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Pat Brydges RN, MHA, ACM Regional Vice President, Care IntegrationElisol McKim RN, BSN, CCM Care Manager, Care Connect

Misty J Rydelski, MD Internal Medicine, Utilization Medical Director

Intensive Outpatient Care Program

CARE Connect

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St. Joseph Health

SJH serves communities in Northern California, Southern California and West Texas/New Mexico

• 16 hospitals, • 2 home health agencies• Integrated physician groups in

every market • Discharges 155,400• ER Visits: 537,800

St. Joseph HealthMission: To extend the healing ministry of Jesus in the tradition of the Sisters of St.

Joseph of Orange by continually improving the health and quality of life of people in the

communities we serve.

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St. Joseph Hoag Health

• 9 Hospitals

• 26 Urgent Cares

• 10 Physician Networks –

• 475 Primary Care Physicians

• 1,250 Specialists

Orange County, CA

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Population HealthHealth Status & Cost Breakdown of our Full Risk Populations

Chronic/Episodic

Medium -Risk

Healthy – Low Risk77.7%/73.3%

Complex Care

High Risk

Complex8.1%/8.3%

Health Status

14%/18.6%

Cost Breakdown

40%

43%

17%

%=Medicare Advantage and BSC Commercial4

Almost 50% of our costs are on less than 10% of our patients

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Population Health ManagementPrograms developed to help meet Triple Aim Improve Health, Enhance Patient Experience, Reduce Costs

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• Nurse Advice Line• New Member On boarding• Centralized Prescription Refill• Patient Portal• Wellness/Weight Management• Preventive Care• Tele-Medicine

• Standardized Clinical Protocols

• Tele- monitoring• Diabetes Education

• CARE Connect/Regional Care Management

• Transitional Medical Clinic (TMC)

• Post Discharge Phone Calls• Regional Palliative Care• Tele-Monitoring

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What is Care Connect?• A team of Specially Trained Care Managers, Health

Advocates and Social Workers managing Medically and Socially complex patients

• Support team of Clerical Staff and access to a Pharmacist

• Embedded in PCP Offices – are members of the PCP team

• Perform Motivational Interviews, Patient-Centered and Patient Driven Shared Action Plans Goals

• Provide home visits, see patients in office, clinic, hospital, skilled nursing facility

• 24/7 access for patients through Nurse Advice Line

• Develops strong trusting relationship with patient and family

• Provide coordination of care across the healthcare continuum

• Technology/Documentation – Patient Identified as “Care Connect” with Care Manager

Name/Phone Number in Allscripts Touchworks (EMR)

– Documentation in Allscripts Touchworks (EMR)

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Patient Selection/Processes

• Risk Stratification using Verisk

– Likelihood of hospitalization

– Concurrent Risk

– Predictive Risk

• Other Reports: Readmission, ER Visits, LACE Reports

• Referrals from Providers, Hospitals, Transitional Medical Clinic) Care Managers

• Focus on Full Risk Patients (Medicare Advantage) and Domestic Full Risk (Commercial)

• Criteria

– Diagnosis, Cognitive, Understanding Condition, Meds, Self management skills, Overall Health Status

– Frequent PCP, ER, Hospital visits

– Living Situation, Care at home, depression, hopeless feelings

• All information is shared with PCP in selection of patients

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Care Connect Program

Regional Program - All networks Southern California

14 Care Managers and 8 Health Advocates

1,858 patients enrolled since April 2013 - >900 Active patients

132 Participating PCPs

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Care Connect - Financial Outcomes Patients enrolled between April 2013 thru December 2014

- 954 patients)

90 days prior to enrollment

90 days post enrollment

Estimated Events and Spending Avoided

Inpatient visits 278 204 74

Estimated inpatient Spend (using $11K as average cost per visit)

$3,058,000 $2,244,000 $814,000

ED visits 315 212 103

Estimated ED spend (using $1354 as average

cost per visit)$426,510 $287,048 $139,462

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A Care Manager PerspectiveElisol McKim RN, BSN, CCM

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How the Physicians IntroduceCARE Connect to Patients

• The CARE Connect Team (RN/LVN Care Manager, Social Worker, and Healthcare Advocate) are here to help me take care of you.

• The CARE Connect Team is your “Disneyland Fast Pass to me (Physician)”

• The CARE Connect Team is your “GPS to the healthcare system”

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This is a CARE Connect Doll

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Initial Super Visit

Nurse/Patient Visit

20-30 minutes

Nurse/PCP/ Patient Visit

15 minutes

Nurse/Patient Visit

15-20 minutes

•Relationship

building with patient

•Ask then listen

•What bothers you

most?

•Where do you want

to be in a year?

