Overcoming Psycho-Social Hurdles to Transitional Care

Overcoming Psycho-Social Hurdles to Transitional Care Matt Eisenhower Director, Community Health Development Peter Rice, M.D. Medical Director

Overcoming Psycho-Social Hurdles to Transitional Care This publication was made possible by Grant Number 1c1cms330966-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. 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. Matt Eisenhower Director, Community Health Development Peter Rice, M.D. Medical Director

PeaceHealth Ketchikan Medical Center

PeaceHealth Ketchikan Medical Center

PeaceHealth Ketchikan Medical Center Ketchikan Population: 12,000 Prince of Wales Population: 4,000

Overview Review of CMS Demonstration Project Our Population Health Journey: On Ramping To Transitional Care Medical Director & Provider Perspective Questions and Discussion

CMS Demonstration Project 2010 Affordable Care Act: HCIA Funds 3 Year, $3.1 million award Functionally started in January 2013 Over 3300 Unique Encounters

Demonstration Project Goal: Explore primary care redesign model of PCMH, particularly care coordination to work toward the Triple Aim. Reduce cost of care per beneficiary per encounter: 1. Reduce Readmission Rates 2. Reduce Unnecessary Utilization 3. Increase Chronic Disease Care 4. Increase Community Literacy 5. Increase Access

Baseline Apr May June July Aug Sep Oct Nov Dec Jan Feb Mar Apr May June Jan-13 Feb Mar Apr May June July Aug Sep Oct Nov Dec Jan-14 Feb Mar Apr May June Baseline Jan-13 Feb March April May June July Aug Sep Oct Nov Dec Jan-14 Feb Mar Apr May Jun Outcomes (Some examples) 17% 16% 15% 14% 13% Hemoglobin A1c Poor Control A1c>9 20 15 10 Emergency Room Clinic Referrals 12% 11% 10% 5 0 100% Discharged Patient Follow-Up Hypertension patients on active management plan has risen from 84% to 89% 80% 60% 40% 20% 0% Successful follow-up Attempted

ADULT 30 DAY READMISSION RATES www.premierinc.com

14.00% 12.00% ADULT 30 DAY READMISSION RATES QUEST Predictive Rate 10.00% 8.00% 6.00% 4.00% 2.00% 0.00%

14.00% 12.00% QUEST Predictive Rate 10.00% Readmission 8.00% 6.00% 4.00% 2.00% 0.00%

14.00% 12.00% 10.00% QUEST Predictive Rate Readmission Linear (Readmission) 8.00% 6.00% 4.00% 2.00% 0.00%

Demonstration Project Adult Readmission Rate (18 months): 5.93% (n=1821) 33% reduction compared to expected 8.87% 8.00% 7.00% 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% Six Month Periods 7.42% 5.73% 4.86% Jul-Dec 13 Jan-June 14 July-Dec 14

30 Day All Cause Readmissions Control Group 18.00% 16.00% 14.00% 12.00% 10.00% Non-PHMG PHMG Poly. (Non-PHMG) Poly. (PHMG) 8.00% 6.00% 4.00% 2.00% 0.00% July August September October November December January February March Rate.98% 12.9% 7.79% 10% 12.28% 3.33% 15.78% 7.27% 7.14% 8.08% Numerator 1 8 6 8 7 2 9 4 4 49 Denominator 102 62 77 80 57 60 57 55 56 606 Rate 3.5% 5.1% 11% 8% 5.6% 9% 7.9% 0% 3% 5.88% Numerator 1 2 3 2 2 3 3 0 1 17 Denominator 29 39 27 25 36 35 38 27 33 289

Demonstration Project Per Beneficiary Per Encounter Cost Reduction Payer FY12 FY13 Net Change Medicare/Medicaid $536/encounter $457/encounter -15% Commercial Payers $730/encounter $655/encounter -10% All Payers $630/encounter $545/encounter -14%

Demonstration Project Per Beneficiary Per Encounter Cost Reduction Payer Clinic PBPE Hospital PBPE 2012 2013 2012 2013 Medicare/ Medicaid $134 $130 $1,187 $921 All Payers $203 $207 $1,373 $1,028

On Ramping: Merging Onto the Population Health Highway

On Ramping: Merging Onto the Population Health Highway VISION Buy In Discrete Goals

Importance of Leadership Leadership line in the sand: Continue journey from Fee For Service to Quality Payments The right thing to do for patients Working through revenue cycle challenges of decreased hospital care- CEO/CFO perspective

Discrete Outcome Goals Meaningful Look at payer quality objectives Attainable What is your practice group good at doing? What does your EMR provide now? Sustainable What is doable and not extraordinary?

