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Nurse Practitioners Bridging the Gap: The Impact of a Nurse Practitioner Managed Transitional

Care Chronic Disease Management Clinic on Low Income and Uninsured Patients in Southeast Texas

Seth Stephens DNP, APRN, ACNP-BCBaptist Hospitals of Southeast Texas

Beaumont, Texas

DisclosuresNothing to disclose.

Objectives• Recognize the importance of the 1115 Medicaid Waiver program and how Nurse Practitioners are participating in waiver programs to transform healthcare in Texas.• Define patient and community activation.• Summarize Wagner's Chronic Care Model. • Describe the strategies utilized by the SmartHealth Clinic to reduce hospital readmission and ED utilization.• Describe how Nurse Practitioners might utilize their professional expertise to achieve the IHI Triple Aim.

What is an 1115 Medicaid Waiver?

Section 1115 of the Social Security Act gives the Secretary of Health and Human Services authority to approve experiment al, pilot, or demonstra ti on projects that promote the objectives of the Medicaid and CHIP programs. The purpose of these demonstra ti ons, which give states additional flexibility to design and improve their programs, is to demonstra te and evaluate policy approaches such as:

• Expanding eligibility to individuals who are not otherwise Medicaid or CHIP eligible;• Providing services not typically covered by Medicaid; or• Using innovative service delivery systems that improve care, increase efficiency, and reduce costs.

What is an 1115 Medicaid Waiver?

There are general criteria CMS uses to determine whether Medicaid/CHIP program objectives are met. These criteria include whether the demonstration will:– increase and strengthen overall coverage of low-income individuals in the state;

– increase access to, stabilize, and strengthen providers and provider networks available to serve Medicaid and low-income populations in the state;

– improve health outcomes for Medicaid and other low-income populations in the state; or

– increase the efficiency and quality of care for Medicaid and other low-income populations through initiatives to transform service delivery networks.

What is an 1115 Medicaid Waiver?

• Demonstrations must also be "budget neutral" to the Federal government, which means that during the course of the project Federal Medicaid expenditures will not be more than Federal spending without the waiver.• Generally, section 1115 demonstrations are approved for an initial five-year period and can be extended for an additional three years. States commonly request and receive additional 3-year extension approvals.

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What is an 1115 Medicaid Waiver?Public Comment

• The Affordable Care Act requires opportunity for public comment and greater transparency of the section 1115 demonstration projects. • A final rule, effective on April 27, 2012, establishes a process for ensuring public input into the development and approval of new section 1115 demonstrations as well as extensions of existing demonstrations. • This final rule sets standards for making information about Medicaid and CHIP demonstration applications and approved demonstration projects publicly available at the State and Federal levels.

The Texas 1115 Medicaid Waiver• In December 2011, Texas received federal approval of an 1115 waiver that would preserve Upper Payment Limit (UPL) funding under a new methodology, but allow for managed care expansion to additional areas of the state.

• The purpose of the 1115 Healthcare Transformation waiver, supplemental payment funding, managed care savings, and negotiated funding will go into two statewide pools now worth $29 billion (all funds) over five years. Funding from the pools will be distributed to hospitals and other providers to support the following objectives: (1) an uncompensated care (UC) pool to reimburse for uncompensated care costs as reported in the annual waiver application/UC cost report; and (2) a Delivery System Reform Incentive Payment (DSRIP) pool to incentivize hospitals and other providers to transform their service delivery practices to improve quality, health status, patient experience, coordination, and cost-effectiveness (THHSC, 2010).

The Texas 1115 Medicaid Waiver• Uncompensated Care Pool Payments are designed to help offset the costs of uncompensated care provided by the hospital or other providers.

• DSRIP Pool Payments are incentive payments to hospitals and other providers that develop programs or strategies to enhance access to health care, increase the quality of care, the cost-effectiveness of care provided and the health of the patients and families served.

• Under the transformation waiver, eligibility to get Uncompensated Care or DSRIP payments will require participation in a regional healthcare partnership. Within a partnership, participants include governmental entities providing public funds known as intergovernmental transfers (IGT), Medicaid providers and other stakeholders. Participants will develop a regional plan identifying partners, community needs, the proposed projects, and funding distribution. Each partnership must have one anchoring entity, which acts as a primary point of contact for HHSC in the region and is responsible for seeking regional stakeholder engagement and coordinating development of a regional plan. (THHSC, 2010)

SmartHealth Patient Navigation

• What is Patient Navigation?– The patient navigators build relationships with patients through education and coaching … they serve as clinical experts to patients, they work with staff to meet clinical outcome measures, and they facilitate seamless care transitions (The Advisory Board Co, 2011).

• Why is Patient Navigation necessary?– Risk factors for receiving fragmented care.

