Managing Risk Through Health Initiatives Vicki DeBaca, DNS, RN Vice President, Health & Provider Services Sharp Rees-Stealy Medical Centers 1 Sharp Rees-Stealy Medical Centers San Diego s Multi-Specialty Medical Group Physicians 450 Employees 1,887 Active Patients 300,000 Enrollees 200,000 Visits per Year 1,000,000 Patient Mix (HMO/FFS) 70% / 30% 2 1
Locations Across San Diego 3 4/16/2015 Design a Care Model 2020 Care Model Clinical Redesign Care Programs Health Disease Chronic Care Nurses Complex Case Pharmacy Refill Clinic Mental Health Integration Leveraging Technology Office Standardization Physician & Staff Communication Skills Training Leadership Training Improve Access to Care Peer to Peer Reviews Performance Transparency Patient Activation & Shared Decision Making Health Coaching Health Education Classes Community Resources Healthier Living Classes Patient Representatives on Committees Patient Portal Automated Reminders 4 2
Key Components of the Health Program 5 Patient Data Collection Clinical Claims Registry Patient Data Analytics & Predictive Modeling 6 3
Health Risk Stratification Interventions Keep Patients Healthy, Happy & at Home Tier 4: Complex 5% Tier 3: High Severity 15% Chronic Diseases with 2 hospitalizations Needs Coordination of Care Reduce Avoidable Hospitalization Tier 2: Moderate Severity 20% Programs for Chronic Diseases Implementation of Evidence Based Guidelines Tier 1: Low Severity 60% Preventative Care Reminder Program Annual Wellness Exam & Targeted Outreach 7 Systematized Care Provider Office/ Medical Home Personal Connection Face to Face Care Coordination Team Engagement Support Patient Self Wellness/Gaps in Care Shared Care Plan Educational Material Biometric Monitoring Expand Care Settings Home Hospital TeleHealth SNF 8 4
Continuum of Care Health & Wellness Promotion of knowledge, healthy attitudes and practices to help our patients achieve their personal best health. Healthier Living Chronic Disease Self Weight Dietician Consultation Heart Failure Healthy Hearts Asthma Stress Strength Training Smoking Cessation Disease : Education and support customized to the patient s level of health, allowing them to self-manage their chronic medical condition, promote wellness and prevent complications. Disease Managers/Coordinators Diabetes Asthma CAD Obesity/Sleep Apnea Heart Failure Pharmacy Focus on medication therapy management and improved patient adherence. Lipid Clinic Refill Clinic Medication Reconciliation Chronic Care Nurses Provide patient support in the Primary Care Offices. The RN supports and reinforces the treatment plan prescribed by the physician. 5 or more chronic medical conditions 4 or more ER visits in the last 12 months 4 or more hospital admissions in the last 12 months Complex Coordination and assessment of care and services for members who have experienced a critical event or diagnosis that requires the extensive use of resources and system navigation in order to facilitate appropriate delivery of care & services. 9 Team Based Care Disease M/M Programs Healthier Living Chronic Care Nursing w/pcp Complex Case M/M Pharmacy Programs Outpatient Transitions Palliative Care Home Continuum of Care ER & Urgent Care Urgent Care Collaboration Home Health Case Manager Extended Care Team SNF ALF/B+C Hospital Hospital CM Hospitalist COC Post Discharge Calls 10 5
Teamwork Who is on your team? 11 22 20 18 16 14 12 10 8 6 4 2 0 Hours Safe Care Requires a Team & a System 8-hour day Prevention 10 hours/day Patient Education: 2 hrs/day Care Coordination: 2 hrs/day Direct Patient Care 7 hours/day PCP Physician day (Based on a panel size of 2500 patients*) 8-hour day *Preventing Chronic Disease Apr 2009, 6(2): A59 - Family Physicians as Team Leaders: Time to Share the Care Kimberly S H Yarnail, MD ; etc 6
Hospital and SNF Case Roles of Continuum of Care Teams Hospital and SNF discharge planning Coordination of care to reduce readmissions Complex Case Chronic Care Nursing Disease Catastrophic or high risk cases e.g. Organ Transplant, MVA, Multiple Comorbidities, UM, Discharge Plan Team work with PCP, embedded model Post hospital and coordinate care of high risk multiple chronic condition patients -- short term Long term engagement and management CHF, COPD,CAD, Asthma, Diabetes Pharmacy Program Medication therapy management High cost, Refill, Adherence, High risk, Reconciliation Healthier Living Group classes and peer support group Example Chronic Diseases, Obesity 13 Have a Common EHR Platform How to find us in Touchwork 14 7
How are Patients Referred? Lead Triage Nurse for Care Continuum Phone Referral Electronic Health Record (EHR) Referral 15 Create Workflows with Automation 16 8
