Patients at the Center Care Managers By Their Side

Transcription

1 Patients at the Center Care Managers By Their Side Outcomes and Lessons Learned from Pilot Project to Embed RN Care Managers at Safety Net Clinics June 30, 2015

2 Agenda Introduction to the Primary Care Coalition of Montgomery County, Maryland Project Description Evaluation Demographics Biometric Improvements Emergency and Inpatient Utilization Related Activities, Learnings and Challenges 2

3 About the Primary Care Coalition (PCC) Vision: A community in which all residents have the opportunity to live healthy lives Montgomery County: A model for providing access to high quality, efficient care for all. Mission: Develop and coordinate a community-based health care system that strives for universal access and equity for low-income, uninsured, and ethnically diverse community members. 3

4 A System of Care for Low Income, Uninsured Residents 4

5 Project Description Goal To develop a PCMH program focused on patients with multiple chronic conditions and based on the Joint Principles of the Patient Centered Medical Home Primary Objective Establish patient care management using RN Care Managers embedded in care teams in each of two participating clinics; Holy Cross Health Center and Proyecto Salud. These clinics serve low-income, uninsured Montgomery County residents. Strategies include patient assessment and development of evidence-based care plans using standardized tools; monitoring progress proactively; patient self-management education and health coaching; coordinating providers of care; smoothing transitions of care; facilitating access to community resources and essential services Final Evaluation 310 patients enrolled through September 2014 Evaluation conducted on patients enrolled >30 days and with available biometric data 89/129 PS patients eligible for evaluation (69%) 35 missing biometric data (? EMR conversion) 5 enrolled < 31 days 172/181 HCHC patients eligible for evaluation (95%) 9 enrolled <31 days Expect to reach target enrollment of 500 by June 30, 2014 Funding CareFirst PCMH Grant Award 5

6 2007 Joint Principles of PCMH (AAFP, AAP, ACP, AOA) Physician directed medical practice Whole person orientation Coordinated/Integrated Care Quality and safety Enhanced access to care Appropriate payment 6

7 Adult Primary Care Chronic and Preventive Care Behavioral Health POS Pharmacy Specialty Care Referrals Supplemented with Health Coach Adult Primary Care Chronic and Preventive Care Behavioral Health POS Pharmacy Limited Specialties 2,500 patients and 10,000 annual visits 5,000 patients and 13,000 annual visits Diverse patient population, including Latino/Hispanic immigrants, African Americans, Caucasians and patients from Africa and the Caribbean Predominantly Latino/Hispanic immigrants from Central and South America

8 Patient Story Social Determinants 43 year-old unemployed Latino male with uncontrolled diabetes, hypertension and hyperlipidemia was referred to care management after an inpatient hospitalization. The patient set a goal to take English classes, and subsequently was able to secure employment. He told his care manager, I have two months before I begin working. Help me and teach me everything you can in those two months. Through selfmanagement of his modifiable risk factors, the patient decreased his A1c from 12.7 to 7.7; his total cholesterol from 377 to 185, and his triglycerides from 185 to 75. 8

9 PCMH Care Management Process The Improvement Guide, 2 nd Edition, Langley, Nolan, et.al., Jossey-Bass 2009

10 Patient Assessment Adapted Guided Care assessment tools for non-geriatric population with permission Comprehensive Assessment Tool RN Chart Review Patient Self Assessment (overall, goals, confidence, satisfaction) SDOH History and Current Medications Lifestyle, ADLs and Assistive Devices Standardized Behavioral Health Screens Brief Assessment Tool Patient Priorities Focused History and Current Medications SDOH PHQ-9 10

11 Care Plans 11 Presentation Name

12 Tracking Prevention, Education and Referrals 12

13 Patient Story

14 Process Measures Complete initial assessments and care plans for 72 patients per quarter effective October 1, Establish one to four learning collaboratives Conduct a baseline PCMH readiness assessment in each participating clinic Document changes in the average number of primary care visits completed by participants pre- and postinitial assessment Assess participant retention through metrics of length of time in active care management and % discontinued due to completion of goals, lost to follow-up, and discontinued for other reasons to be determined. 14

15 Outcome Measures 20% of PCMH patients with care plans will have a clinically significant improvement in biometric indicators Increase by 30% patients self-reported health status scores Reduce by 20% the number of ED visits pre- and post initial RN assessment Reduce by 20% the number/duration of hospitalizations pre- and post initial RN assessment Reduce by 25% the annual average cost per patient 15