– Lack of, or delayed provider- to -provi de r communica tion.– Socioeconomi c, cultural, and racial issues creating barriers to care.– Lack of insurance or transport ati on , poor health literacy, and fear or mistrust of the healthcare system.(Dillon, 2006 & Natalie-Pere ira, et al, 2011)

Patient Navigation• Community Outreach

Patient Care Navigation

(THHSC, 2010)

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Chronic Disease Management • Transitional Care, Chronic Disease

Management– Heart Failure – Cardiac Risk reduction

– Hypertension– Dyslipidemia– Smoking Cessation– Anticoagula ti on

– Acute Myocardial Infarction (AMI)– COPD– Renal Failure– Sepsis– Diabetes Mellitus

Chronic Disease Management • The Dispensary of Hope

Chronic Disease Management Patient Activation Hibbard & Greene (2012)

• Emphasizes patients’ willing-ness and ability to take independent actions to manage their health and care. • Understanding one’s role in the care process and having the knowledge, skill, and confidence to manage one’s health and health care.• Activation differs from compliance, in which the emphasis is on getting patients to follow medical advice.

Patient Activation• Research shows that more activated patients have better health outcomes and better care experiences than patients who are less activated • This has been shown with medically indigent patients, different racial and ethnic groups, and patients with multiple chronic conditions.

Community Activation Wick izer et al (1993)

• As a health promotion strategy, includes organized efforts to increase community awareness and consensus about health problems, coordinated planning of prevention and environmental change programs, interorganizational allocation of resources, and citizen involvement in the process.• Emphasis on organizational change and the development of rational planning strategies to achieve change goals.

– Identif ication of stakeholders– Creation of partnerships– Free exchange of information

– Organizational services and goals

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Wagner’s Chronic Care ModelWagner EH. Chronic disease management: What will it tak e to improve care for chronic il lness? Eff Clin Pract. 1998;1:2-4.

• The Chronic Care Model (CCM) identifies the essential elements of a health care system that encourage high-quality chronic disease care. – The community– The healthcare system– Self-management support– Delivery system design– Decision support and clinical information systems.

• The Model can be applied to a variety of chronic illnesses, healthcare settings and target populations. The bottom line is healthierpatients, more satisfied providers, and cost savings.

Wagner’s Chronic Care Model

The Institute for Healthcare Improvement Triple Aim• What is the Triple Aim?– The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance.

• Why do we need it?– The US health care system is the most costly in the world, accounting for 17% of the gross domestic product with estimates that percentagewill grow to nearly 20% by 2020

The Institute for Healthcare Improvement Triple Aim• How do we implement it?– identif ication of target populations

– definition of system aims andmeasures

– development of a portfolio ofproject work that is sufficiently strong to move system-level results

– rapid testing and scale up that is adapted to local needsand conditions.

SmartHealth Outcomes: Clinic Visits• 2014 Visits- 1840• 2015 Visits- 2572• 2016 Visits YTD- 1288

15

148

91

118

151172

199

143

218

159

195

231212

190

218

249

132

228214

203192

232 223

279 271293

265

229 230

JAN-14

FEB-14

MAR-14

APR-14

MAY-14

JUN-14

JUL-14

AUG-14

SEP-14

OCT-14

NOV-14

DEC-14

JAN-15

FEB-15

MAR-15

APR-15

MAY-15

JUN-15

JUL-15

AUG-15

SEP-15

OCT-15

NOV-15

DEC-15

JAN-16

FEB-16

MAR-16

APR-16

MAY-16

SHC Clinic Visits

SmartHealth Outcomes• Payor Mix

21%

42%

29%

8%

DY4 CDM Payor Mix

MCAID

Self-pay

MCARE

MNGD CARE

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SmartHealth OutcomesMedical Diagnoses

26%

18%32%

12%

8%

3% 1%

MedicalDiagnoses

CHF

COPD

DM

HTN

MI

PNA

ESRD

SmartHealth Outcomes: Dispensary of Hope

• Dispensary of Hope

• 2014 >$250,000• 2015 $407,495

• Diabetic Supplies– 2014 $7,000– 2015 $8,755

35 68 82 138 309 374 328 398602

181 443 561

1924

1063

2426

1147 1257

2300

0 0 0 0 0 0 195 238 320

Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 2015 Q1 2016

SHC: DoH Stats

Pt. encounters # 30d Rx F il ls # of Unique Pts L inear (# 30d Rx F il ls)

SmartHealth Outcomes: Hospital Encounters• Statistically significant decrease in Inpatient and

Observation hospitalizations after entering the SmartHealth Program.

– Avg pre 1.01 vs Avg post 0.31– n = 729

t(728) = 17.943 p = .000

SmartHealth Outcomes: Hospital Encounters

0

50

100

150

200

250

300

350

400

450

500

0 1 2 3 4 5 6 7 10

RangeofIP/ObsVisitsPreSHC

0

100

200

300

400

500

600

700

0 1 2 3 4 5 9

RangeofIP/ObsVisitsPostSHC

SmartHealth Outcomes: Hospital Encounters• Average reduction of IP/OBS encounters by 0.7 per patient.

• Average cost per encounter: $3,317.00• Total Cost savings in reduction of IP/OBS visits:

$1,692,665.10

SmartHealth Outcomes: 30d readmission Rates• 4.23% 30d Readmission rate for clinic patients vs 14.84% for patients with like Dx.• Significant reduction in 30d Readmission rates for MCAID and Self-Pay patients with chronic illness.

