Camden Coalition of Healthcare Providers Camden Coalition of Healthcare Providers Exploring High-Utilizer Intervention Programs April 2 nd, 2014 www.camdenhealth.org
Overview of the Camden Coalition of Healthcare Providers Vision: Camden will be the first city in the country to bend the cost curve while improving quality. Mission: To improve the quality, capacity, coordination and accessibility of the healthcare system for all residents of Camden. 60 staff, $6.1 million annual budget Mix of foundation, federal grant funding and hospital support Membership organization, 20 member board, incorporated non-profit
Overview of the Camden Coalition of Healthcare Providers Structure of the Coalition: - Operations - Health Information Exchange - Research/Data/Evaluation - Finance/Admin - Programming - Care management for socially/medically complex patients - Clinical Redesign - Legal/Policy/Advocacy
Long-term Federal Debt
Hospital Costs Camden Residents, 2011 Total hospital revenue $108 million $1,396 per capita Total inpatient revenue $79 million $1,021 per capita Total Emergency Department revenue $29 million $375 per capita
Camden Cost Curve, 2011 10% of patients accounted for 73% of all charges 5% of patients accounted for 58% of all charges 1% of patients accounted for 26 % of all charges www.camdenhealth.org
Camden ED use by diagnosis, 2011 Primary ED Diagnosis, 2011 Visits % of visits Receipts Upper respiratory infections (head cold)* 4,858 16.3% $1,456,464 Sprains and strains 3,295 11.1% $1,159,452 Superficial injury; contusion 2,786 9.4% $837,132 Abdominal pain 2,318 7.8% $926,239 Skin and subcutaneous tissue infections 2,213 7.4% $673,115 Urinary tract infection* 2,182 7.3% $720,050 Spondylosis; and other back problems 1,735 5.8% $517,997 Asthma* 1,580 5.3% $675,230 Total 65,992 $23,106,476 *conditions which are typically amenable to outpatient management
Theory of Change Clinical Redesign Data Engagement
Clinical Interventions The Push The Carry The Catch
Become a Coalition Member Open to any individual or organization that supports the mission and vision of the Coalition Receive regular updates about Coalition activities and invitations to Coalition events Membership application available upon request from natassia@camdenhealth.org www.camdenhealth.org
Official Cross-Site Learning Communities Available to pilot programs for high-utilizers Two-year program includes in-person visits and biweekly technical assistance/consultation For more information, email Andrea Miller, Senior Program Manager: andrea@camdenhealth.org www.camdenhealth.org
Improving care & reducing costs with hotspotting & innovative local data systems Stephen Singer Senior Manager for Data Analytics & Maggie Hawthorne Senior Manager for Research & Evaluation
The mission of CCHP is to improve the health of all Camden residents by increasing the capacity, quality, and accessibility of the city s healthcare delivery system. A core value of CCHP is to be data-driven Where s the data in the mission?
It is a capital mistake to theorize before one has data. -Arthur Conan Doyle Where s the healthcare data?
Thanks to lots of slow, hard work we have data continuous high-stakes Claims behavioral
Camden City 77,344 residents 9 square miles 3 hospitals
Data processing/cleaning Yearly Clams Data Data Use Agreements IRB Agreement Probabilistic matching Geocoding Camden Health Database
So we have the data. Why should you care?
Data Philosophy:Data are your Friends Why? Data access is a long-term, trusting relationship. Outliers, not averages define system failure. Think like an advertiser not an epidemiologist. Find the stories in the data. Data feeds iterative exploration & discovery. Put data staff close to clinical staff.
Camden Hospital Utilization 2011 Snapshot total hospital revenue: $108,000,000% total patients with a hospital visit: 43,710% patients visiting multiple hospitals in a year: 41%
% of total hospital receipts 100 90 80 70 60 50 40 30 20 10 0 Camden Cost Curve 10% of patients accounted for 74% of receipts 1% of patients accounted for 30% of receipts 0 10,000 20,000 30,000 40,000 50,000 patients
: a data driven process for the timely identification of extreme patterns in a defined region of the healthcare system used to guide targeted intervention and follow up to better address patient needs, reshape ineffective utilization, and reduce cost.
