXXXX YYYYYYY -15 hphc dollars/pt XXXXXX YYYYYYY -5 12
Thank You & I look forward to taking questions 13