16 Demographics Table 2: Demographics Characteristics of Patients in PCMH Care Management Evaluation Demographics Proyecto Patients n=89 HCHC Patients n=172 Age < % 23 13% % 98 57% > % 51 30% Average Age *** (Range 20-80) (Range 23-88) *** Gender Male 39 44% 92 53% Female 50 56% 80 47% Ethnicity Hispanic or Latino 71 80% 93 54% Not Hispanic or Latino 9 10% 70 41% Unknown 9 10% 9 5% Enrollment Period Average 267 days *** 206 days *** 16

17 Clinical Descriptors Table 3: Participants characterized by ICD-9 diagnosis ICD-9 Category Diagnosis Proyecto Patients with Condition HCHC Patients with Condition (n = 89) (n = 172) Diabetes 87 98% % Hypertension 71 80% % Hyperlipidemia 76 85% % Table 4: Significant Differences in Participant Clinical Descriptors ICD-9 Category Diagnosis Group Proyecto Patients with Condition 17 HCHC Patients with Condition (n = 89) (n = 181) Neoplasms 0 0% 26 14% Endocrine, Nutritional, Metabolic, Immunity 88 99% 56 31% Behavioral Health 21 24% 65 36% Circulatory System 71 80% 49 27% Digestive System 16 18% 53 29% Genito-Urinary System 24 27% 78 43% Musculoskeletal System/Connective Tissue Symptoms, Signs, Illdefined Conditions 19 21% 99 55% 29 33% % Injury & Poisoning 2 2% 32 18%

18 Reasons for Case Closure Table 5: Reasons for ending PCMH Enrollment Proyecto Salud Reasons n=89 Closed Cases n=104 Closed Cases RN Care Manager resignation 45 51% 0 0% Unable to Contact/Lost to Follow Up 38 42% 30 29% Stable Condition 3 3% 25 24% Transferred to Outside Care 0 0% 24 23% No longer eligible 2 2% 12 11% Patient Death 0 0% 5 5% Moved out of area 0 0% 4 4% Patient Refused 0 0% 2 2% Unknown 1 1% 2 2% Total 89 99% (rounding) % HCHC 18

19 Patient Story Engaged and Activated New Diabetic Latino man in his 30s newly diagnosed with diabetes was referred and met with care manager and nutritionist after his PCP visit. Initial A1c He refused insulin. Began oral hypoglycemic and lifestyle modification (DM diet, decreased his beer consumption and joined a gym). Later asked to discontinue the oral medications when he began experiencing headaches and hypoglycemic symptoms. His daily blood sugars were well controlled, so the oral hypoglycemic was discontinued. Return A1c (3 months later) decreased from 14.8 to

20 Biometric Improvements Table 7: PS Biometric Evaluation of PCMH Population Total PCMH Population (n-89) A1c LDL BP Weight At enrollment / End of enrollment (or 7/1/14) / Now (after case closed) / Table 8: PS Biometric Evaluation of Pre-enrollment Poorly Controlled Diabetes Poorly Controlled DM PCMH Population A1c LDL BP Weight (n-62/87 Diabetic Patients) At enrollment / End of enrollment (or 7/1/14) / Now ( after case closed / Proyecto Salud Patients 61% of diabetic patients improved A1c (initial ) 71% of poorly controlled improved 38% of hypertensive patients improved BP (initial 101/60-190/109) HCHC Patients 46% of diabetic patients improved A1c (initial ) 70% of poorly controlled improved 49% of hypertensive patients improved BP (initial 93/58-181/114) 72% of poorly controlled improved Table 11: HCHC Biometric Evaluation of PCMH Population Total PCMH Population (n-172) A1c LDL BP Weight At enrollment / End of enrollment (or 9/30/14 for open / cases Now ( after case closed or after 9/30/14 for open cases) Now ( after case closed or after 9/30/14 for open 20 cases) / Table 12: HCHC Biometric Evaluation of Pre-enrollment Poorly Controlled Diabetes: Poorly Controlled DM PCMH Population (n-52/104 Diabetic Patients) A1c LDL BP Weight At enrollment / End of enrollment (or 9/30/14 for open cases / /76 187