Create Workflows with Standardization Chronic Care Nursing PHN Checklist Before the Patient Visit Touchworks Review last PCP note Review last Specialist Note Review Immunizations (Flu, PNA, Zoster) Review Advanced Directives Review recent labs (if labs ordered but not completed, remind patient to the lab ASAP) Cerner Review discharge note Review labs Review discharge medications Review past ER/Hospital admissions records CCN Compare Cerner & Touchworks medications list. If different, reconcile & notify the PCP 17 Care Team Staff Ratios RN Supervisor 1:15 20 Care Managers RN Triage 1:500 Referrals/Month RN Case Manager Level 3 1:125 150 Members RN Case Manager Level 2 1:195 250 Members Health Case Manager 1:250 500 RN Case Manager Telehealth 1:500 1000 Members MSW 1:125 150 Members MA 1:500 Members Community Health Worker 1:100 Members Administrative Support 1:5 RN DMS 750 1000 Members 18 9
Optimize Care Team Roles Disease Activity Report Case Load by Status 19 Engage the Patient: Partner with me! Form personal connection Face-to-face interaction Step-by-step wellness plan Coordination of care across the system Patient specific education material Shared care plans Medication adherence reporting Use HIT to engage all patients not just present 20 10
Goals: Yours or mine? Personal Goals Smart Goals What are your personal goals? What s important to you today, next week, a month from now? How do you want to be living each day? Where and with whom do you want to be? What motivates me/inspires you? What impact is my illness having on the achievement of my goals? 21 Measure the Engagement Rate 22 11
Devices that Drive Healthier Behavior the booming mhealth market will grow to $26 billion by 2017, with a worldwide market of 1.7 billion users looking to use their smartphones and tablets to take care of their health. Currently, there are about 97,000 mobile health applications ~ Research 2guidance 2013 88%of physicians want patients to track or monitor their health at home. ~PricewaterhouseCoopers-HRI Physician Survey 2010 23 Sometimes, people like talking to computers. 24 12
Outreach in Multiple Ways Outreach using Follow My Health web portal and Nuance telephonic outreach messages New Motto: Minimize the number of lists which go out to the Physicians and Clinic sites. 25 Personal Health Record 26 13
Clinical 27 Continuous Improvement Process 28 14
Quality Results: Chlamydia Screening Chlamydia Screening Rate in Women 16-24 Years: Commercial HMO 29 Quality Results: Cervical Cancer Screening 30 15
Quality Results: Breast Cancer Screening 31 Quality Results: Breast Cancer Screening 32 16
Quality Results: Diabetes 56% SRSMG Advanced Perfect Care Percentage Diabetes Patients with HA1c<8, 2HA1cs, LDL<100 or Active Statin, Blood Pressure <140/90, and Nephropathy Screening methodology: 12 month rolling inclusion period 54% 52% Compliance Rate 50% 48% 46% 44% Goal: 50% 47.36% 42% 40% Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Old APC 45.00% 44.30% 44.45% 45.40% 47.34% 49.42% 52.78% 54.63% New APC 44.56% 44.73% 44.91% 45.67% 48.61% 50.25% 52.36% 53.37% 52.90% 52.05% 52.85% 48.51% 47.62% 47.36% 33 Continuous Improvement Process Benchmark 12% 34 17
Appropriate Resource Utilization: 30 Day Senior CHF Readmission Rate 35 Appropriate Resource Utilization: 30 Day All Cause Senior Readmission Rate 36 18
Aligning Community Stakeholders: Sharp Extended SNF Care Contracted Network of 60 SNFs Collaborators 10 SNF Reduced Length of stay by 20% Improved 30 days readmission rate to be <12% 37 Awards & Recognition Acclaim Award Honoree Top 10% Nationally for Patient Satisfaction 2014 Doyle Award CHF Program recognition by MCG Guidelines with its highest honor Number two medical group state score in 2013 by Consumer Reports based on patient experience among 170 medical groups Top Medical Group 2012, 2013 & 2014 Ranked #2 by local newspaper based on local newspaper, based on local resident votes Baldrige Quality Award Winner 38 19
Awards & Recognition (continued) CAPG Elite Status for 7 years in a row IHA state Top Performing Medical Group status for 10 years in a row State s Office of Patient Advocate 2013 4/4 stars rating: 207 groups In top 90% of scores for all the medical groups across the specific quality measure AAAHC accredited 39 Challenges & Opportunities 40 20
Challenge: Moving from Individual to Team Based Fee for Service Value Based Care Accountable Care 20 minute visit 22 patients a day Unknown Health Risks Episodic Care Panel Health Risk Assessment Quality Care Preventive Care Total Cost of Care Patient Experience 41 Lessons Learned Change is Hard: Share Best Practices Align stakeholders Organization scorecard Patient care workflows Keep it simple and centralized Team based healthcare Engage Patients Highest scope of license Measure Use Technology Integrate and leverage it Engage Physicians Measure & Performance Address practice variation Demonstrate the ROI 42 21
It is all about Teamwork! 43 22