•Team approach

•Patient agreement

•PCP introduce

nurse as a member

of care team

•Non-stethoscope

visit

•Assessments and

goal setting

PAM

VR-12

PHQ -9

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Care Management Interventions

• Disease Education and Coaching

• Advise, educate, and support Caregivers

• Home Safety evaluation as necessary

• Social Work referral for multiple psychosocial stressors or abuse/neglect concerns

• Medication Reconciliation & Adherence

• Referral Management and Education

• Advance Directive Discussion

• Coordination of overall care across continuum

• Provide community resources

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Patient Success

• 71 year old male with CHF, DM Type II, A-Fib., CAD, CKD, HTN, Hx. CVA, Hemiplegia, Recent MI

• Elisol met with the patient in physician office on 07/2013

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On going support• Connected the patient with specialists (cardiology,

endocrinology)

• Medication reconciliation

• Medication Education

• Home visit to evaluate barriers to patient’s self care.

• Educate patient regarding symptom management and when to call the health care providers.

• On going communication with the health care providers to ensure continuity of care.

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Outcome• Hgb A1c- 9.7 upon enrollment to CARE Connect

– Current Hgb A1c-7.5

• Inpatient or ED admission

– None in 2013

– 1 inpatient admission in December 2014

– 1 inpatient admission in September 2015

• Patient and family are engaged in taking care of their health.

• Patient and family are appreciative of nurse relationship

• Call or text nurse with appropriate questions or concerns

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A Physician PerspectiveMisty J. Rydelski, MD

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How do we move from current state to future state? We do it through Population Health Management (PHM). In PHM, we use information to look proactively at our population and develop programs to better meet the needs of those population. Different from the “old” way of waiting for patients to be sick and seek care.

We measure success in Population Health Management in terms of the Triple Aim: Improving community health, enhancing the patient experience and reducing costs.

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PHM is defined as using information to manage the outcomes of groups of individuals. We have broken down our population into 4 segments and we are working to develop programs and services to meet the needs of each segment. Here are some examples:

Complex care are very sick patient who need a nurse to call them on a regular basis to help them stay healthy and out of the hospitalCase management are patients who have had an inpatient stay and need help transitioning back into their home. We help connect them to their provider of care.Disease management are patients with a chronic condition: diabetes, asthma or heart failure. Programs such as health education and the Center for Health Promotion serve these patients.Health promotion are the “healthier” patients who are not accessing care but we still care about them and want them to stay healthy. So we reach out to them for preventive screenings.

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Management of thePatient with Complex Disease

William H.

• 94 year old with metastatic prostate cancer , diffuse atherosclerosis with cardiomyopathy, CHF, AICD, S/P stent, and CKD.

• Lives with son and daughter in law who brings him to appointments.

• Depression in past which has been managed well for 6 months

• Came in feeling “more tired and depressed”.

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How did Complex Care/Care Connect help William, his family and the “Triple Aim”?

• The “fatigue” was found to be a hgb of 9.8 from his baseline of 13. We were able to admit him just as he began to have hematemesis.

• This was an easy transition to hospital. No ambulance or 911 services. The hospitalist saw , treated and transitioned him back to the office setting.

• William and his family were able to get all the out patient supportive DME he needed with the coordinated effort of case management in the hospital and care connect in the outpatient setting.

• In follow up at the office, we were able to have family meetings and discuss end of life care, especially for the prostate cancer, CHF and GI bleed. He did not want to go back to hospital or have more procedures.

• Pt was able to make decision with family to consider hospice.

• Hospice accepted a week after that office visit. Within 24 hours patient was set up at home with hospice.

• William passed at home with his family within 4 weeks of that initial “fatigue “ visit.

• I talked to the family just after he passed. Son sent his complements to the team approach and all we were able to do for him outside the hospital after the smooth transition from inpatient. He asked if he and his wife could be patients.

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• Able to manage GI bleed through Care Connect avoiding complications of MI, CHF through coordination of home health, care connect. (Enhance patient experience and Healthcare savings)

• Patient made informed decision to join hospice. (Enhance patient experience)

• No recurrent trips to ER for admissions or procedures patient did not want(Healthcare savings and improve patient experience)

• Patient passed as he wished with family at his side and with dignity (Enhance patient experience)

• Family sees value of care provided and we are caring for them as well.(Improve Community Health)

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Does this work with other Disease Management?

• Sally M

• 72 yo female with T2DM insulin dependent with CKD, ASHD and bipolar disorder who lives in facility

• Health challenges 3 admissions last year for ATN and ARF, urosepsis and Lumbar fracture.

• Social and community challenges: Family cannot accommodate living arrangements, lives in facility that cannot monitor blood sugar readings or administer medications

How did we address issues?

• Engaged care connect to meet with family and patient in office at visit.

• Home health initiated to obtain blood sugar readings daily.

• Blood sugars reported to me directly via Care Connect staff. I was able to manage insulin and other medications.

• Engaged Social services team member via IDCT to find home for patient where there is closer monitoring of blood sugars.

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• No hospital admissions for following year.

• Blood sugar under better control

• No cardiovascular complications

• Transitioned patient with family assistance to facility that was better equipped to serve her needs and theirs.

Results