community-based chronic care management
DESCRIPTION
A PowerPoint used in a webinar that (1) describes the importance of community-based chronic care management today and in the future; and (2) details programs that have worked. A video of the webinar is available at our web site www.housecallsolutions.com.TRANSCRIPT
Community-based Community-based Chronic Illness Management:Chronic Illness Management:
Strategies and Tools to Reduce Strategies and Tools to Reduce Costs and Improve OutcomesCosts and Improve Outcomes
Community-based Community-based Chronic Illness Management:Chronic Illness Management:
Strategies and Tools to Reduce Strategies and Tools to Reduce Costs and Improve OutcomesCosts and Improve Outcomes
Steve H. Landers MD, MPHSteve H. Landers MD, MPHDirector, Cleveland Clinic Center Director, Cleveland Clinic Center for Home Care and Community for Home Care and Community
RehabilitationRehabilitation
[email protected]@ccf.org
April 5, 2010
Brent T. Feorene, MBABrent T. Feorene, MBAPresident, House Call SolutionsPresident, House Call Solutions
[email protected]@housecallsolutions.com
Today’s AgendaToday’s Agenda
• Welcome and Introduction
• Current trends
• What is on the table?
• Future tense
• Programs that hold promise
• CCF: Today and Tomorrow
• Q&A
Powerful Trends Impact Medical Practice
Powerful Trends Impact Medical Practice
Aging Population
Chronic Illness
Economic PressuresConsumer Expectations
Technology
Demographic ImperativeDemographic Imperative
Administration on Aging. A Profile of Older Americans: 2007. Accessed at www.aoa.gov
Activity LimitationsActivity Limitations
Administration on Aging. A Profile of Older Americans: 2007. Accessed at www.aoa.gov
Chronic Illness EpidemicChronic Illness Epidemic
Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update
Aging + Chronic IllnessAging + Chronic Illness
Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update
Costly Costly
Congressional Budget Office
2005 MCR FFS stats from MedPAC DataBook June 2008
“High Risk” “High Risk”
Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update
Jencks SF et al. N Engl J Med 2009;360:1418-1428
Readmissions
Half of Medicare Patients Rehospitalized Without Seeing Doctor After Discharge ~60% of
Rehospitalized HF patients hospitalized due to another problem
“Train Wrecks” “Gomers”
Frustration with the complexity, communication barriers, and administrative burdens…
Adams WL, McIlvain HE, Lacy NL, et al. Primary Care for Elderly People: Why Do Doctors Find it So Hard? The Gerontologist. 2002;42(6):835-42.
Adams WL, McIlvain HE, Geske JA, et al. Physicians’ Perspectives on Carring for Cognitively Impaired Elders. The Gerontologist. 2005;45(2):231-9.
Physician Frustration
Quality ConcernsQuality Concerns
• “suffering in spite of spending”• “silo care” “no care zone”• avoidable readmissions• hospital acquired conditions• the “hidden patient”• frustration
•Patient Centered Medical Home•Bundled Payments •Penalties for Re-hospitalizations•“Accountable Care Organizations”
What’s On the Table?
Chronic Care is DifferentChronic Care is Different
• Engaging community• Self-management support• Advanced information systems/
tracking
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. Jama 2002;288(15):1909-14.
‘New Model’ Primary Care‘New Model’ Primary Care
• Practice “Redesign”
• Team Approach
• Advanced Information Systems
• “Patient-Centered”
• “Healing Relationships”
14. Martin JC, Avant RF, Bowman MA, et al. The Future of Family Medicine: a collaborative project of the family medicine community. Ann Fam Med 2004;2 Suppl 1:S3-32.
Patient-Centered Medical HomePatient-Centered Medical Home
• Whole-Person
• Team Based
• Accessible
• Advanced Information Systems
• NCQA Certification Process
Kellerman R, Kirk L. Principles of the patient-centered medical home. Am Fam Physician 2007;76(6):774-5.
The Case of Mrs. JonesThe Case of Mrs. Jones
• 82 year old woman, h/o HF and OOP
• “Tired and weak and swollen ankles x 5 days”
• Walker, Oxygen, Son’s Assistance
Bringing Home Medical Home?Bringing Home Medical Home?
• Highest risk patients may not be able to access offices
- Permanent
- During time of vulnerability
• Accessibility and whole person approach enhanced when care is done at home
• Scalability of team
Landers SH. The other Medical Home. Jama 2009;301(1):97-9.