Healthcare Hotspots in Camden, NJ
Intervention Paradigms Hotspotting Traditional Medical
Bigger Data? Fancy Models? Insurers predictive modeling? based on linear regression claims adjusting = highly flawed & weakly predictive Focus on current patients. The psychosocial variables that drive utilization won t appear in the claims data, so: Think non-linear complexity Use all of the other possible segments first and then use diagnosis last. You can t vendor your way to a solution There s no substitute for local knowledge.
Patient Typology, 2011 Inpatient Visits 0 1 2-3 4 or more 0. 2,900 patients (6.6%) $132m charges (14.8%) $16m receipts (14.7%) Emergency Department Visits 1-2. 3-5. 26,819 patients (61%) $87m charges (9.9%) $11m receipts (10.6%) 2,332 patients (5.3%) $115m charges (13%) $14m receipts (12.9%) 9,010 patients (20.6%) $298m charges (33.6%) $37m receipts (33.8%) 355 patients (.8%) $165m charges (18.6%) $20m receipts (18.6%) 6+. 2,293 patients (5.2%) $90m charges (10.2%) $10m receipts (9.4%)
Inpatient Emergency Department either Patient Segmentation Utilization Cluster % total % total ED % total IP % total LOS % total charges % total receipts % total 60 day readmits Total charges Total receipts Low 36.9 16.7 0 0 4.1 3.9 0 $29,459,067 $3,216,749 Average 20.3 21.2 0 0 5.0 4.7 0 $35,843,429 $3,867,264 High 10.1 23.8 3.0 1.7 6.5 6.6 0 $46,579,465 $5,505,723 Borderline ED/IP 7.9 3.3 8.1 7.5 7.8 7.7 0 $56,204,358 $6,439,403 Moderate 7.8 9.5 6.2 3.7 6.3 6.5 0 $45,433,623 $5,391,079 Outlier 2.1 11.6 2.5 1.7 3.9 3.4 0.3 $28,203,522 $2,829,333 Borderline IP/ED 11.3 6.6 41.9 34.9 27.3 27.3 0 $196,526,193 $22,735,172 Moderate 2.8 3.6 24.5 22.5 18.5 20.4 75.9 $133,209,990 $16,957,202 High 0.8 1.5 13.0 27.5 20.0 18.8 23.0 $144,148,652 $15,652,705 Extreme 0.1 2.1 0.7 0.5 0.7 0.6 0.9 $5,192,345 $537,555
High Inpatient Utilizers 215 patients (1%) Mean # ED visits Mean # IP visits Mean total LOS Mean % of all unique primary ICD classified as chronic Mean % of IP that are 60 day readmissio ns Mean total charges Mean total receipts Median Age 4.48 5.33 54.71 34% 55% $673,592 $73,143 57 % total % total ED % total IP % total LOS % total charges % total receipts % total 60 readmits Total charges Total receipts.8% 1.5% 13.0% 27.5% 20.0% 18.8% 23.0% $144,148,652 $15,652,705 2 UV 611 4 UV 611 676 95 9 1 " 4 5 1 2 1 " " 0 4 1 1 3 6 1 " " " " " 4 7 5 # 3 5 3 0 0 4 " 7 5 v # 10 9 2 3 7 30 0 3 " 2 0 3 2 3 1 2 1 " 1 2 v 0 676 0 1 " v 2 2 " 1 3 " 1 7 5 UV 168 " " 1 5 130 " # 0 # " 130 UV 70 UV 38 Patients Percent RESPIRATORY ABNORM NEC 34 2.2 CHEST PAIN NOS 29 1.9 SHORTNESS OF BREATH (Begin 1998) 28 1.8 REHABILITATION PROC NEC 26 1.7 ABDOM PAIN NOS (Begin 1994) 25 1.6 SEPTICEMIA NOS 23 1.5 ACUTE RENAL FAILURE NOS 21 1.4 URIN TRACT INFECTION NOS 21 1.4 PNEUMONIA ORGANISM NOS 19 1.2 6 " ACUTE ON CHRONIC SYSTOLIC HEART FAILR 17 1.1 0 1 130 30 76 2 3 6 Copyright: 2012 Esri, DeLorme, NAVTEQ
Hotspotting in Other Communities Newark Maine (Medicaid)
Hotspotting Toolkit www.healthcarehotspotting.com @medhotspotting
Program Planning and Performance Improvement Data Informed Programs
Customized Data System Solutions Camden s Health Information Exchange
Customized Data System Solutions Camden s Health Information Exchange
Customized Data System Solutions TrackVia and Tableau
Real-time Feedback Loops
Care Management Randomized Controlled Trial Treatment: Care Management Control: Standard Course of Care Administrative Data Outcomes: Medical claims and other social service data (e.g. housing, benefits)
Community-Based Multidisciplinary Care Management for Vulnerable Populations Jason Turi, RN, MPH, Associate Clinical Director
A City Invincible
The Medical Manifestations of Social and Economic Crisis
