CARE COORDINATION PROJECT Improving Care Coordination for Patients Diagnosed with Congestive Heart Failure, Diabetes and Hypertension History Objectives CONTENTS Implementation and Information Technology Results Insights from the Patient Navigators Challenges Future of the Program 1
PATIENT R 47 years old Patient of South Central Family Health Center Spanish Speaking patient who frequently uses CHMC s Emergency Department Chronic condition: HTN and Type 2 Diabetes PATIENT STORIES Patient JM JM is a 67 year old Spanish speaking patient at SCFHC. She has been diagnosed with Diabetes and HTN. She comes to the hospital with shortness of breath and chest pain. By providing her immediate appointments after discharge, she is able to follow up with her doctor (Dr. Mull) at SCFHC, so that they can review her current symptoms and continue to track her health. 2
PATIENT STORIES Patient F Patient F is a 75 year old male with history of HTN. He came in due to a leg injury and informed us how challenging it can be to see his doctor (Dr. Butler) at THE Clinic. Due to this doctor's popularity with his patients, Mr. F won't be able to see his doctor until April. He was told he may be seen sooner by another doctor, however, Mr. F feels most comfortable and has build rapport about his health conditions with this doctor. He was pleased to know that this Care Navigation program at CA Hospital, is there to help him get an appointment with his doctor within 72 hours of discharge. History South Los Angeles Health Disparities & Stakeholder Engagement 3
LOS ANGELES COUNTY SERVICE PLANNING AREAS (8 SPAS) AND HEALTH DISTRICTS (26 HDS) PREVENTABLE HOSPITALIZATION DISPARITIES 4
HEART FAILURE RATES BY FREQUENCY OF VISITS Source: OSHPD 2009 rates per 100,000, analyzed for unique cases of CHF hospitalizations based on AHRQ PQI#8 definitions Compton Southeast Antelope Valley San Antonio Bellflower Whittier Harbor Pasadena East Valley Torrance San Fernando West Valley West 35 47 52 50 58 41 31 56 36 35 43 39 34 45 24 30 28 31 27 21 114 95 91 78 73 96 54 Hospitalizations due to Diabetes Complications by LAC Health Districts, per 100,000, OSHPD 2009 205 180 174 163 151 149 155 135 131 127 117 115 119 104 115 102 94 88 81 82/100,000 213 220 213 156 30 240 257 29 30 30 24 25 24 26 23 22 41 35 43 26 407/100,000 Hospital admissions for diabetes are MORE THAN 4Xs as HIGH in some Health Districts than others diabetes short term complications diabetes long term complications uncontrolled diabetes lower extremity amputation Source: OSHPD 2009; Rates less than 20 are not labeled. 5
Hospitalizations and Emergency Department Encounters due to Hypertension by LAC Health Districts, per 100,000, OSHPD 2009 Southwest South Inglewood Compton Southeast Bellflower San Antonio Antelope Valley Glendale Central Pasadena Long Beach Northeast Whittier San Fernando Harbor East Valley West Valley East LA Pomona Torrance Hollywood Wilshire Foothill El Monte Alhambra West 97 183 149 145 155 153 205 186 189 178 176 231 217 224 213 197 195 207 195 208 201 24 240 339 296 281 292 54 48 37 39 48 46 30 37 44 31 45 41 62 76 73 54 65 73 69 58 97 88 76 115 125 ED encounters and hospital admissions for hypertension are MORE THAN 3Xs as HIGH in some Health Districts than others Emergency Department Encounters Hospital Inpatient Admissions Definition: PQI #07 per 100,000 adults for hospital and ER admissions among adults 18 and over; Source: OSHPD 2009 STAKEHOLDER ENGAGEMENT Community Health Councils convened the South Los Angeles Healthcare Leadership Roundtable which served as an incubator for advocacy, shared analyses, and demonstration projects Executives from health centers, hospitals, physician networks, health plans, and health policy advocates that serve South LA willing to work together to eliminate the structural barriers to delivering quality healthcare A 2012 pilot project: What is the South LA safety net healthcare capacity to diagnose and treat heart failure? Structured dialogue with stakeholder group and monthly meetings, clinical leadership meetings, and phone calls Can we? Do We? How? Could we? Highlighting resource needs and role of payer variation How can we move forward? Facilitated dialogue and prioritization: Modified World Café facilitation method Elicited suggested solutions: What are easy wins or low hanging fruit that can have an impact in the next 1-2 years? 6
