Advanced Illness Management Leveraging Person Centered Care and Reengineering the Care Team Across the Continuum Betsy Gornet, FACHE Chief Advanced Illness Management Executive Sutter Health / Sutter Care at Home AGMA 2014 Institute for Quality Leadership Nov 12-14, 2014 1
Health Care Innovation Award The project described is supported by Grant # 1C1CMS331005-01-00 from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. The contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. 2
Learning Objectives 1. Identify a minimum of 3 tools to enhance patient centered care and patient engagement 2. Understand at least one model of reengineering the care team across the continuum 3. Describe the linkages between person centered care and outcomes 3
Roadmap for Session Sutter Health & AIM Environment Outcomes & Program Evaluation Challenges and Opportunities Imperative for AIM Resourcing Physicians Next Steps Design: Person Centered Care AIM Characteristics Q & A 4
Sutter Health at a Glance-Serving more than 100 communities with: 5,000 physicians 24 acute care hospitals and 24+ surgery centers Approximately 48,000 employees $9.6 billion in revenues (2013) Home based services: Home Health, Hospice, Home Infusion, HME, Private Services Sutter Center for Integrated Care Health care research, development and dissemination program 5
Change in Utilization Improving Health AIM Snapshot Improving Care Change in Utilization 90 Days Post AIM Enrollment 9 of 10 sites reporting; Q2 2013-Q1 2014); n-1544 (Results not yet confirmed independently by CMS Evaluators) Lowering Cost 1800 Now serving 15 counties; enrolled more than 6,500 persons with advanced illness; 335 staff members trained Current census is 2200+; 87,000 patient contacts/yr 1600 1400 1200 1000 800 Pre Post Sutter received a $13 million Innovation Award from CMS to fund the ongoing implementation and evaluation of the AIM program; Sutter provided $21.4 M Ongoing high patient and provider satisfaction. 600 400 200 0 67% Reduction 59% Reduction 19% Reduction Hospitalizations ED Visit ICU Days Service Utilization The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. 6
This Is What It s All About AIM Patient: Eduard Fogarty 7
$ per Decedent Total Medicare Spending Last Year of Life 28% 28% in Last Year of Life 8% in Last Month of Life 8% Variation = Overtreatment: Hospitalization Readmissions ICU days LOS ER Visits Specialty consults Tests, procedures Months Prior to Death Dartmouth Atlas 2008 US Dept. of Health & Human Services 2003 8
How did we approach the problem? Design Leadership Team- Physicians, Care Managers, Home Care Across System Care Delivery Model; Referral Management; Data Management/Analytics; Board Level Approval for Pilot; Home Care Affiliate to Create Implementation Design Conduct Pilot and Complete Formal Program Evaluation Business Planning; Senior Leadership and Board Engagement for Expansion Project/Test Healthcare Innovations Award and System-Wide Expansion Sustainability Planning and Execution 9
What would you do if you could do anything? 10
Person Centered, Evidenced-Based, Coordinated Care for Persons living with Advanced Illness Continuous, Non-Episodic ID/Sustain Primary Physician Relationship Leverage Existing Care Network Personal Goals, Engagement, Self Support Mix of In- Person Visits and Phone Based Visits AIM Team as Navigator Rather than One Person Add Palliative Care to Curative Care AIM Person & Family Integrate Across All Care Settings 11
System Fragmentation System Integration EHR Patient Registry HOSPITALS Emergency Dept. Hospitalists Inpatient palliative care Case managers Discharge planners AIM Care Liaisons MEDICAL OFFICES Physicians Office staff Care managers Telesupport 911 HOME-BASED SERVICES Home health Hospice Transitions Team (Non Skilled Care) Telesupport After Hours Triage CRITICAL EVENTS Acute exacerbation Pain crisis Family anxiety New AIM staff & services 12
What Are the Characteristics of an AIM Patient Diagnosis Increasing utilization of services Clinical, functional, nutritional decline High burden of disease Self -rated health status What do we do about it? 13
AIM Care Pillars Advance Care Planning (Personal Goals) Red Flags & Symptom Management Plans Medication Management Follow Up Visits Patient Engagement & Self Management Support Dual Approach to Care: Curative + Palliative 14
The Virtual AIM Team AIM Medical Director & Program Leader [Matrix: Hospice and Home Health, and Outpatient Case Management leadership] AIM Home Health RNs and MSWs AIM Transitions RNs and MSWs AIM Telesupport RNs AIM Office Based Case Managers RNs After Hours Triage RNs Primary Lead Physician and Specialists Patient and Family 15
Additional Drivers of Outcomes Care Pillars Consistently Applied 24/7 Availability; Extended time line In Sickness & in Health Each Setting 16
Have you ever said to yourself : I don t understand why my patient doesn t follow my instructions. If they would only do what I recommended, they wouldn t constantly be having problems. Let s take a closer look at Person Centered, Health Literate Care 17
One Patient One Message Across Settings Integrated Health Literate Care Multiple Senses Engaged Person Living with Advanced Illness Personal Goals Communication Tools Engagement Tools 18
