the hot spotters - center for health journalism · 2012. 7. 31. · top 10 er diagnosis 2002-2007...
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The Hot Spotters: Lessons from the Front Lines of
America's Health Care Crisis
1Jeffrey Brenner, M.D.
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Bending the Cost Curve and Improving Quality in One of America’s Poorest Cities
Jeffrey Brenner, MDExecutive Director/Medical Director
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Long-term Federal Debt
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More Specialty Care is Not Better Care
- 180 patients randomized to sham arthroscopy vs real arthroscopy with no difference in outcomes- 650,000 arthroscopies/year
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Disruptive Change- Patient Centered Medical Home
Geisinger Demo- 18% reduction hospitalization, 36% reduction in 30 day readmissions
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History of CCHP
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Overview of the Coalition- 20 member board, incorporated non-profit- Foundation and hospital support- Structure of the Coalition:
- Operations- Health Information Exchange- Research/Data/Evaluation- Finance/Admin/Legal
- Programming- Citywide Care Management Project- Camden Chronic Disease/Primary Care Collaborative- Community-based Patient Engagement Strategies
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Camden Health Data 2002 – 2011 with Lourdes, Cooper, Virtua data
500,000+ records with 98,000 patients 50 % population use ER/hospital in one year
Leading ED/hospital utilizers citywide 324 visits in 5 years 113 visits in 1 year
Total revenue to hospitals for Camden residents $100 million per year Most expensive patient $3.5 million 30% costs = 1% patients 80% costs = 13% patients
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Top 10 ER Diagnosis 2002-2007 (317,791 visits)
465.9 ACUTE UPPER RESPIRATORY INFECTION (head cold)
12,549
382.9 OTITIS MEDIA NOS (ear infx) 7,638079.99 VIRAL INFECTION NOS 7,577462 ACUTE PHARYNGITIS (sore throat) 6,195493.92 ASTHMA NOS W/ EXACER 5,393558.9 NONINF GASTROENTERI (stomach virus) 5,037789.09 ABDOMINAL PAIN-SITE NEC 4,773780.6 FEVER 4,219786.59 CHEST PAIN NEC 3,711784.0 HEADACHE 3,248
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11
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ED visits, 2011
Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011
ED visits, 2011 0 1 2 3 to 4 5+
0 0 1,293 57 4 1
1 26,128 2,075 117 7 0
2 to 3 13,390 1,842 373 68 3
4 to 5 3,216 666 223 118 15
6 to 7 1,020 251 106 84 24
8 to 9 386 112 39 41 11
10 + 339 96 70 65 62
Utilization typology
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ED visits, 2011
Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011
ED visits, 2011 0 1 2 3 to 4 5+
0
Normal Range of UtilizationNormal Range of Utilization
Potential High Utilizers
Inpatient High Utilizers
Inpatient High Utilizers
1 Normal Range of UtilizationNormal Range of Utilization
Potential High Utilizers
Inpatient High Utilizers
Inpatient High Utilizers
2 to 3
Normal Range of UtilizationNormal Range of Utilization
Potential High Utilizers
Inpatient High Utilizers
Inpatient High Utilizers4 to 5
Emergency Department
High UtilizersPotential High
Utilizers
Potential High Utilizers
Inpatient High Utilizers
Inpatient High Utilizers
6 to 7Emergency Department
High UtilizersPotential High
Utilizers
Potential High Utilizers
Inpatient High Utilizers
Inpatient High Utilizers
8 to 9
Emergency Department
High UtilizersPotential High
Utilizers
Potential High Utilizers
Inpatient High Utilizers
Inpatient High Utilizers
10 +
Emergency Department
High UtilizersPotential High
Utilizers
Potential High Utilizers
Inpatient High Utilizers
Inpatient High Utilizers
Utilization typology
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ED visits, 2011
Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011