STAKEHOLDER ENGAGEMENT Stakeholder engagement process identified 37 unique recommendations and four highest ranking included Solutions: Short Term Goals/Low Hanging Fruit (Overall rankings) Linking EHR-data sources/health Information Exchange: Stages A, B, C, D (22 votes) Increase capacity for structural heart disease diagnostic tests: Stage B (21 votes) Coordination of Post Discharge Care and Information Exchange: Stage C (13 votes) Group visits for high risk populations: Stage A (12 votes) STAKEHOLDER ENGAGEMENT Several partnership efforts developed between South Los Angeles serving entities capable of addressing many of these shared concerns and potential solutions One of these was the project described today The Care Coordination Project: Improving Care Coordination for Patients Diagnosed with Congestive Heart Failure, Diabetes and Hypertension Linking EHR-data sources/health Information Exchange Increase capacity for structural heart disease diagnostic tests Coordination of Post Discharge Care and Information Exchange Group visits for high risk populations 7
The Pilot Clinics South Central Family Health Center UMMA Community Clinic THE Clinic, Inc. PARTICIPATING COMMUNITY HEALTH CENTERS Initial Centers South Central Family Health Center To Help Everyone Health & Wellness Centers UMMA Community Clinic Centers Added in Q4-2017 St. John s Well Child & Family Centers South Bay Family Health Care Watts Health Corporation Center Added in 2018 Eisner Health 8
SOUTHSIDE COALITION CLINICS CHRONIC CONDITION PATIENTS Congestive Heart Failure: Diabetes: Hypertension: 1,368 patients 36,062 patients 44,246 patients CHF+Diabetes CHF+Diabetes+Hypertension CHF+Hypertension Diabetes+Hypertension 680 patients 622 patients 1,104 patients 19,216 patients WHY DID WE DO THIS? Need for more timely care navigation posthospitalization UMMA leadership Early feedback with area pilot program Growth in dual risk relationships with multiple IPA s CMS tracking 30 day readmissions Baby step toward care integration Lack of movement with other HIE s in the area 9
PROJECT PARTNERS Dignity Health California Hospital Medical Center Bob Quarfoot, Vice President, Business Development Mitzi Bastida, Patient Navigator Wendy Bastida, Patient Navigator Southside Coalition of Community Health Centers Andrea Williams, Executive Director PROJECT PARTNERS Trans World Health Services, Inc. Bryan Lang, CEO David Geffen School of Medicine at UCLA and Charles Drew University Roberto Vargas, MD, MPH 10
1 2 3 4 Increase medication adherence Create protocol for missed appointments Increase clinic appointments within 72 hours of hospital discharge Reduce 30-day readmissions by 15% Clinical Objectives Make available data for their patients with the three chronic conditions EXPECTATIONS OF CLINICS Designate office staff for scheduling, care coordination Provide short-term appointment availability Create individualized, evidence based care plans Provide clinic attendance for navigated patients 11
5% 12% PROJECT EXPENSES 20% 63% IT Expenses Patient Navigators Clinics Hospital Funded by California Community Foundation, Centinela Valley Medical and Community Funds, and LA Care Health Plan GETTING STARTED Contracts Care Navigator Staffing Clinic Staffing and Protocols Clinic Patient Data Real-time Hospital Data Health Education and Referrals Reporting Six months from contract start, the program went live January 1, 2016 Run continuously for over two years 12
INFORMATION SYSTEMS FOR REAL-TIME PATIENT IDENTIFICATION AND CARE NAVIGATION Clinic EHRs periodic data exports Dignity Patient Care System real-time interface Inpatient ER Outpatient Walk-In Clinic HIE*Lite Second LA-Area Implementation of Real-Time Care Navigation Regional patient data repository at center Real-time hospital care system interface Care Navigation Workflows Assessments Clinic appointment bookings Attendance follow-up IMPLEMENTATION CONSIDERATIONS FOR INFORMATION TECHNOLOGY Legal approvals from all participating entities for data security, access, and use Divergent IT standards, security, access, and certification requirements Concerns over data sharing Interfaces, whether batch or real-time Data standardization Third-party vendor considerations Once implemented, challenges don t all go away Participating entities can (and do) change: Application versions Application vendors Hosting platforms VPNs IT management and support staff Each change may require support 13
OVERVIEW OF THE PROCESS Southside Clinic patient checks in at hospital HIE*Lite immediately identifies home clinic and whether patient has selected chronic condition Patient review task placed on care navigator task list Navigator engages patient, ideally before discharge Establishes appropriateness for follow-up clinic care Makes clinic appointment, ideally within 72 hours of discharge Verifies patient kept appointment If not, contacts patient and reschedules as appropriate Surveys periodically for medication adherence RESULTS: MEDICATION ADHERENCE Telephonic 8-question medication adherence surveys administered to 487 navigated patients Baseline adherence rate established in first six months of program 305 surveys completed in 2016 and 273 completed in 2017 85.4% of patients were given one survey 11.5% of patients were given two surveys 3.1% of patients were given more than two surveys In the 18 months following establishment of baseline, medication adherence improved by 2.8% over baseline 14
RESULTS: CARE COORDINATION 5,451 eligible hospital encounters in the first two years Eligible patients have been previously seen by one of the aligned clinics and who have been diagnosed with one or more of the chronic conditions of diabetes, hypertension, or congestive heart failure. Eligible patients may have one or more visits to CHMC over the reporting period. 3,875 encounters evaluated (71.1%) 51.5% of eligible visits had follow-up clinic appointments booked 74.8% of booked clinic appointments were kept 30-DAY READMISSIONS/ REVISITS BASELINES FOR THE THREE CHRONIC CONDITIONS Baseline 30-day Readmission/Revisit Rates for patients diagnosed with CHF, DM, or HTN: Inpatient readmissions 20.9% ER revisits 24.6% Outpatient walk-in clinic revisits 23.3% 15
RESULTS: REDUCTION of 30-DAY READMISSIONS/ REVISITS 30-day Readmission/Revisit Rates for Chronic Condition Patients Assessed and Clinic Booking Made and Subsequently Kept: Encounter Type Rate Reduction Inpatient readmissions 18.83% -9.79% ER revisits 14.22% -42.2% Outpatient clinic revisits 7.72% -66.8% REDUCTION OF 30-DAY INPATIENT READMISSIONS WHEN CLINIC BOOKED BEFORE DISCHARGE 30-day Inpatient Readmission Rate for Chronic Patients Assessed and Clinic Booking Made Before Discharge and Subsequently Kept: Encounter Type Rate Reduction Inpatient readmissions 10.00% -52.1% Key Takeaway For maximum benefit, engage with patient and make a follow-up clinic booking before the patient leaves the hospital. 16
WHY REVIEW TIMELINESS MATTERS 140 120 100 80 60 40 Kept Appointments Kept Appointments and Readmission And Revisits Distribution Distribution A large number of revisits happen within the first week of discharge. Had clinic appointments been made during the patient hospital visit and kept within 72 hours of discharge, many of these revisits could have been avoided Revisit Count Kept Appt Count 20 0 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 Days After Discharge INSIGHTS FROM THE NAVIGATORS Working with patients Working with the clinics E-scheduling Emergency Department Usage Education 17
CHALLENGES Staff turnover I.T. Changes Changing Patient Behavior Scheduling Appointments with the Clinics VALUE OF PROGRAM Cost Savings Education on appropriate use of Emergency Department Relationship Building with Navigators & Providers Reduced Readmissions and Emergency Department Usage 18
FUTURE OF PROGRAM Sustainability Integration with other HIE Systems Program Expansion Replication QUESTIONS 19
CONTACTS Andrea Williams, MPA Executive Director Southside Coalition of Community Health Centers (213) 741-0821 ext. 261 Andrea@southsidecoalition.org Bob Quarfoot, MSIA Vice President, Business Development Dignity Health California Hospital Medical Center (213)742-5832 Bob.Quarfoot@DignityHealth.org Bryan H. Lang CEO Trans World Health Services, Inc. (775) 852-9440 BHL@transworldhealth.com Roberto B Vargas, MD, MPH Associate Professor David Geffen School of Medicine at UCLA (310) 794-3703 RBVargas@mednet.ucla.edu Charles R. Drew University (323) 249-5736 RobertoVargas@CDrewU.edu THANK YOU We would like to thank the funders of this project California Community Foundation CentinelaValley Medical and Community Funds And LA Care Health Plan 20