National Assessment of Adult Health Literacy Adult health literacy by highest level of education Only 1/3 of those with a graduate degree have the skills to effectively manage a chronic illness Source: U.S. Department of Education, 19 Institute of Education Sciences, 2003 National Assessment of Adult Literacy
Adult health literacy by age Only 3% of those age 65+ have the skills to effectively manage a chronic illness Source: U.S. Department of Education, Institute of Education Sciences, 20 2003 National Assessment of Adult Literacy
With Health Literacy, You Can t Tell By Looking 21
Goals: Yours or mine? Personal Goals What are your Personal Goals? Smart Goals What do you want for your life? What s important to you today, next week, a month from now? How do you want to be living each day? Where and with whom do you want to be? What motivates me/inspires you? What impact is my illness having on the achievement of my goals? The intention is to generate motivation for a different kind of engagement in self care 22
Health Literate Stoplight Tool 23
Health Literate Personal Health Record (PHR) 24
Leveraging the Wisdom of SBAR Well accepted format for physician communication Use for team conferencing Use for documenting the care pillars in physician record Teach the patient/family how to use when talking with their physician about a problem Situation Background Assessment Recommendation 25
Examples of a Person Centered Exchange Opening UP Tools Don t Forget Ask what they want Ask permission Provide choice of topics What do they already know? How do they learn? Cognitive Velcro Teach Back; Chunk & Check Stop Lights Personal Health Record What questions do you have, I have time? 26
Patients Cannot Afford This 27
Resourcing the Physician Larger Care Delivery Network Inpatient/Out patient Services and Emergency Department AIM Proscribed and Timed Communication; Pre/Post Follow up; Engagement Tools; Palliative Care AIM Home Health AIM Transitions Person & Family All other Care and Support AIM Telesupport & Office Based Case Management AIM Hospital Lead Physician All other Physicians 28
Outcomes & Program Evaluation Internal Evaluation Avalere / SCAN Foundation Pilot Ongoing Matched comparison group - Medicare claims; Managed care based Focus groups CMMI / NORC Sutter Health Research Development & Dissemination Quantitative; Matched comparison group - Medicare claims Qualitative Validation of outcomes; Matched comparison group - Medicare claims Predictability model Identification of evaluation of high and low value interventions 29
Examples of AIM Measures Care at the End of Life % Transferred to Hospice % Died in Hospital Hospital Days in Last 6 months of life Ed Use in Last 30 Days of Life ICU Use in Last 30 Days of Life LOS of Hospice Stay Outcomes, Resources and Costs Inpatient and ED visit Rates per 100 patients 30, 90 and 180 Day Pre/Post Enrollment Utilization Hospital ED ICU ALOS in Hospice 90 Day Payer Impact, Hospital Cost Impact, Total Cost of Care 30
Outcomes through July 2012-June 2014 (Results not yet confirmed independently by CMS evaluators) 94% Depression Screening completed within 30 days 77% Advanced Care Plan completed within 30 days Transfers to Hospice 58%; 6 day increase to median length of stay Hospitalizations down 60% Emergency Department visits down 33% ICU Days down 67% Total Cost of Care down 52% 31
Opportunity: Impact of AIM Program on Utilization of Services and Costs AIM Financial Impact Per Enrollee Based on 90 Day Pre/Post Analysis (Results have not yet been independently validated by CMMI) Estimated Payer Savings / 90 Day Pilot Period (2011) n 497 Q2-13 to Q1-14 n 1544 $9,985 $5,858 $5,872 $10,622 $3,607 $8,290 Based on current projections, estimated total Payer Savings for the nearly 5,120 enrollments served through July 2012-June 2014 is greater than $51 Million, Payer Savings Reductions in Hospital Costs Reductions in Total Costs 32
living in two worlds at the same time is challenging Fee For Service Value Based Population Reimbursement 33
Challenges Virtual team concepts; Communicating despite disparate systems Conflicting regulations Paradigm Shift: From tasks to managing the care continuum FFS environment vs Value based purchasing environment Systems and skills to perform specialty analytics in timely, consistent and reliable manner 34
Opportunities Improve the life and experience of persons living with advancing illness Create access as a new national care model and payment model Inform approaches for broader complex care management Improve experience of care professionals of caring for this population 35
Next Steps Pursue Continuous Improvement Patient & Provider Experience Quality, Utilization, Resources Finalize approach to AIM SNF care Meet Innovation Award Targets and Evaluation Potential Key Targets Successful Program Evaluation Complete Internal Research and Development Locally Development Payment Models for Care FFS Value Based (Quality and Cost) Support Creation of a New National Model of Care for Persons with Advanced Illness (with Accompanying Payment Model) Expand test of model + payment model FFS Bridge Value Based (Quality and Cost) 36
Health Care Innovation Award The project described is supported by Grant # 1C1CMS331005-01-00 from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. The contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. 37
What Questions Do You Have? I have time. 38