BreakThrough Care Center: A New Care Model for High Risk Patients Dr. Richard Krouse Dr. Paul Merrick
About DMG Why Population Health About BreakThrough Care Center Patient Stories Questions?
About DuPage Medical Group Physician owned and directed multi-specialty group Committed to preserving physician independence Established in 1999 (from groups practicing since the 60s) 425+ Physicians; ~2,850 employees $500+ million Revenue 53 Specialties; 60+ Sites 530,000 Active patients; locations in 4 counties Predominant Physician Group at 4 area hospitals On Epic since 1999 (EMR: 2006; MyChart: 2010) Formed Illinois Health Partners with Edward-Elmhurst Healthcare: improve quality, efficiency and access in the region
About DuPage Medical Group Recruit and equip the best doctors Provide physicians the ability to leverage their influence and opportunity Physician directed Professionally managed
Foundational Principles Doctor directed Professionally managed CARE values Patient Experience QEA
Our Growth Revenues Physicians Employee FTE Encounters
Innovations Access - SDA - AHC - Immediate Care Centers - Telemedicine e-visits, video visits and online scheduling - BreakThrough Care Centers - Central scheduling/shared services
Quality Initiatives - Improving LOS and readmission rates - Generic utilization - Integrated Oncology Program - High Risk Breast Clinic - The Spine Center - Hospitalist program
Do the right thing, at the right time Pricing/Utilization/Quality
Challenges Enrollment Physician engagement Growing (MA) Financing Easiest part is clinical performance
Ms. G 60 year old Presented on 1/22/15 with debilitating back and lower leg pain Lumbar fusion in April 2014 went to several physicians and clinic locations, had extensive work up Reviewed all of her charts and noted that her pain was inconsistent with L4/L5 neuropathy with S1 sparing MRI of spine showed screws loose in her lumbar spine, pushing into disc space Saw DMG Spine surgeon for revision surgery and removal of hardware In a few weeks she was walking without pain or walker
Mr. H 96 year old, WW2 Veteran Presented on 2/2/15 after being driven here by his family from a skilled nursing facility in Florida Thorough medical record review and exam, determined extensive fluid overload, minimal ability to walk for weeks prior Administered IV diuretics and noted improvement; admitted to hospital for daily IV diuretics in coordination with DMG hospitalist more than 25 lbs. of fluid removed Had a nephrotic range proteinuria with over 9 grams of protein in a 24 hr. period Now walking, living with family here, feels better than he has in over 6 months I jump out of bed now with an extra spark
Current Healthcare Reality
Why Population Health? 15% of patients drive 85% of the costs in the healthcare system These patients experience poor and inappropriate access to care, the wrong level of care and duplication of services The sickest/most frail patients are unable to access the healthcare system appropriately, costing it money and contributing to a decline in their health Aging baby boomer population - As of 2011, 10,000 baby boomers enter retirement each day This will continue for most of the next two decades By 2030, when all baby boomers have reached 65, 18% of the nation will be a least that age
Why Medicare Advantage All major IL carriers are in this space More providers in the area are NOT going to accept assignment
Medicare Advantage Growth Actual The Congressional Budget Office is projecting a 50% increase in Medicare Advantage enrollment between 2013 and 2023
Why Medicare Advantage/Risk? Declining reimbursements from CMS Poor clinical outcomes Fragmented Care Poor patient experience Poor physician experience
Risk Opportunities 1% sickest patients consume 22% of all Medicare dollars 5% = 50% 15% = 80%
The Importance of Risk Medicare is a $900 billion industry Medicare estimates 30% is waste inappropriate access to care duplication of tests unnecessary procedures/tests fragmented care/communication across the medical landscape
Current delivery of care Office-based with inadequate resources Void between the primary care office and the next level of care - the Emergency Room
DMG approach In our communities, we have filled the void with: After Hours Care 4 sites open 6-10 pm nightly and on weekends Immediate Care Centers Handles most medical issues not requiring the resources of an ER BreakThrough Care Centers
DMG approach DMG has 60+ clinics across a four county area in suburban Chicago with a population of over one million people ~500,000 unique patients 425+ physicians To take on Risk across such an expanse is a daunting task.