Poverty is a thief http://mobile.nytimes.com/2014/03/16/business/income-gap-meetthe-longevity-gap.html?referrer= Poverty not only diminishes a person s life chances, it steals years from one s life
John s Story http://www.camdenhealth.org/testimonials/john
Length of Stay High Utilization Example Patient 14 12 14 2011 payments ~$173,000 10 8 8 6 6 4 5 4 4 5 4 2 3 3 2 3 0 Inpatient Visit ED Visit ED IP
Clinical Interventions The Push The Carry The Catch
The Carry: Community Based Care Coordination
Goals Stabilize Coordinate Improve Health Reduce Costs
It Takes a Team
What Does Good Care Look Like? Active Listening Accompaniment Harm reduction Motivational Interviewing Trauma-Informed Approach Servant Leadership Program for All-Inclusive Care of the Elderly (PACE) Assertive Community Treatment (ACT) Nurse Family Partnership Ryan White Clinic Hospice
Real-Time Data Feeds
Hospital Engagement
Home Visits
Accompaniment to Primary Care & Specialists
Advocacy
Team and Self Care
Breakdown of Time Spent with Patients
Social Complexity Variations of Patient Complexity Higher 42 y.o. male Hx Asthma Exacerbation Homeless Mental health illness No social support Crack cocaine addiction 23 y.o. male Hx of Type 1 Diabetes Lives with grandmother Works as day laborer Learning disability 67 y.o. female Hx CHF, HTN, COPD Depression, anxiety 17 meds daily Work history D/C to LTAC Daughter is primary caregiver High Medical Complexity Higher
John s Story 44 year old former Pro Wrestler The Black Scorpion Suicide Attempt by hanging Homeless Lack of Family Support Poor Medication Adherence Drug Use Seizures & Hypertension Anxiety & Depression Insulin Dependent 1 YEAR PRIOR- 7 INPATIENT ADMISSIONS 7 ED VISITS
Home-Based Medication Reconciliation
Patient Centered Care Coordination
The Black Scorpion Speaks At first I was reluctant, but the communication and the relationship with the team is wonderful and very supportive. They are always in touch with me and assist me in meeting my goals. For example, guiding me to my new apartment and MICA program. I feel security with the team. I was not just left, put out in the middle of nowhere. They actually did what they said they were going to do and that made all the difference. 1YEAR POST- 2 INPATIENT ADMISSIONS 1 ED VISIT
Health Coaching 1 year Americorps commitment Accompaniment: doing with Relationship building Connecting to resources Ongoing/comprehensive
Next Steps Cross-site learning Currently working with 12 sites across the country Michigan Howard County San Diego Humboldt County Colorado Kansas City Maine Cincinnati Boston Pittsburgh Allentown Cleveland Randomized Control Trial with MIT/JPAL Forging Partnerships Medicaid ACO United Healthcare-Medicaid HMO
Questions info@camdenhealth.org www.camdenhealth.org Twitter: @camdenhealth
Camden Coalition of Healthcare Providers CCHP Open House Clinical Redesign Overview Connecting with Primary Care Providers
Intervention Model The Push The Carry The Catch Data Lourdes Cooper Virtua Triage Assessment Assignment Care Mgmt. Medically complex Socially complex 90-day engagement Medical Home Quality improvement Patient engagement Care coordination Patients Flagged: 2+ hospital admissions < 6 months Selection Criteria: History of chronic disease related admits Non-compliance noted in chart Rule out criteria Pregnancy Oncology Trauma www.camdenhealth.org
Study Finds Limited Benefit to Some Medical Homes
The Catch: Primary Care Redesign DATA CULTURE WORKFLOW Build a quality improvement infrastructure focused on access and care coordination in primary care Create a culture of good care within primary care and CCHP Establish the use of real-time data to drive decision-making in primary care.
