Managing Patients with Multiple Chronic Conditions Sponsored by AMGA and Merck & Co., Inc. 1 Group Pre-work Affinity Medical Group Heart, Lung & Vascular Center COURAGE Clinic
2 Medical Group Profile Affinity Medical Group (1954) Part of a larger regional Catholic Healthcare System Affinity Health System that consists of 26 clinics 250+ physicians 3 hospitals, one being critical access an insurance plan 26 specialties 600,000 patients (avg # annual outpt visits) Currently using Meditech transitioning to CentricityEMR
3 Team Composition Nurse (RNs) Physician Champions Cardiology, Lipidology, Primary Care Doctor of Pharmacy Dietitians (RDs) Exercise Physiology CMA Patient Registrars Medical Director Manager Director
4 Chronic Care Goals & Objectives Main objective: Reduce the progression and development of CAD and to reduce healthcare costs through optimal medical therapy. Goals supporting main objective: provide patients with a year-long program of education on chronic disease states, personal risk, life-habit risk factors, and family history offer standardized, aggressive, guideline-driven chronic disease management provide personalized intradisciplinary care through a core team identify and reduce residual CAD risk or cardiometabolic risk
5 Chronic Care Goals & Objectives Current Program: 12 month program consisting of six office visits focused on chronic disease management and personalized education. All visits conducted one-on-one (no group visits) Homework is distributed at all visits to hold patient accountable. Personalized lifestyle modification education is provided by expert RDs and EPs with reinforcement by RN. Weekly meetings to with Core Team to discuss patient care and clinic processes
6 Chronic Care Goals & Objectives Visit Structure: First Visit: a personalized educational curriculum is assigned to each patient and is divided between visits Second Visit: the patient meets with the Core Team members Schedules of the health care providers are pre-arranged so that the patient can see each provider during one cohesive visit (total visit length of 2 hours) Recommendations of core team members are compiled into one goal sheet for the patient to work on for the next appointment
7 Chronic Care Goals & Objectives Visit Structure: Remaining follow-up visits: the patient meets with COURAGE RN Review personalized education curriculum Discuss attainment of goals and current barriers to reaching goals Set personalized future goals *Patient has the option of a second office visit with the RD and/or EP during follow-up visits.
8 Chronic Care Intervention & Population Baseline Target population: patients at high-risk for cardiovascular disease, including those with known CAD, myocardial infarction or history of revascularization. Identification: rely directly on referrals Demographics (March 2011): 137 Total enrolled to date 37 female, 100 male 39-81 years old age range 61.4 = average age
9 Chronic Care Intervention & Population Baseline Behind the scenes implementation: Development of cost reimbursement structure Contracting with insurance plan(s) Using LEAN mentality to structure program Hiring of staff, expanding/restructuring staff roles Development of evidence based protocols Coordinating schedules for Core Team members to be in one central location Presentation/Marketing to referring and collaborating physicians Developing education content and format
Chronic Care Intervention & Population Baseline Workflow changes: Moving 2 part-time RNs to the COURAGE role allowed us to back-fill positions with more cost-effective staffing Registered Dietitians were brought onsite part-time Exercise Physiologists time was blocked for COURAGE Clinic Coordination across several disciplines to modify schedules to allow the patient to be seen by multiple healthcare providers at one central location (i.e. COURAGE Clinic) Staff: Core Team (as previously mentioned), coding & billing specialists, insurance carrier liaisons, other referring physicians, support dietitians, department managers 10
Chronic Care Intervention & Population Baseline Healthcare information technology: Microsoft Xcel spreadsheets utilized for modified Chronic Care Registry RelayHealth by McKesson In process of creating an advanced software program to store and analyze core metrics. Currently using parts of RelayHealth to track stage in program and problem lists. Methods used to change physician practices: Flagging provider schedules for patients not to goal for possible referral to COURAGE Clinic Standardizing methods of preventive care across physician practices 11
12 Self Efficacy Improvement in the patient s management of their condition by Empowerment through personalized education (disease state, lifestyle [exercise, diet, stress], medication education) Providing information on how to make sustainable, lifelong lifestyle changes Distribution of homework holding the patient accountable Individual goal setting with confidence scoring
13 Self Efficacy Tracking sustainability in this area: (currently considering options) Measuring number of patients remaining at goal after two years of completion may be feasible through insurance claims Tracking number of patients returning to program for loss of control
14 Improvement Interventions Core Team weekly meetings Daily staffing of patients with Pharm.D. Hiring of a medical assistant for help with rooming patients and clerical work Streamlined data collection sheets Development of software program to store and analyze core measures and metrics (in progress) New process to flag patient charts for possible referral to program if not to goal on metrics Continuous education program refinement
15 Measures Used National clinical standards ATP-III JNC-7 ACC/AHA Original C.O.U.R.A.G.E. Trial protocol The best current evidence is integrated into clinical guidelines and standards of practice. Following these standards ensures optimal care for our patients.
16 Measures Used Data sources and data collection processes: Current electronic health record has very limited capabilities for tracking and analysis We are in the process of developing a unique software program to store and analyze core measures and metrics. This program will be able to run statistical reports and provide specific outcome data. Currently, core team members compile and enter patient data into spreadsheets. Intense analysis of the data has been difficult due to the inadequacies of the spreadsheet Spreadsheets are currently being analyzed by an intern.