DMG approach Models using Case Managers have not been very successful in managing this population PCMH models focusing on disease states (diabetes, chf, etc) have mixed results due to the fact the additional co-morbidities and complexities of these patients are not addressed, thus resulting in fragmented care
DMG approach Instead of reengineering care at all 60 clinics we took our lead from the fact that the sickest 15% of Medicare patients consume 80% of all the dollars Toward Increased Adoption of Complex Care Management Clemens S. Hong, M.D., M.P.H., Melinda K. Abrams, M.S., and Timothy G. Ferris, M.D., M.P.H. N Engl J Med 2014; 371:491-493August 7, 2014DOI: 10.1056/NEJMp1401755
Our Infrastructure DMG has built an infrastructure that will optimally manage the Medicare Advantage population Low Risk Patients ~55% of patients; Conditions are managed effectively by our PCPs Keep patient healthy, loyal to the system Focus on the patient experience Rising Risk Patients ~30% of patients; may have conditions that are not under control Avoid unnecessary higher acuity, higher cost spending Additional support to our physicians provided by MPAS thru Case Management High Risk Patients ~15% of patients; usually with complex disease (s), comorbidities, risk factors that will lead to serious health situations Trade high cost services for low cost management
About BreakThrough Care Center Developed our own proprietary Health Risk Assessment tool Identified the sickest 15% Triaged patients to our BreakThrough Care Centers for their care We avoided embedded case managers at our primary care offices Focused on doctor directed care This allowed our patients to receive their care at the appropriate level/site
BreakThrough Care Center infrastructure Focus is on: patient centric care rather than on physician/clinic centric care Focus is on: providing access eliminating waste driving superb clinical outcomes
Infrastructure Primary Care Physicians Health Coaches/ RN MA s MTM PT/OT Social Services Lab Radiology Specialists (cardio, pulmonary, ortho, physiatry, psychiatry)
Clinical Objectives Provide access for the highest risk population Improve adherence to clinical recommendations Improve medical outcomes Improve quality scores Improve patient experience Enhance patient s quality of life Improved physician satisfaction
Results Clinical UM Financial
Utilization Results All patients seen within 24 hours of discharge 30-day hospital readmission rate of 7.2% compared with Chicago market average of 13.6% Lower acute admissions Average length of stay of 3.9 days compared with Chicago market average of 5.0 days Lower ER utilization 89% generic pharmacy utilization
Patient experience On January 15 Dr. Krouse saw a patient with an HbA1c of 16.9 Staff worked with him for 6 hours administering insulin and obtained stat labs to get real time results Patient was able to go home, with pharmacist calling to monitor blood sugar and insulin Patient also had a 4 in. abscess on his neck that Dr. DeHaan (Surgery) treated him for urgently Without BreakThrough Care Center: patient would have been in the ER for ~6 hours followed by a 5-6 day hospital stay
Patient experience Patient was 75 year old male Insulin dependent diabetes For the last 12 months has been admitted for hypo and hyperglycemia Pharmacist discovered he was illiterate Now, we fill his pillbox weekly No admissions for the last 18 months Without BreakThrough Care Center: patient would have continued to be admitted monthly, following his trend for last 12 months
PCP s at DMG Physician Experience the most difficult and time consuming patients are removed from their clinic When these patients are on track to managing their health, they are returned to their PCP BreakThrough Care Center physicians are delivering care with a new skill set that will need to be learned as we expand But Where?
Flexibility BreakThrough Care Center can accommodate all risk patients. This is accomplished by providing access, eliminating waste, and driving clinical outcomes MA, ACO, Commercial Risk
Additional applications Academic Medical Centers/Large hospital systems have unique threats to their traditional delivery of care Narrow panels Health exchanges Elimination of the uninsured subsidy Declining admissions Where will the skill set be learned to care for these complex patients who are in the outpatient arena? The BreakThrough Care Center model allows independent physician groups to succeed outside of a large hospital system
Questions