Maryland Association of Healthcare Executives presents: 1
PCP Networks-Hospitals- Post-Acute Care Population Health Across the Continuum Session 3 2
Panel Moderator: Michael Poku, MD, Resident, Internal Medicine & Urban Health, Johns Hopkins Hospital David Stewart, MD, Chair of Family & Community Medicine, University of Maryland Jeanne C. Keruly, MS, CRNP, Director of Adult Ryan White Services, Johns Hopkins Catherine Hamel, MA, Vice President of Continuing Care, Greater Baltimore Medical Center 3
University of Maryland Care Coordination Center David Stewart M.D., M.P.H. Chairman Department of Family and Community Medicine University of Maryland School of Medicine
Goals Primary care perspective of care transition space Description of University of Maryland C 3 Preliminary data for year I
Reality: among frequent utilizers of healthcare there exists the following characteristics Multiple chronic disease states Mental health conditions chronic, established diagnosis anxiety, depression, PTSD associated with violence / trauma unresolved grief learning disabilities / literacy family dysfunction
Characteristics associated with high utilizers of healthcare Substance abuse Housing: instability > homelessness Cultural variances: social > legal
Population Health Models to Address High Utilizers of Healthcare Must Consider Quality Containing costs External forces: local > regional > national Uniqueness of healthcare organization
Population Health Models to Impact Quality of Care & Contain Costs Health Insurance Plan Model telephonic Patient Centered Medical Home advanced primary care embedded care management Hospital Discharge Model transition from hospital > home > primary care
Population Health Models Emergency Department Based Model ED teams designed to provide care management Housing First Model emphasis on stability associated with housing
Population Health Models Community Based Model engages patient wherever community health worker Ambulatory Intensive Care Unit high utilizing complex patients receive all primary care from a high risk interdisciplinary team focused on a defined panel of patients
Care Coordination Center / CCC / C3 Conceptualization Transitional Care Intensive Ambulatory Care Subspecialty: CHF & Sickle Cell Potential Fluidity / Cushion mental health, substance abuse, further primary & subspecialty care relationships, define community health worker role
C3 Team Physician medical director Nurse manager Nursing Coordinator Nurses Cardiology Nurse Practitioner Pharm PhD Social worker Community Health Worker Medical Assistant Trainees
Patient Referrals to Intensive Ambulatory Care Component of C3 Transitional Care Team located in ER and on Inpatient Floors Hospital Transitional Care Team Program Outlying hospital discharges Campus Urgent Care Primary & subspecialty care outpatient offices System hospitals
Intensive Ambulatory Care July 1, 2016 until June 30, 2017 Scheduled patients 2,350 Arrived patients 1,292 Canceled w/o reschedule 389 Canceled with reschedule 285 No shows 384
Intensive Ambulatory Care Referrals July 1, 2016 until June 30, 2017 Radiology 183 Vascular surgery / lab 99 / 93 Internal 87 Nephrology 61 Psychiatry 31
Intensive Ambulatory Care Outside Labs July 1, 2016 until June 30 2017 Comprehensive chemistry 76 CBC 57 Drug screen 55 Total of all labs ordered 420
Intensive Ambulatory Care Year 1 Source of Payment Medicare 27 % Medical assistance MCO 27 % Medical assistance 5 % Medical assistance eligible 4 % Commercial 2 %
900 Volumes Pre / Post IAC Visit IAC Volume Pre- & Post-Visit 800 700 600 500 400 300 200 100 0 Pre-IAC ED Post-IAC ED Pre-IAC INP Post-IAC INP Pre-IAC OBS Post-IAC OBS
Patient Referrals to Heart Failure Program at C3 Inpatient Units Emergency room Cardiology Primary care Internal C3 Self referral when established
Heart Failure Year 1 Scheduled patients 1087 Arrived patients 623 Canceled w/o reschedule 200 Canceled with reschedule 173 No show 87
Heart Failure Year 1 Source of Payment Medicare Medical assistance Commercial
350 300 Volumes Pre / Post Heart Failure Program Volume Pre- & Post-Visit Heart Failure Program 250 200 150 100 50 0 Pre-IAC ED Post-IAC ED Pre-IAC INP Post-IAC INP Pre-IAC OBS Post-IAC OBS
Patient Referrals to Infusion Component at C3 Heart Failure Program Sickle Cell Program Internal C3 Self referral when established
C3 Infusions Year 1 Heart Failure 978 Sickle Cell 896 Total 1874
600 Volumes Pre / Post Infusion Volumes Pre- & Post-Infusion 500 400 300 200 100 0 Pre-IAC ED Post-IAC ED Pre-IAC INP Post-IAC INP Pre-IAC OBS Post-IAC OBS
Conclusions Population health models such as those utilized by the University of Maryland C3 are valid methods to impact quality, cost containment, and patients experience with care. Institutions should design and implement such models depending upon specific population and organizational needs.