ED visits, 2011 0 1 2 3 to 4 5+
044,728 (85%) patients5,210 Inpatient visits
63,489 ED visits
$28,000,000 (50%) IP payment$25,800,000 (59%) ED payment
44,728 (85%) patients5,210 Inpatient visits
63,489 ED visits
$28,000,000 (50%) IP payment$25,800,000 (59%) ED payment 985 (2%) patients
1,856 IP visits4,129 ED visits
$10,000,000 (17%) IP payment
$1,700,000 (4%) ED payments
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
1
44,728 (85%) patients5,210 Inpatient visits
63,489 ED visits
$28,000,000 (50%) IP payment$25,800,000 (59%) ED payment
44,728 (85%) patients5,210 Inpatient visits
63,489 ED visits
$28,000,000 (50%) IP payment$25,800,000 (59%) ED payment 985 (2%) patients
1,856 IP visits4,129 ED visits
$10,000,000 (17%) IP payment
$1,700,000 (4%) ED payments
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
2 to 3
44,728 (85%) patients5,210 Inpatient visits
63,489 ED visits
$28,000,000 (50%) IP payment$25,800,000 (59%) ED payment
44,728 (85%) patients5,210 Inpatient visits
63,489 ED visits
$28,000,000 (50%) IP payment$25,800,000 (59%) ED payment 985 (2%) patients
1,856 IP visits4,129 ED visits
$10,000,000 (17%) IP payment
$1,700,000 (4%) ED payments
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
4 to 5
4,961(9%) patients28,447 ED visits
$11,500,000 (27%) in ED payment
1,563 (3%) patients1,239 IP visits6,962 ED visits
$6,700,000 (18%) in IP payment
$2,800,000 (6%) in ED payment
985 (2%) patients1,856 IP visits4,129 ED visits
$10,000,000 (17%) IP payment
$1,700,000 (4%) ED payments
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
6 to 74,961(9%) patients28,447 ED visits
$11,500,000 (27%) in ED payment
1,563 (3%) patients1,239 IP visits6,962 ED visits
$6,700,000 (18%) in IP payment
$2,800,000 (6%) in ED payment
985 (2%) patients1,856 IP visits4,129 ED visits
$10,000,000 (17%) IP payment
$1,700,000 (4%) ED payments
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
8 to 9
4,961(9%) patients28,447 ED visits
$11,500,000 (27%) in ED payment
1,563 (3%) patients1,239 IP visits6,962 ED visits
$6,700,000 (18%) in IP payment
$2,800,000 (6%) in ED payment
985 (2%) patients1,856 IP visits4,129 ED visits
$10,000,000 (17%) IP payment
$1,700,000 (4%) ED payments
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
10 +
4,961(9%) patients28,447 ED visits
$11,500,000 (27%) in ED payment
1,563 (3%) patients1,239 IP visits6,962 ED visits
$6,700,000 (18%) in IP payment
$2,800,000 (6%) in ED payment
985 (2%) patients1,856 IP visits4,129 ED visits
$10,000,000 (17%) IP payment
$1,700,000 (4%) ED payments
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
Utilization matrix
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0
4
7
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1/3/111/4/111/6/111/23/111/27/111/31/112/8/112/9/112/9/112/16/112/19/112/20/112/21/112/22/112/23/113/6/113/6/113/13/113/19/113/27/113/30/113/30/114/2/114/3/114/4/114/18/114/19/114/20/114/21/114/22/114/24/114/25/114/26/115/5/115/6/115/8/115/13/115/16/115/17/115/19/115/21/115/23/115/26/115/28/115/29/115/30/116/3/116/6/116/8/116/9/116/12/116/15/116/16/116/17/116/19/116/20/116/23/116/24/116/25/116/26/116/27/116/28/117/5/117/6/117/8/117/10/117/11/117/12/117/18/117/19/117/21/117/25/117/31/118/6/118/7/118/8/118/10/118/14/118/15/118/20/118/21/118/30/119/15/119/16/119/22/119/28/1110/9/1110/12/1110/13/1110/19/1110/31/1111/10/1111/22/1111/24/1111/24/1112/3/1112/4/1112/4/1112/5/1112/6/1112/8/1112/22/1112/22/1112/23/1112/24/11
Leng
th o
f St
ay
EDIP
Estimated 2011 PaymentED: $38,000 to $76,000 (93 visits) IP: $65,000 to $130,000 (12 visits)Total: $103,000 to $206,000
Saving Estimates30% reduction in utilization :
Patient A
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Patient Case Presentation #1 55-yo Male At time of enrollment, admitted for GI bleed and SOB (November 2011) Dual coverage Lives alone in high-rise apartment Complex chronic conditions