21 Patient Story Home Visit Insulin-dependent 35 year old formerly homeless Spanish speaking man living in a county-run group home. His diabetes was poorly controlled despite the physician increasing insulin dosages and modifying regimens. He was recently discharged from the hospital where he had surgical intervention for cellulitis resulting from an infected ingrown toenail. The Care Manager visited the patient at the group home and discovered: Insulin was not being given as prescribed. The group home does not allow residents to selfinject, but the person responsible at the group home did not recognize the difference between regular and NPH insulin and used them interchangeably; the patient was not receiving the intended insulin regimen, so the physician could not evaluate the effect of the prescribed regimen. Neither the group home employees nor the patient s social worker, speak Spanish. The patient does not speak English. The RN Care Manager provided bilingual education to both patient and staff, and is very carefully monitoring the patient. 21

22 Utilization Pre and Post Enrollment in Care Management 100 Inpatient Admissions Inpatient Admissions 0 IP Admissions Prior (90) IP Admissions Post (59) 22

23 ED Utilization 23

24 ED Utilization Special Cause 6 patients Increased ED Utilization 2 patients (33%) with serious mental health diagnosis 2 patients (33%) with oncology diagnosis 4 patients (67%) with chronic pain diagnosis 5 Patients Decreased ED Utilization 2 patients (40%) transferred to outside care One death 1 patient (20%) with history of thrombosis and pulmonary embolus on anticoagulants obtained insurance (enrolled 6 weeks) 1 patient lost to follow-up 1 patient with DM and HT enrolled still enrolled after 4 months 24

25 Inpatient utilization Prior and Post Enrollment 25

26 Inpatient Admissions Special Cause Decreased Admissions (9 patients) o o o o 6 patients (67%) had prior single episode of extended illness (eg. acute pericarditis, open heart surgery, serious mental illness) - Including a single 2 ½ month admission. Case closed after 2 weeks because condition stable. 1 patient transferred to outside oncology care 1 patient moved out of area (returned to home country) 1 patient with serious mental illness obtained mental health care Increased Admissions (5 patients) o o o 2 Deaths (40%) - oncology and renal failure diagnoses 1 Homeless patient (oncology) to LTC 2 Patients with chronic pain 26

27 Hospital Days Special Cause Decreased Days (10 patients) o Prior acute episodes (60%) - 1 patient had 2 prior admissions for acute pericarditis (single episode within one month). Lost to follow-up after one month - 1 patient had a single 2 ½ week admission (ESRD). Lost to follow-up after 3 months. - 1 patient had a single 3 week prior admission (liver abscess. Closed due to stable condition. Transferred to outside care - 1 patient with 3 prior admissions; s/p open heart surgery - 1 patient with single extended prior admission for newly diagnosed renal failure; on dialysis. o o o o - 1 homeless patient with prior admissions/cva requiring surgical intervention 1 patient death 1 patient lost to follow up after 3 clinic visits; transferred to outside oncology care 1 patient lost to follow-up; paralysis, chronic narcotic meds, chronic liver disease, serious mental illness 1 patient with 5/6 inpatient admissions prior to enrollment (suicidality); successfully secured behavioral health care. Increased Days (4 patients) o o o 1 patient had a single 2 ½ month post-enrollment hospitalization. Case closed after 2 weeks because condition stable. 2 deaths - 1 oncology patient transferred to outside care. Deceased. - 1 patient death after 2 month enrollment (renal failure; morbid obesity; diabetes, serious mental illness) 1 patient case closed after 2 weeks because unable to contact (PS) 27

28 Special Variation Patients at a Glance (n=28) 8 (29%) with renal disease (primarily ESRD) 7 (25%) with serious mental illness 5 (18%) with malignancy 5 (18%) with chronic pain No clear intervention-related reductions on a population level 5 (18%) no longer in Maryland (no CRISP data) 3 Deaths 2 Moved out of area/returned to home country 3 Obtained insurance 28 Presentation Name