Population Specific Care Jeanne C. Keruly, MS, CRNP, Director of Adult Ryan White Services, Johns Hopkins 43
Care Continuum https://www.hiv.gov/federal-response/policies-issues/hiv-aids-care-continuum accessed 10/10/2017 44
HIV Care Continuum Where We Are https://www.hiv.gov/federal-response/policies-issues/hiv-aids-care-continuum accessed 10/10/2017 45
HIV Care Continuum Why is it Important? HIV testing and diagnosis Access care to stay healthy Stop the spread of the disease Getting and staying in medical care Access treatment Prevention counseling Lifelong process (no cure) Antiretroviral therapy Controls the virus Reduces sexual transmission of the virus (Treatment as prevention) Achieving viral load suppression Live longer, healthier Reduce the chance of passing HIV to others https://www.hiv.gov/federal-response/policies-issues/hiv-aids-care-continuum accessed 10/10/2017 46
2016 Continuum of Care - Maryland Slide courtesy of Colin Flynn, Maryland State Department of Health Using data as reported through 6/30/2017 47
Testing and Linkage to Care JHH ED & HIV Clinical Services Intake with RN/Social Worker within 48 hours of diagnosis Navigators available to counseling/support In 2013, 87% successfully linked to care with this intervention In 2016, patients diagnosed within the year, 95% linked to care within 90 days, average: 31 days (JHU RSR data, 2016) Graphs courtesy of Kisten Nolan, RN, MPH 48
Engaged and Retained in Care Adherence Monitoring & Navigators Engagement in Care is associated with better clinical outcomes Missed visits increased mortality 1, 2 Missed visits Lack of viral suppression 3 HRSA and CDC have funded demonstration projects to better understand what types of programs best support adherence Multidisciplinary Use of navigators (peers) Motivational interviewing techniques 4 JHU HIV program has made use of an adherence strategy since 1997 which includes: nurses, case managers and navigators 1 Giodarno et al. Retention in Care: A Challenge to Survival with HIV Infection; CID, 2007. 2 Mugavero et al. Beyond Core Indicators of Retention in HIV Care: Missed Clinic Visits Are Independently Associated With All-Cause Mortality. Clin Infect Dis. 2014 3 Mugavero et al. Early retention in HIV care and viral load suppression: implications for a test and treat approach to HIV prevention. Acquir Immune Defic Syndr. 2012. 4 Gardner et al. Efficacy of a brief case management intervention to link recently diagnosed HIVinfected persons to care. AIDS 2005 49
Engaged and Retained in Care Adherence Monitoring Clinical Pharmacists (2) & Registered Nurses (10) Instruction Medication Readiness Assessment Medication Teaching & Simplification Side effect management Instructions in the use of Adherence Tools Pill box, cell phones, diary, medication calendar HIV 101 education Adherence monitoring Self report Pill box refill demonstration Continuous pill box refill Pharmacy pick up review Slide Courtesy of Shivaun Celano, Pharm D 50
Engaged and Retained in Care Adherence and Navigation Services Patient Navigator (5): works directly with patient and the clinical care team. HIV navigation is a process of service delivery to help a person obtain timely, essential and appropriate HIV-related medical and social services to optimize his or her health and prevent HIV transmission and acquisition. 1 Navigators in our HIV practice Meet and greet new patients Support newly diagnosed (ER and Inpatient units) Serve as group facilitators Escort patients to outside visits or procedures Long-term support to selected patients Outreach in the community Document activities in the EMR (member of the team) Patrice Henry, a patient advocate/community program coordinator for the Moore Clinic at Johns Hopkins Hospital, also was diagnosed with HIV in 1995. She's pictured outside the Carnegie Building at Johns Hopkins Hospital, which houses the clinic. (Algerina Perna, Baltimore Sun) http://www.baltimoresun.com/health/bs-hs-aidswomen-20120308-story.html 1 https://effectiveinterventions.cdc.gov/en/highimpactprevention/biomedicalinterventions/hivnavigationservices.as px 51
