Maria X Martinez
1. Urgent/Emergent Care and challenge 2. HUMS hypothesis 3. High users, multiple systems, and multiple domains of disorders 4. Was FY 11-12 different? 5. IDS goals: 1. Targeted Street Outreach (EST) 2. Coordinated Case Management 3. Ambulatory Acuity Index
Medical System EMS transports ED medical Inpatient 24hr Medical Respite (hospital offset) Urgent care clinics at TWHC, hospital *Programs in red are the only ones studied in other communities. Psychiatric Sytem PES, Dore St (PES offset) Psych Inpatient 24hr Adult Diversion Units (hospital offset) 24hr Crisis clinics at Westside, Mobile Crisis Substance Abuse System Sobering Center Res Medical Detox 24hr Res Social Detox 24hr
High Users of Multiple Systems 2007 study showed common features for high ambulance users: costly, multi-disordered, receiving care in multiple service agencies, unknown to individual systems, not sticking to any stabilizing services, and no care coordination. HUMS Hypothesis: Coordinated care, supported by integrated data, can be an effective intervention to reduce costs and improve health outcomes.
$200 million annual urgent/emergent care estimated actual costs 50,000 55,000 unique individuals served annually Top 1% of individuals account for 25% of costs. Top 5% account for 55% of costs.
Summary of FY 10-11 # Patients Total Costs % Total Costs Ave Cost/Pt Ave # Svcs Top 1% 511 $49,793,566 25% $97,443 89 Next 2-5% 2,078 $58,527,401 30% $28,165 30 Remaining 95% 49,207 $88,187,508 45% $1,792 2.5 Totals 51,796 $196,508,475 100%
Number patients in each group, FY 10-11 HUMS 312 Any 1 sys Any 2 sys All 3 sys totals Ave Top 1% HU 199 175 137 511 Next 2-5% HU 1,009 800 269 2,078 Remaining 95% 46,344 2,654 209 49,207 Totals 47,552 3,629 615 51,796
Average Urgent Care Cost per Individual FY 10-11 HUMS Any 1 sys Any 2 sys All 3 sys totals Ave Top 1% HU $94,375 $98,148 $101,000 $97,443 Next 2-5% HU $27,311 $28,281 $31,028 $28,165 Remaining 95% $1,584 $4,913 $8,308 $1,792 Totals n/a n/a n/a
No, average number services per urgent care patient is same. HUMS HUMS FY 10-11 1 sys 2 sys 3 sys TotAve FY 11-12 1 sys 2 sys 3 sys TotAve Top 1% 86 90 93 89 Top 1% 85 91 92 89 Next 2-5% 29 30 33 30 Next 2-5% 28 30 33 30
Yes, average cost per patient decreased for multi-system users, but increased for single system users. HUMS HUMS FY 10-11 1 sys 2 sys 3 sys TotAve FY 11-12 1 sys 2 sys 3 sys TotAve Top 1% HU $94,375 $98,148 $101,000 $97,443 Top 1% HU $104,365 $82,862 $57,488 $85,449 Next 2-5% HU $27,311 $28,281 $31,028 $28,165 Next 2-5% HU $32,073 $21,367 $17,703 $26,498
Ambulatory Acuity Index Targeted Outreach Coordinated Case Management
Multiple Systems 1 system 2 systems 3 systems SA Psy Med SA-Med SA-Psy Psy-Med Tri Totals Top 1% HU - 56 143 44 6 125 137 511 Multi-disorders measured by Elixhauser Co-morbidity Index 0 Domains* Diagnosis in 1 Domain Co-Morbidity Diagnosis Tri- Morbid No Elix SA Psy Med SA- Med SA-Psy Psy- Med Totals Top 1% HU 12 5 8 52 81 63 58 232 511 * 0 Domains usually means the patient received urgent care services for acute, resolving condition; not chronic, progressive condition
30 diagnostic measurements add together to form final score. Even a single positive response predicts early mortality if untreated. All conditions are progressive without treatment. Most conditions are chronic. They can be ameliorated and stabilized with treatment. Some conditions are acute. They can be cured with treatment.
Circulatory System Cardiac Arrhythmias Valvular Disease Congestive Heart Failure Hypertension, Uncomplic. Hypertension, Complic. Peripheral Vascular Dis. Pulmonary Circulation Dis. Digestive System Liver Disease Peptic Ulcer Disease, Excl Bleeding Endocrine System Diabetes, Uncomplicated Diabetes, Complicated Obesity Weight Loss Hypothyroidism GenitoUrinary System Renal Failure MusculoSkeletal System Rheumatic Arthritis / Collagen Vascular Disease
Hematology System Deficiency Anemia Blood Loss Anemia Coagulopathy Fluid and Electrolyte Disorders Neurological System Paralysis Other Neurological Disorders Respiratory System Chronic Pulmonary Disease Cancer Solid Tumor w/o Metastasis Metastatic Cancer Lymphoma Immune System AIDS/HIV Psychiatric Disorders Psychoses Depression Substance Use Disorders Alcohol Abuse Drug Abuse
SFHOT Engagement Specialist Team Targeted street outreach with the goal of more effectively engaging and placing HUMS into care (warm handoffs and follow-up) 24-hr schedule Covers grid based upon CCMS knowledge of ambulance pickup histories Responds to 311, police, EMS for street intervention Transportation to & from urgent/emergent facilities
Current: HUMS Clinical Case Conference monthly EST Planned: Central call-in line for EDs to consult with EST and RNs at Sobering Center (use of CCMS) Addition of electronic case coordination tools including provider communication and oversight of community care plan EST assist in finding patients who were engaged with case managers but have been lost to follow-up
HUMS + conditions are useful way to monitor high cost / high risk patients HUMS method helps plan interventions to improve health outcomes and reduce costs EST and Care Coordination changing interactions with HUMS patients Further interventions and grant applications are planned Spotlight may be reducing costs already