Build a quality improvement infrastructure focused on access and care coordination in primary care
Establish the use of real-time data to drive decision-making in primary care.
Create a culture of good care within primary care and CCHP
Interdisciplinary Framework I Do We Do You Do
Primary Care Redesign Case Studies Tenets of Good Care at lower cost Trauma-informed Team-based Approach Sustainability Innovative Care Delivery Leadership Buy-in Data Management and Analytics Standardization of clinical treatment Background All practices are local, Camden-based Serve primarily Medicaid Patients Camden Population: 77,000 Hospital A and Hospital B are competitors MD in practice 3 previously worked for Hospital B and had negative experience 1. Based on the profile of each practice, which components of good care are they ready to accomplish? 2. What are some ways they can move towards integrating these good care initiatives into their everyday practice?
ltidisciplinary New Directions in Care for Vulnerable Populations Nadia Ali, Director of Clinical Redesign Victoria DeFiglio, Associate Clinical Director Jason Turi, RN, MPH Kelly Craig, MSW, LSW
New Directions 1. Clinical/Business Dyad 2. Trauma-informed care
Clinical + Business Dyad RN PM CHW HC HC LPN LPN PA
Trauma-informed care The Relationship of Adverse Childhood Experiences to Adult Health Status A collaborative effort of Kaiser Permanente and The Centers for Disease Control Vincent J. Felitti, M.D. Robert F. Anda, M.D.
THE ADVERSE CHILDHOOD EXPERIENCES STUDY (ACEs STUDY) In 1998, largest study of its kind ever (almost 18,000 participants) Examined the health and social effects of adverse childhood experiences over the lifespan Majority of participants were 50 or older (62%), were white (77%) and had attended college (72%).
ABUSE HOUSEHOLD 1 POINT /CATEGORY ADD TO GET TOTAL ACE SCORE ACE CATEGORIESWHEN YOU WERE 18 OR YOUNGER PHYSICAL ABUSE SEXUAL ABUSE EMOTIONAL ABUSE PHYSICAL NEGLECT EMOTIONAL NEGLECT MENTAL ILLNESS SUBSTANCE ABUSE DOMESTIC VIOLENCE PARENTAL SEPARATION/ DIVORCE INCARCERATION
One in nine had an ACE score of 5 or more One in six had an ACE score of 4 or more One in four had ACE score of 2 or more Only one-third had a zero ACE score ACES SCORE
ACES SCORE OF 4 OR MORE Twice as likely to smoke Seven times more like to be alcoholics Six times more likely to have had sex before the age of 15 Twice as likely to have been diagnosed with cancer Twice as likely to have heart disease Four times as likely to suffer from emphysema or chronic bronchitis Twelve times as likely to have attempted suicide Five times more likely to be involved in IPV or get raped Ten times more likely to have injected street drugs ACEs score of 8 gives four co-occurring problems
CHANGING THE FUNDAMENTAL QUESTION It s not What s wrong with you? It s What happened to you?
By the team caring for me, I learned that I was valuable and started to care for myself www.camdenhealth.org