Examples of Our Discrete Outcome Goals 1. Chronic Disease Focus Hypertension, Diabetes, CHF 2. High Risk Follow-up Hospital Discharge, Pregnancies, ER 3. Patient Navigation for At-Risk Patients Overcoming non-medical hurdles (Financial, travel, psycho-social, motivation, literacy)

On Ramping: Merging Onto the Population Health Highway VISION Buy In Discrete Goals BUILDING Data Hire Right

Data: Transitional Care 1. Daily Report (102) that is generated from inpatient EMR and is emailed to Care Coordinators 2. Patients are listed by PCP 3. Gives primary and secondary diagnosis along with basic demographics 4. Risk Stratification

HIRE THE RIGHT PEOPLE Mature Staff/Nurses (not necessarily old) Social Work Mentality Teachers Limited healthcare experience is not a negative Ask population health questions in interview Do you like to help people heal or keep them healthy?

On Ramping: Merging Onto the Population Health Highway VISION Buy In Discrete Goals BUILDING Data Hire Right EXECUTION No Excuses Refinement

Physician s Perspective Patient Discharge Report Next Course of Treatment Medication Reconciliation Hurdles to Care: Medical & Non-Medical

Physician s Perspective Patient Discharge Report Social Worker PCP Others: Financial, Education, Community assistance

TRANSITION OF CARE CALL TEMPLATE PHKMC (Daily Discharge Report is Mailed to CC) ADMITTED on: [Date] DISCHARGED from: [ER, In-Patient, Observation, etc.] First call attempted within: [Within 2 business days] Face to face within: [Protocol for visit in clinic] DISCHARGE DIAGNOSIS:

PRE CALL PREPERATION/BACKGROUND (gathered from chart review): Education Resources/Red Flag Conditions: Specific symptoms to watch for include: Medication review: Medications discontinued: Medications changed: Medications added: F/U Apt(S) Scheduled: Home Health: Other Community Support: Supplies and Equipment:

PHONE CALL/ASSESSMENT: Next Steps for Care Confirm F/U Appointments Confirm further follow-up tests, etc. Education of red flag symptoms: is able to verbalize instructions for care and concerning symptoms to report, with cues. Medication Reconciliation Psychosocial assessment/support needs Motivation Interviewing/active listening Barriers/Other: List services/referrals RECOMMENDATION:

Physician s Perspective Psycho-Social/Non-Medical Hurdles to Follow-Up Care: Financial o No insurance/under insured o Fear of non-coverage (ignorance of plan benefits) o Lack of pricing transparency for follow-up care Housing (homeless, marginal housing, boats) Family/social support Transportation challenges (cost, knowledge of bus routes, etc.) Access to food and basic needs Disabilities General medical literacy challenges

Provider Dot Phrase: EPIC @NAME@ presents for follow up after hospitalization from *** to *** for ***. The nurse care coordinator contacted patient on *** (within 2 business days after hospital discharge) to discuss @HIS@ status and discharge concerns - I have reviewed this note during today's office visit. I have reviewed the pertinent hospital notes, including the H & P, test results, procedural notes and Discharge Summary, related to this patient's hospitalization. HPI: *** This patient's past medical history, current medications, and social history have been reviewed during today's office visit. Physical Exam: Pertinent Test Results: Assessment/Plan: Transitional Care Management Visit, {Desc; low/moderate/high:110033} complexity @DIAGMED@ Discussion: I {ACTIONS; HAVE/HAVE NOT:19434} interacted with the providers involved in patient's hospital care. I educated the patient and @HIS@ caregivers regarding the expected recovery from this medical condition and the necessary medication changes and follow-up tests ordered. Appropriate community services have been arranged for this patient as well. Patient instructions discussed and included with After Visit Summary. @FOLLOWUP@

Physician s Perspective Things I learned (or re-learned): Array and scope of non-medical hurdles that can contribute to unnecessary readmissions Criticalness of a good hand-off /transition from in-patient setting to post-acute environment Important role of psychological hurdles o Over 1/3 of frequent users of Alaska ERs have a primary diagnosis in the mental health field. Critical role of care coordination team o Multi-licensure team approach o Increased non-provider encounters improving outcomes

Learnings Importance of Social Work in Care Management New Role??? Traditional Nursing Traditional Social Work

Learnings Importance of Social Work in Care Management New Role??? Traditional Nursing Traditional Social Work

Learnings of a New Field Traditional Nursing Population Health Traditional Social Work

QUESTIONS AND DISCUSSION