Engaged and Retained in Care Practice Enhancements Care Teams Medical provider (MD, PA-C, CRNP) teamed with a nurse and case manager to support care coordination Co-located Services within the main ambulatory practice 5 Subspecialty services Substance Abuse treatment- buprenorphine Medical case managers, nurses and navigators Group counseling On site Pharmacy Ability to purchase medications/support payment of copays Care programs within the larger care program ACE dedicated multidisciplinary group for young adults Latino multidisciplinary group for Latino population Surrounding County Program providers, nurses and case manager travel to health departments and health centers (9) to deliver HIV specialty care 52
Engaged and Retained in Care Practice Enhancements Care Coordination post Acute Care HIV Clinical program has had a dedicated inpatient since 1985 Managed by ID faculty; Dedicated RN care coordinator; Social Worker HIV provider notified of admission and discharge (EMR notification & notification from the and Care Coordinator Discharge Planning Appointment with the primary HIV provider within 7 days of discharge All medications filled at the time of discharge (pill box) and appointments to specialty providers are made. 53
Engaged and Retained in Care Practice Enhancements Care Coordination post Acute Care Stay HIV Clinical program has had a dedicated inpatient since 1985 Managed by ID faculty; Dedicated RN care coordinator; Social Worker HIV provider notified of admission and discharge (EMR notification & notification from the and Care Coordinator Discharge Planning Appointment with the primary HIV provider within 7 days of discharge All medications filled at the time of discharge (pill box) and appointments to specialty providers are made. Outpatients Social work and Navigators engaged if warranted.( 54
Care Continuum https://www.hiv.gov/federal-response/policies-issues/hiv-aids-care-continuum accessed 10/10/2017 55
Prescribe Antiretroviral Treatment (ART) to Achieve Viral Suppression Demonstration Projects to Fast track initiation of ART Pilcher, JAIDS, 2017 56
Prescribe Antiretroviral Treatment (ART) to Achieve Viral Suppression Why Rapid HIV Treatment initiation (RHTI)? Early ART start with sustained viral suppression decreases morbidity and mortality with risk of transmission negligible to non-existent (START Study, HPTN 052, PARTNER study) Successful Rapid HIV Treatment RapIT South Africa RAPID San Francisco Port-au-Prince, Haiti same-day ART initiation IMPROVED ART INITIATION, VIRAL SUPRESSION, RETENTION (S. Africa, Haiti) INSIGHT START Study Group, NEJM, 2015 Cohen, NEJM, 2011 Rodger, JAMA, 2016 Rosen, PLOS Med, 2016 Pilcher, JAIDS, 2017 Koenig, PLOS Med, 2017 Slide courtesy of Joyce Jones, MD 57
Prescribe Antiretroviral Treatment (ART) to Achieve Viral Suppression Project RHAE: Rapid HIV treatment initiation access and engagement in care (funding: CFAR) Recruitment: Johns Hopkins ED, BCHD STD clinics, John G. Bartlett Specialty Practice Criteria: Newly diagnosed and previously diagnosed patients (no ART and no care >6 months) Treatment: Patients receive 14 days of HIV medication + expedited access to clinical services Outcomes Number of patients started on ART Time to ART initiation Number of patients who achieve an undetectable HIV viral load Retention in care Slide courtesy of Joyce Jones, MD 58