ESRD Renal Carcinoma Hepatitis B Hypertension Hyperlipidemia Peripheral vascular disease Asthma Glaucoma (blind in one eye) Sleep Apnea Severe Back Pain
12 Medications daily
www.camdenhealth.org
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Patient Case Presentation #1
6-Month hospital utilization 9 ED visits 6 Inpatient stays Average time b/t hospitalization - 45 days
Contributors to hospital readmission Family resistance to sub-acute rehab
November 2011 - CCHP Identified through HIE daily hospitalization report Visited by CT team during hospitalization
RN, LPN, MA
www.camdenhealth.org
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Patient Centered Care Coordination
www.camdenhealth.org
Patient
Hospital #1
Sub-Acute Rehab
Hospital #2
Home Nursing
HomePT/OT
Durable Goods
MealsTransport
Dialysis
Nephrology
Transplant
PCPUrology
OncologySurgery
GICardiology
Optho
Pain Mgt
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www.camdenhealth.org
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www.camdenhealth.org
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Patient Case Presentation #2
52 y/o female Spanish-speaking with COPD/Trach/Vent dependent, admitted for resp. distress.
8 readmits last 12months. Avg. admit every 29 days prior to intervention.
No referral, directly outreached by team @ hospital
www.camdenhealth.org
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Patient Case Presentation #2
Transitioned at LTACH in Philly, while family trained on vent and vent was placed at home.
Transitioned home and f/u to PCP & Specialist appointments
Currently at home and medically stable – “graduated” May 2012
120 days without hosp. utilization, scooter delivered to home!
www.camdenhealth.org
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www.camdenhealth.org
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www.camdenhealth.org
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Clinical Model
www.camdenhealth.org
Data• Lourdes• Cooper• Virtual
Triage• Assessment• Assignment
High Risk• Medically complex• Socially complex• 6-12
Medical Home• Quality Improvement• Patient Engagement
••Medically complex
••30-90 day Engagement
Interm.Risk
Patients Flagged:• 2+ hospital admissions
< 6 months
Selection Criteria:• History of chronic
disease related admits• Rule out criteria• Assigned to pathway
“Care Transitions”
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Daily Admissions Feed
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Train local residents to participate in decision-
making over health care resources
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Promote collaboration among providers and
between providers and the community
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Emergency Department High Utilizers Top 1% 2007CamdenPatients 386Visits 5169Visits/Patient 13.4% visiting more than one hospital 80.6%
TrentonPatients 504Visits 7616Visits/Patient 15.1% visiting more than one hospital 78.2%
NewarkPatients 928Visits 14367Visits/Patient 15.5% visiting more than one hospital 71.1%
Comparing Emergency Room High Utilizers in Camden, Trenton, and Newark
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The Plan: Competing ACOs
Cooper ACO
Lourdes ACO
Virtua ACO
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A Different ACO Model for Camden
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Camden cost savings strategies1. Nurse practitioner led clinics in high cost
buildings2. More high utilizer outreach teams3. Medical home-based nurse care
coordination4. More same day appointments (open
access scheduling)
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Lessons from Camden
Strategic ability to filter, focus, and segment Comfort with ambiguity and willingness to
tinker Adaptive challenge not a technical challenge Passion for moving towards standardization
and efficiency when the time is right Meaningful solutions are local, gradual, and
require chunking