“Secret Weapons”“Secret Weapons”
Enhances view of patient and caregivers
Reduces barriers to care
Strengthens patient relationships
Avoids hazards of hospitalization
Costs less
Desired more
Enabling technology emerging
Workforce EstimatesWorkforce Estimates
• Annual FFS MCR HHA Visits > 110,000,000
• Medicare Home Health FTEs >250,000
• Annual FFS MCR Physician Visits < 2,000,000
• Home Care Physician and Mid-Level FTE’s ?
• Total Primary Care Physician FTEs ~270,000
Role for Home HealthRole for Home Health
Home health is likely the (only) truly scalable infrastructure for improving quality and access for the low-mobility, high risk Medicare beneficiaries who drive the majority of program expenditures and suffer the most---1st step in impacting quality for this group may be conceptualizing home health as THE central architecture/ platform to deliver transitional, post-acute, and primary care/ chronic care management for these individuals
Programs that hold promisePrograms that hold promise
• Transitional Care
- Multi-level targeting patients with the right provider at the right time
• House call programs
- Reserved for the frailest, most complex patients
Technology in the form of EMR/EHR and telehealth among others is not an absolute necessity, but has proven itself to be an excellent
enabler to improve productivity, reduce costs and enhance outcomes.
HealthCapacity
A Role for Chronic Care Management
Time
Disability
RiskFactors
Death
NormalAging
Chronic Care Management
• Hip fracture• Stroke• CHF• COPD
• Hypertension• Rapid weight gain/loss• Hyperglycemia
• Incontinence• Dementia• Caregiver burnout• IADL/ADL decline
• Obesity• Tobacco and alcohol• Environmental
Cumulative, inter-related risk factors require ongoing, coordinated care interventions.
PublicHealth
PrimaryCare
AcuteCare
Long-termCare
High
Accelerated Loss of Health
Acute Event
Disease Management
Adapted from, “The Glide Path” Kyle R. Allen, DOMedical Director, Post-Acute and Senior ServicesSumma Health System
Transitional CareTransitional Care
• Goal- Ensuring a smooth transition for the
patient from one site or level of care to another that meets goals of care
• Why?- Limits of traditional disease and case
management in preventing adverse events and unnecessary utilization/costs
Rates of Rehospitalization within 30 Days after Hospital Discharge
Jencks SF et al. N Engl J Med 2009;360:1418-1428
Who to target?Who to target?
• Community dwelling• Admitted for ambulatory sensitive
conditions, such as COPD, CHF, Diabetes, Pneumonia and Dementia
• Frequent flyers – two or more admissions in the past six months to one year
• Individuals currently enrolled in case management
Patient Factors Contributing to Poor Post-Discharge OutcomesPatient Factors Contributing to Poor Post-Discharge Outcomes
• Multiple conditions/therapies*• Functional deficits• Emotional problems • Poor general health behaviors• Poor subjective health rating*• Lack of support • Cognitive impairment**• Language, literacy and culture
Level ILevel I
• A health coaching model using RNs- 25 – 30 patients per coach- Not a “doing” model
• Lowest-intensity, lowest-cost model• Target thirty day duration• Enroll patients who are able to be
“coached” to effectively self-manage through the transition
Level ILevel I
• Five Principals
- Medication self-management
- Nutrition management
- Patient health record
- Physician follow-up
- Red flag awareness
Level IProcessLevel IProcess
• Health coach visits while I/P - Introduce the program and gain acceptance- Prepare patient and family for follow-up
• Home visit- One visit within 48 – 72 hours of discharge- Structured
• Review the program in detail• Environmental scan• Medication reconciliation• Review discharge instructions• Introduce PHR • Discuss physician follow-up• Educate on red flags
Level IProcessLevel IProcess
• Key follow-up phone calls- 2 – 3 calls as needed- Ensures compliance and continuity- Modify plan
• Plan to call after major post-acute events- Physician visit- Home health/therapy- Change in Rx regimen- Graduation
Level IILevel II
• Use RNs in a more active model of care
• RN must balance “coach” and “do”
- Patient capabilities
- Support systems
• More extended time frames up to 6 months
• Criteria are the same as Level I, but add
- Significant ADLs/IADLs
- Psycho-social concerns
Level IIProcessLevel IIProcess
• Builds on Level I activities
- RN visits while I/P
- Initial home visit within 48 – 72 hours of discharge
- Key follow-up phone calls
• Coaches and provides care
• May need additional home visit(s)