HIV Care Continuum JHU HIV Services Large HIV Clinical Practice Urban, regional and rural HIV Specialty Care Significant external support for Practice Enhancement 3 million dollars annually in clinical care and supportive service funding Able to achieve good clinical outcomes > 95% prescribed ART 89 % viral load suppression 59
GBMC Catherine Hamel, MA VP Continuing Care and President, Gilchrist
Reducing Avoidable Admissions General Strategies Building a Continuing Care Network Integrating Behavioral Health 61
GBMC HealthCare System GARRETT ALLEGANY WASHINGTON CARROLL HARFORD BALTIMORE FREDERICK CECIL HOWARD KENT MONTGOMERY QUEEN ANNE ANNE'S ARUNDEL CARROLL COUNTY HARFORD COUNTY PRINCE GEORGE'S TALBOT CAROLINE CALVERT BALTIMORE COUNTY CHARLES ST. DORCHESTER WICOMICO MARY'S WORCESTER HOWARD COUNTY BALTIMORE CITY SOMERSET 6
Resources for this work ED Care Managers Community Health Worker, Mosaic Care Managers Inpatient Care Managers Hospitalists Advanced Care Management (Palliative Care) Continuing Care Network Skilled Nursing Facility Network Elder Medical Care at Home Elder Medical Care in residential care facilities Hospice, Inpatient, home and residential care Primary Care Providers Medical Assistants Patient Service Assistants Care Manager Care Coordinator Behavioral Health Specialists Psychiatrist LCSW-C Substance Abuse Specialists
General Strategies 64
Delivering the Right Care to Patients at GBMC Health Care 5% of Patients Dying Advanced Illness Complex Illness Chronic Disease ~15 Primary 30% Care of Patients Providers Medical Assistants Patient Service Assistants Healthy Care Manager Individuals Individuals Care with Coordinator Asymptomatic Conditions ~ 60 80% of Patients GBMC Services Gilchrist Hospice Care Elder Medical Care Home and Residential Care Advanced Care Management/Palliative Care Medical and Surgical Hospital Care Medical Neighborhood PCMH Specialists Advanced Primary Care Patient-Centered Medical Home (PCMH) 65
Specific Initiatives Risk Screening Mandatory Wrap-around services PCP Appointments Loyalist Care Plans and Care Alerts ED, Inpatient, PCMH s, Payers Serious Illness/End of Life Care Mandatory triggers for PC consults
Dartmouth Atlas Data 2014 Understanding the Efficiency and Effectiveness of Health Care HOSPITAL % admitted to hospice Hospice Days GBMC 66.6%* ** 20.5 Carroll Hospital Center 61.6% 15.1 UM St. Joseph 60.2% 17.3 Howard County GH 59.4% 20.9 Medstar Franklin Square 58.8% 17.7 Northwest Hospital 58.2% 16.4 UM Upper Chesapeake 57.2% 21.1 Johns Hopkins Hospital 54.1% 21.4 ** Medstar Harbor Hospital 54.1% 19.3 Harford Memorial 51.8% 19.8 Region Low 29.0% 8.3 *Hospital with significant hospice affiliations/ownerships **Region High ***Region Low Maryland Average 49.3% 19.0
Building a Continuing Care Network 68
Continuing Care Network RFP s, HH, LTC, Adult Day Care, Ambulance Liaisons, Rounds Quarterly meetings-metrics/goals Collaboratives Readmissions Committee/Data ED Messaging from LTC Case Studies reviewed New Programs Elder Medical Care Advanced Care Management, LTC
Integrating Behavioral Health 70
The PCMH Care Team Restructured Physician Lead and Practice Manager Primary Care Providers Medical Assistants Patient Service Assistants Care Manager Care Coordinator Behavioral Health Consultant (Sheppard Pratt) Substance Use Consultant (Kolmac Clinic) Psychiatrist/Specialist (Sheppard Pratt/Mosaic) Community Health Workers (Mosaic)
ED Interventions Mosaic Community Health Worker Joined the team in June 2017 Key responsibilities Placement assistance Continuity for existing Mosaic patients Reconnect to existing services 160 cases placements 60 reconnections Data collection on placement gaps
Substance Use 15,849 screenings on primary care patients (NIDA tool) 269 visits performed with Substance Use Consultant from Kolmac