17 Measures Used Sampling of Data Metrics: Body Mass Index (actual number, not range) Weight Systolic Blood Pressure Diastolic Blood Pressure LDL-Cholesterol Triglycerides HDL-Cholesterol Non-HDL-Cholesterol LDL-particles LDL-particles small HDL-particles Lipoprotein (a) High sensitivity CRP Goal LDL-particles Goal LDL-Cholesterol At goal for LDL-p At goal for LDL-C At goal for HDL-C Waist Circumference Fasting blood glucose Hemoglobin A1C On antilipid medication On BP medication Core Medications Death Nonfatal MI Stroke Angina (CCS class) # min total exercise/week Nutritional Score Adherence Score Smoker
Demographics COURAGE all patients, March 2011 CAD 122 of 137 (89%) Metabolic Syndrome 105 of 137 (77%) Diabetes 47/137 (34%) Without metabolic syndrome 32/137 (23%)
19 Payment Reform We predict that our intervention would be successful in bending the cost curve for the total cost of health care; unfortunately, lack of payment reform in our area has been a significant barrier When approaching insurance companies for coverage we have not found a forum to even start discussions on coverage Coverage of our program is currently limited to our in-system health care plan
20 Challenges or Obstacles Biggest challenges: Work-flow COURAGE staff education Adapting to educational needs of patients Marketing to other providers Cost to patients Marketing to other insurance companies Employee turnover Steady referral base
21 Outcomes and Successes Key elements to success: Systematic efficient follow-up of this population of complex patients Dedicated staff Staff who have a solid foundation in preventive cardiology and ability to educate and motivate patients Staff development through speakers, educational days Administration support from cardiology director/manager Utilization of partner insurance company
COURAGE Clinic Outcomes at 12 months, Lipids: Averages 0 mo, 12 mo Tot Chol 160 153 LDL-C 91 77.6 HDL-C 40 48 Trigs 139 133 % improvement 4% drop 14% drop 20% rise (good) 4% drop N=44 patients
COURAGE Clinic Outcomes patients at 12 months, Weight: Average Start to Finish Weight 231 lbs 216 BMI 35 32.5 Waist Circ 42 41 % improvement 6.5% drop 7% drop 2% drop N=44 patients
COURAGE Outcomes All 12 months Patients: Average Start to Finish Glucose 127 119 Syst BP 130mmHg 122 Diast BP 75mmHg 71 HbA1c in Diabetes 7.57, decreased to 7.28 % improvement 6% drop 6% drop 5% drop 4% drop N=44 patients
COURAGE Clinic Percent Reaching Goal, 12 months in Program Average % Start to Finish LDL <80 in CAD 55 % 72% achieved LDL-C <100, all 12 month patients 70.5% 89% Achieved % improvement = 16% improved to goal =18.5% improved to goal BP<130/80, all 12 month patients 50 73% Achieved = 23% improved to goal
COURAGE Clinic Change in Weight, Obesity 231 221 216 Weight improved 6.5% in 12 months Number of obese dropped 11% Baseline 77 69 66 9 months in program 12 months in program Average Weight in Pounds % of Obesity September 2010 to March 2011
AHS COURAGE Clinic BMI, Waist Circumference Outcomes September 2010 to March 2011 45 40 35 30 25 20 15 10 5 0 7% improvement BMI 2% improvement Waist Circ Baseline 9 months 12 months
Systolic, Diastolic BP Comparisons, COURAGE trial vs. Affinity COURAGE Clinic SBP Improvement Trial 4.5%, Clinic 6% 140 130130 124122 120 100 80 60 40 20 0 SBP Starting DBP Improvement Trial 5.5%, Clinic 5% 7475 DBP Starting 7071 COURAGE Trial 12 months COURAGE Clinic 12 months
LDL-C Comparisons, COURAGE trial vs. Affinity COURAGE Clinic 160 140 120 100 80 60 40 20 0 102 81 91 77.6 Trial LDL-C CLINIC LDL- C 149 133 Trial Trig 139 133 CLINIC Trig Beginning 12 months
Comparisons with National Trials for Change in BMI 35 30 The COURAGE Clinic BMI improved 7% unlike the the COURAGE trial, which saw a small increase in BMI 25 20 15 10 Baseline BMI Endpoint BMI 5 0 COURAGE Trial COURAGE Clinic COURAGE Clinic data from September 2010 to March 2011
Value of Screening in 6 month patients October 2010 (96 total patients) CAD screened for angina 100% Depression screening 100% Metabolic Syndrome Screening 100% 75% were positive at 6 months (Oct 2010) Sleep Apnea Screening 100% Hs-CRP screening 100% 40% Were positive (38/96) Lp(a) Screening 100% 30% were positive (29/96)
32 Future Steps Next steps Grow referral numbers Approach other payer sources Expand program to other sites in our system Hope to achieve: Continued excellence in care delivery and outcomes Bring attention to the value of collaborative care provided by a multidisciplinary team. Spread the word that innovative care can be achieved in a non-academic center in a medium sized city
33 Lessons Learned Importance of selecting team members who are not only passionate and well-qualified but also comfortable with the uncertainty of innovation Systematic programs based on national guidelines do in fact help patients reach optimal goals The findings of the COURAGE Trial can be implemented in any practice but the model may vary and payment reform is needed.
34 Questions Do you have any questions you d like to pose to the group? 1) Advice on approaching insurance companies for coverage of programs such as this. 2) How do you effectively communicate the value and market a complex program such as this to referring providers and patients? 3) Are there better data collection and processing options with a limited budget and staff? What would you like to get from this collaborative? 1) Input from fresh eyes of fellow innovators.