29 Other Grant-inspired Accomplishments Developed comprehensive Assessment Tools Developed computerized Care Plan Tool Enrolled in/utilized CRISP (query portal and electronic notification) Completed PCMH readiness assessment One site has included PCMH recognition in its strategic plan Established leadership learning collaboratives to include presentations and guest speakers on a variety of topics including: PCMH Practice transformation Managing change and transition Sustainability Created opportunities for collaboration, networking, learning CRISP IHI Quality Improvement and Practice Redesign Diabetes and DSME Care Management (UM) Case Presentation Motivational Interviewing Redesigned clinical office practice Interdisciplinary team meetings RN Standing Orders (and training) to perform monofilament foot exams (vs podiatry referral), and standard referrals for diabetic retinal and dental exams CRISP ENS and follow-up of ED and inpatient visits 29

30 Lessons Learned Refine target population specific to objectives Reliable data and metrics are critical to inform process improvement, refine patient selection criteria, and evaluate outcomes Pre/Post comparisons are insufficient to evaluate intervention effectiveness; consider comparison group or special cause variation Develop Evaluation Plan at project onset Home visits provide unique opportunity to evaluate and intervene Consider focused interventions for conditions associated with ED/inpatient variation Renal disease, mental illness, chronic pain, malignancy) Care Coordination PCMH Leadership and Staff Engagement is essential to success Care Coordination can be successful in the absence of optimized and high functioning teams, but is ideally embedded within a robust PCMH model of care 30

31 Change for Practice Transformation (Care Coordination PCMH) Change Concepts for Practice Transformation Changing Care Delivery Building Relationships Reducing Barriers to Care Care Coordination Enhanced Access Patient-Centered Interactions Organized Evidence-Based Care Continuous and Team-Based Healing Relationships Empanelment 1 Laying the Foundation Quality Improvement Strategy Engaged Leadership Wagner EH, et al. The Changes Involved in Patient-Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:

32 Challenges Maintaining robust referral process/provider engagement in the absence of optimized care teams Turnover of RN Care Managers Both clinics converted to EMR and introduced Medicaid during the grant period Uninsured population poses unique challenges Patient specific (literacy, language, culture, housing, telephone and transportation) System specific (absence of referral sources or claims data) Clinic Resources (clinic staffing; clinic space; dedicated meeting time) Access to structured data 32

33 Process Measures Complete initial assessments and care plans for 72 patients per quarter effective October 1, The project averaged 40 enrollments/quarter Establish one to four learning collaboratives 4 learning collaboratives involving clinic leadership were completed (PCMH Overview, Leadership in PCMH Transformation, Managing Change and Transition, Sustainability) Conduct a baseline PCMH readiness assessment in each participating clinic HCHC completed Joint Commission assessment. PS completed NCQA assessment. Document changes in the average number of primary care visits completed by participants pre- and postinitial assessment N/A - Accurate pre-visit data was not obtained. PCMH patients had more than double the estimated encounters. Assess participant retention through metrics of length of time in active care management and % discontinued due to completion of goals, lost to follow-up, and discontinued for other reasons to be determined. Completed (Detail follows) 33

34 Outcome Measures 20% of PCMH patients with care plans will have a clinically significant improvement in biometric indicators 63% of all project patients improved A1c, and 54% improved blood pressure. 70% of patients with abnormal (high) results at baseline saw improvements in relevant indicators. Increase by 30% patients self-reported health status scores Insufficient data was available on which to evaluate. Since only a small minority of cases were closed due to stable condition, there was not sufficient opportunity to re-assess self-reported health status prior to case closure. Reduce by 20% the number of ED visits pre- and post initial RN assessment No reduction in ED visits was demonstrated pre vs. post enrollment in care management. Reduce by 20% the number/duration of hospitalizations pre- and post initial RN assessment The project demonstrated a 35% reduction in hospital admissions and a 42% reduction in hospital days, but these results are not attributable to project interventions. They are reflective of population regression to the mean. See detailed evaluation of utilization. Reduce by 25% the annual average cost per patient The project demonstrated a 42% reduction in gross per diem, but savings are not attributable to project interventions. They are reflective of population regression to the mean. See detailed evaluation of utilization. 34

35 Patient Story Ripples in a stream Daughter (clinic patient) accompanied her 60 year old father to diabetes education and RN visits; the daughter is very appreciative of the education and food logs provided; she shared the information and tools with her own husband who is also diabetic. The daughter is politically active, and spoke of the importance of health education in the community. 35

36 Thank You! Barbara H. Eldridge, MBA, PA-C Manager of Quality Improvement Primary Care Coalition of Montgomery County 8757 Georgia Avenue Silver Spring, Maryland Phone: