Innovative Ways of Achieving The Triple Aim: Lessons from a Rural Community Health System Roxanne Elliott, MS Policy Director FirstHealth of the Carolinas
Goals For Today Review scope of project Integrate multidisciplinary team approach Implement Chronic Care model and shared care plans Review project outcomes Share data collection challenges and solutions Share lessons learned and next steps
Overview of Organization Health Care System South Central North Carolina 4 hospitals One hospital is Critical Access Hospital Serve four county primary care region Two counties classified as Tier One (economically underserved) Core purpose: To Care For People
County Level Demographics Total Population White (%) African American (%) Hispanic/ Latino (%) Asian (%) Native American (%) % Over age 65 NC 9,752,073 72.1 22 8.6 2.3 1.6 13.2 Hoke 49,272 51.1 33.8 12.6 1.3 10.0 7.3 Montgomery 27,667 77.2 19.2 14.5 1.6 0.8 15.7 Richmond 46,611 62.9 31.0 6.2 1.1 3.1 14.5
Population Health Three county region: Montgomery, Richmond and Hoke Disease/Lifestyle Habits 3-county region State/National average Hypertension 40.4 % 31.5 % (NC) Diabetes Prevalence 17.2 % 9.8 % (NC) Depression 30.8 % 26.5 % (US) Tobacco Usage 25.6 % 19.7 % (NC) BMI greater than 25 72.5 % 65.3 % (NC)
Project Background Emergency Department and Hospital Readmission penalties Future Population Health Management Model Developed proposal to create chronic disease clinics ; Transition Care Clinics (TCCs) Focus on moving towards self-management, behavior modification, care coordination, education, monitoring
Leveraging Funds Leveraged funding from HRSA through the Federal Office of Rural Health Policy for Small Health Care Provider Quality Improvement Grant 3-year project started Fall 2013; ends Fall 2016 As a result of project, leveraged additional grant dollars: $50,000 start up grant from Montgomery Foundation $20,000 Flex-fund grant to pilot bluetooth technology for glucometers $25,000 grant from NC Dept of Commerce for gap medications and supplies for TCC patients $450,000 grant Duke Endowment to address diabetes and heart disease outcomes
Creative Solution for Service Delivery Chronic Disease Clinics (Transition Care Clinics) Multidisciplinary approach to care Chronic Care model 6 Core Components Focus on Quality measures and processes Referral criteria ED and hospital patients referred if no primary care provider and/or cannot obtain appointment with PCP within 72 hours of discharge
Multidisciplinary Team Approach Provider Nurse Health Coach/TTS Behavioral Coach Pharmacists CDE/RD Behavioral Services Respiratory Therapist (on-call) Medication Assistance Patient/Family Financial aid (system) Partners: Legal Aid of NC and HealthNet
Transition Care Clinics Phased Openings Montgomery opened March 11, 2014 Opened 2 days per week Richmond opened October 14, 2014 Opened 2 days per week; Transitioned to 5 days per week Hoke opened February 9, 2015 Opened 2 days per week; transitioned to 3 days February transitioning to 4 days
TCC Leadership Daniel Barnes, DO President FirstHealth Physician Group Beth Walker President, Montgomery Memorial Hospital Roxanne Elliott Project Director Leigh Formyduval Clinic manager Consortium Group
Montgomery TCC Richmond TCC Hoke TCC
TCC Providers
Project Implementation with Data Focus Formed Small Quality Committee Included Information Systems and Clinical Practice individuals Provider champion Built data systems to address project challenges Built data systems to monitor project progress, engage multidisciplinary team and analyze data to implement change
New Systems Put Into Place Stabilizing Patients in 30-Day Concept Implementing Multidisplinary Approach Huddle Encounter plans implemented in EMR Workflow/Clinic flow Quality of Life survey PHQ-2 PHQ-9 Performance Improvement Measures (PIMS) collection
Data Collection and Reporting Systems Built Calendars Encounter plans Use flowsheets (PIMS) Discharge Order Sets (primary care) Staff training
Data Systems Created Data Tracking and Collection (PIMS) Calendars Allows data to be pulled on encounters with team Encounter plans Reinforces PIMS data collection Ensures multidisciplinary team is engaged Discussed at huddle Run reports from EMR on orders cued by encounters
Use flowsheets Data Systems Created Provides ability to run EMR reports on specific PIMS measures Disease specific flowsheets to collect PIMS measures Developed a PIMS measure flowsheet to track ongoing data through project Discharge Order Sets (primary care) Cues up when to request follow-up PIMS data Provides information on patient primary care provider Reports run and monitored on regular basis
Shared Care Plan Design and Implementation Shared Care Plans integrates patient knowledge, focus areas for improvement, disease specific targets and short-term goal setting General Diabetes Heart Failure Hypertension COPD
Outcomes/Results Data from March 11, 2014 to Sept. 31, 2015 Unique Patients: 827 Total Encounters: 3,810 Demographics: American Indian 25 African American 349 Other 72 White 368 Declined 10 Asian 2 Pacific Islander 1
Outcomes/Results Data from March 11, 2014 to Sept. 31, 2015 Ethnicity: Hispanic 48 Non-Hispanic 761 Declined 18 Males: 437 Females: 390
Outcomes/Results Data from March 11, 2014 to Sept. 31, 2015 Insurance Status: Medicaid 121 Medicare 128 Private Insurance 161 Uninsured 417 (50.4 % uninsured)
Outcomes/Results Consults with Ancillary Specialist Unique Patients Hoke 159 Montgomery 134 Richmond 252 Total 545 Average Length of Visit: 2.4 hours/patient
Consults With Ancillary Specialists Consults with Ancillary Specialist Encounters Behavioral Coach 187 Behavioral Services 24 Diabetes Educator/Nutritionist 326 Health Coach 821 Total Encounters 1358 Note: unique patients is 545
Chronic Conditions In TCCs TCC Hypertension Diabetes CHF COPD Asthma Hoke 91 49 22 11 11 Montgomery 111 68 19 27 12 Richmond 219 107 34 36 10 Total 421 224 75 74 33
Readmission Rates 30-Day Inpatient Readmission Rates (system) 30-Day ED Readmission Rates (system) Baseline (system readmission rate) 19.4 % 16.7 % Grant Targets 15.5 % 15 % system level readmission rates FY13 9.2 % FY14 8.3 % 10.6 % FY15 8.9 % 10.3 % HRSA TCC specific patients: 3.8 % 16.1 % All TCC clinic patients: 5.9 % 15.8 %
TCC Specific Readmission Rates 30-Day Inpatient Readmissions from Initial TCC visit 30-Day ED Readmissions from initial TCC visit Montgomery 5.0 % 20.0 % Richmond 4.0 % 15.9 % Hoke 2.2 % 12.9 % HRSA clinic 3.8 % 16.1 % average Moore 7.5 % 15.5 % Note: HRSA Grant Targets 15.5% hospital and 15% ED
Predicted Readmission Savings In HRSA grant Submission estimated the following for readmission savings for system: Inpatient readmission avoided $4,000 ED readmission avoided $300
Diabetes Readmission Rates - System
COPD Readmission - System
CHF Readmission - System
Hypertension Readmission - System
Using Data To Steer Project
Data Example Surprising Outcome Predicted clinics would be predominantly Medicaid and Medicare patients with focus on uninsured incorrect assumption 50.4 percent of population served is uninsured (417 out of 827 patients)
Data Example What Does Readmission Data Say Regarding TCC Operations Initial data indicates in-hospital system readmissions declined significantly (19.4% to 8.9%) Initial data indicates ED utilization rates declined system wide (16.7% to 10.3%) TCC specific data hospital readmissions 3.8% and ED utilization 16.4% (note: ED rate was 14%) TCCs open limited hours Patients still seeking services in ED (but less than benchmark) Expanded clinic hours in two locations
Data Example Staff Compliance Data Entry Ran report showed staff were non-compliant entering discharge order set, which cues up PIMS follow-up data orders Hosted meeting Shared results Problem solved Ensured compliance for future Continue to monitor
Project Challenges CHANGE willingness to be innovative Shifting focus to prevention and patient engagement Staffing and reporting structure Staff Training Provider Training and Buy-in Data collection and extraction Monitoring of Compliance with New Processes/Workflows/Systems Implementation of shared care plans
Lessons Learned Must have right people Takes a TEAM Change is difficult for all Include staff when developing systems Staff needs to understand the WHY they need to understand importance of data input Need to create systems to capture data
Lessons Learned Provide staff with periodic reports that demonstrate gaps in data and problem solve involving their input Utilize data to monitor staff compliance Utilize data to monitor project outcomes Utilize data to provide ROI for project Utilize data to make project adjustments
Lessons Learned - Data Reports/Monitoring Run data reports at least quarterly Run reports by clinic to determine any trends (good or needs improvement) Use data to determine if systems need to be changed Use data to demonstrate project successes and challenges Process, perception and outcome measures Developing concrete system for monitoring readmission data specific to TCC patients to determine ROI for project
Quality Checks Are Essential Shared Care Plan Audits Found non-compliant Important to get team to understand it is process issues versus personal Regroup on shared care plans Set small, short-term goals to work towards compliance
Next Steps Adding case manager to clinics Continuing to monitor reports Continuing meeting with clinical staff Methodically determining best means of monitoring readmission data (system level vs. TCCs) Journal articles Taking time to evaluate future data needs Discussed adding fields to EMR for future data reports (separating referral sources) in social history Calculating ROI
This is what it is all about: Patient Success Patient Engagement Better Self- Managers
Contact Information Roxanne Elliott Email: rmelliott@firsthealth.org Phone: 910-715-3487
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