26.4322.62

14.29

24.96

11.67

0

5

10

15

20

25

30

2015 Q1 2015 Q2 2015 Q3 2015 Q4 2016 Q1

BHSET MCAID/Self-Pay All Hospital 30d Readmission Rates: CHF, COPD, DM

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SmartHealth Outcomes: Emergency Department Encounters• Statistically significant decrease in Emergency Department visits after entering the SmartHealth program.

– Avg pre 0.5 vs avg post 0.37– n = 728

t (727) = 3.288 p = .001

SmartHealth Outcomes: Emergency Department Encounters

0

100

200

300

400

500

600

0 1 2 3 4 5 7 11

RangeofEDVisitsPriortoSHC

0

100

200

300

400

500

600

0 1 2 3 4 5 6 8

RangeofEDVisitsPostSHC

SmartHealth Outcomes: Clinical Outcomes• Statistically Significant Improvement in LVEF in patients with Systolic Heart Failure.

– Initial LVEF M = 32.28 Repeat LVEF M = 42.41– n = 64

t(63) = -6.266 p = .000

SmartHealth Outcomes: Clinical Outcomes• Statistically Significant improvement in LVEF in patients with initial LVEF less than or equal to 45.

– Initial LVEF M = 29.28 Repeat LVEF M = 40.14– n = 57

t(56) = -6.793 p = .000

SmartHealth Outcomes: Clinical Outcomes• Clinically significant, though not statistically significant reduction in LDL.

– Initial LDL M = 136.97 Repeat LDL M = 94.31– n = 91

t(90) = 4.833 p = 0.174

SmartHealth Outcomes: Clinical Outcomes• Statistically significant reduction in HgB A1C in Diabetic patients.

– Initial A1C M = 11.29 Repeat AIC M = 8.96– n = 79

t(78) = 8.338 p = .000

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SmartHealth Outcomes: Clinical Outcomes• Statistically significant reduction in A1C in Diabetic patients

whose initial A1C was greater than 9%.

– Initial A1C M = 13.84 Repeat A1C M = 10.30– n = 48

t(47) = 10.690 p = .000

SmartHealth Outcomes: Patient Satisfaction1. Do you feel that you were included as an active participant during your

experience with the SmartHealth Program?

2. Do you feel that you know more about your illness and the warning signs than before you came to the SmartHealth Program?

3. After participating in SmartHealth Program, do you feel more comfortable and/or has your Quality of Life improved.

0 2 014 1825

8780

75

1 2 3

Survey Questi on

2-Disagree 3-Agree 4-St rongly Agree

SmartHealth Outcomes: Patient Satisfaction4. Did the SmartHealth Program provide you and your family

with the support and resources you needed to cope with your illness?

5. Do you now have a better understanding of what medications you are taking and how to take them?

1 013 20

8680

4 5

Survey Questi on

2-Disagree 3-Agree 4-St rongly Agree

SmartHealth Outcomes: Patient Satisfaction6. When you phoned the SmartHealth Clinic to get an

appointment, how often did you get an appointment as soon as you thought you needed?

7. When you phoned the SmartHealth Clinic, how often did you get an answer to your medical question that same day?

1 01 16 10

89 87

6 7

Survey Questi on

1- Never 2- Somet imes 3- Usually 4- Always

SmartHealth Outcomes: Patient Satisfaction8. Did you feel that the providers at the SmartHealth Clinic

explained things in a way that was easy for you to understand?

5

94

8

Survey Questi on

3- Probably Yes 4- Def init ley Yes

SmartHealth Outcomes: Patient Satisfaction9. Using any number from 0 to 10, where 0 is the worst rating

possible and 10 is the best rating possible, what number would you use to rate the SmartHealth Program?

1%1%

3% 6%

89%

9

4

6

8

9

10

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SmartHealth Outcomes: Patient Satisfaction• “Wonderful, compassionate professionals; great all around.” 101686351• “They helped me to live after [a] heart attack, till I got [my] stent 6 months later and [kept] my kidneys in good shape.” 120361429• “My experience with [the] SmartHealth program was very good and [they] saved my life by helping me to get my medicines and get my sugar on track.” 120088573• “With no insurance and the need for medication daily, they saved my life; Forever grateful.” 120017458• “Your PA/Dr was the most honest and straight forward Dr. I’ve ever seen…and I loved it.” 120014939• “They did what needed to be done. Very knowledgeable and courteous.” 101872084

In Conclusion• Utilizing funds made available by the Texas 1115 Medicaid Waiver, we designed a Nurse Practitioner driven intervention that addressed the IHI Triple Aim.• We were able to show statistically significant reductions in IP/OBS hospitalizations and in Emergency department Utilization, which resulted in a cost savings of over $1.7 million over 2 years.• We were able to improved the health of populations by showing statistically significant improvements in LVEF in patients with Systolic Heart Failure, statistically significant improvement in HgBA1C in Diabetic Patients, and clinicaly significant improvement in LDL.• We were also able to demonstrate an improved patient experience vis survey responses indicating high patient satisfaction, improved self-care behaviors and improved disease process knowledge.

Questions?