• Graduation date can be extended based on situation
Level IIILevel III
• Highest level of intensity and care provision using NPs and/or PAs
• A hybrid model, but weighted more toward medical than nursing
• SNF-level patient able to remain community dwelling- Geriatric syndromes- ADLs/IADLs- Polypharmacy
• Risk loss of functionality and/or exacerbation of chronic condition(s)
• Most likely to bridge “at-risk” period successfully with effective, coordinated care
Level IIIProcessLevel IIIProcess
• Builds on concept of Levels I & II• Initial visit within 48-72 hours of
discharge from SNF or hospital• Key follow-up phone call(s)• Typical 30 days enrollment to
graduation - Back to office-based practice- Enrollment in house call program
House Call ProgramHouse Call Program
• Provide a patient-centered medical home to frail, low-mobility elderly
• Physician and NP serve as the patient’s in-residence PCP- Primary care house calls
- Urgent care visits
• Collaborate with hospitalists on IP care• Coordinate specialty care, ancillaries and other
health services, as needed• Offer counseling and social service coordination
for patient and family/caregivers
House Call ProgramsHouse Call Programs
• Typical profile- Difficulty getting to/from the PCP office- Have not seen PCP in 12 -18 months- ED most likely access point for healthcare
services- 2+ deficiencies in ADLs- Complicated, chronic medical conditions and
polypharmacy not likely responsive to other programs
• Disruptive to PCP office flow- Physical/facility issues- Time and resource intensive- Difficult to meet the full spectrum of patient’s
needs
What are the outcomes?What are the outcomes?
• Community-based chronic illness management programs have demonstrated positive outcomes- Reduced utilization- Lower costs- Improved outcomes
• Health• Quality of life/Goals of care
Transitional CareTransitional Care
• Eric Coleman, MD• Randomized controlled trial of a Level I
program• Outcomes
- Reduced readmissions- Lower costs
• In use by over 135 health systems nationally
House CallsMontefiore Medical Center House CallsMontefiore Medical Center
Pre-HCPInitial Six
Mos.Absolute Change % Change
CMO HCP Patients 112 112Member Days 12,936 12,936Total Hospital Days 820.0 503.0 (317.0) -38.7%Total Admits 102.0 59.0 (43.0) -42.2%Hospital Admit PPPY 2.9 1.7 (1.2) -42.2%Hospital Avg. LOS 8.0 8.5 0.5 6.0%Total SNF Days 2,148.0 703.0 (1,445.0) -67.3%Total SNF Admits 41.0 17.0 (24.0) -58.5%SNF Admit PPPY 1.2 0.5 (0.7) -58.5%SNF Avg. LOS 52.4 41.4 (11.0) -21.1%
Results for Medicare Advantage Enrollees
How are these programs paid?Managed Care/Payer PerspectiveHow are these programs paid?Managed Care/Payer Perspective
• The economic incentives are aligned and the programs produce positive ROI
- Montefiore
- Summa Health System
- Inspiris
- United
How are these programs paid?Medicare FFS environmentHow are these programs paid?Medicare FFS environment
• Programs’ downstream benefits - Capacity management
• Avoided admission• Reduced ALOS• Less pressure on ED
- Fewer re- admissions- Increased market share
• Provider professional billings- Partial contribution- MDs, NP & PAs
• Community agencies
Cleveland ClinicCenter for Home Care and Community Rehab
Today: Gaining a beach head
Cleveland ClinicCenter for Home Care and Community Rehab
Today: Gaining a beach head • System-wide recognition
- Oversight and Strategy Board- Department of Home Care Physicians
• Services- Mobile physician services
• Geriatric consults• PCP
- Home care, hospice, home infusion, etc.• Expansion of MPS
- First to a specific CCF member hospital in development for 2010
Cleveland ClinicCenter for Home Care and Community Rehab
The future: Strategic tool for CCF
Cleveland ClinicCenter for Home Care and Community Rehab
The future: Strategic tool for CCF
• Seamless delivery and coordination of care- Regardless of location - Regardless of age/time in life
• Care transitions• New roles for home care staff• Use of telehealth and remote technologies
Transitional Care ResourcesTransitional Care Resources
• Eric Coleman, MD
- www.caretransitions.org
• National Transitions of Care Coalition
- www.NTOCC.org
• Better Outcomes for Older adults through Safer Transitions (BOOST)
- www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm
House Call ResourcesHouse Call Resources
• American Academy of Home Care Physicians
- www.aahcp.org
• American Geriatrics Society
- http://www.americangeriatrics.org/products/positionpapers/housecall.shtml
Thank YouThank You
“The future belongs to those who believe in the beauty of their dreams”
- Eleanor Roosevelt