DIVERT Development of interventions to prevent ED Utilization

Transcription

1 DIVERT Development of interventions to prevent ED Utilization Andrew P. Costa, PhD Institute for Clinical Evaluative Sciences & Mount Sinai, Toronto Department of Medicine, McMaster University, Hamilton Tom Peirce, MBA VP, Strategy, Quality and Performance Management Hamilton Niagara Haldimand Brant Community Care Access Centre 1

2 Agenda 1. DIVERT Scale. HNHB DIVERT Project Goals Planning Care Plans Evaluation

3 Home Care and ED Use Home care patients represent an prevalent and frail subgroup Account for ~ 9% of 6; ~ % of 8 (Ontario estimates) At very high risk for ED use (Wilson and Truman; 00) Efficient Care = Prioritization Evidence that prioritization + intervention is feasible and causes more efficient service provision (Landi et al. 1999; Manuel et. al., 01; Mukamel et al., 1997; Pathy et al., 199; Stuck et al., 00) No prognostic tools to determine likelihood of ED use

4 DIVERT Study N= 61,9 WRHA, Manitoba All LHINs, Ontario

5 ED use by the home care population samples

6 DIVERT Scale 6

7 Kaplan Meier survival curve for days to first unplanned ED visit within 6 months of an assessment, by DIVERT Scale, Validation Sample % 16% 0% 0% % 68% 7

8 Distribution of the DIVERT Scale across diagnostic categories, Validation Sample Cancer (N=1,17) Cardiovascular (N=70,) Demen a (N=8,60) Diabetes (N=9,099) Emphysema/ COPD/asthma (N=7,0) Infec ons (N=10,61) Musculoskeletal (N=98,79) Neurological (N=10,6) Psychiatric (N=,07) Renal Failure (N=9,6) 8 Percent (%)

9 Proportion with any unplanned ED visits within 6 months of an in home assessment by DVERT Scale and across diagnostic categories, Validation Sample Cancer (AUC=0.61) Cardiovascular (AUC=0.61) Demen a (AUC=0.60) Diabetes (AUC=0.6) Emphysema/ COPD/asthma (AUC=0.6) Infec ons (AUC=0.61) Musculoskeletal (AUC=0.61) Neurological (AUC=0.6) Psychiatric (AUC=0.6) Renal Failure (AUC=0.61) 9 Propor on with any ED visits within 6 months of assessment (%)

10 Implications We can estimate risk for future ED visits DIVERT can define an alternate paradigm for decision making Previous ED or hospital use, cardio respiratory symptoms, and mental health Many prognostic factors lie within the realm of ambulatory sensitive conditions and particularly cardio respiratory illness Need for service integration and sharing of information with primary care and specialists Question: We can predict it, but can we prevent ED use? 10

11 DIVERT Scale Acknowledgements Investigators Andrew Costa, PhD (PI) George Heckman, MD MSc John Hirdes, PhD Jeff Poss, PhD Chaim Bell, MD, PhD Susan Bronskill, PhD Paul Stolee, PhD Samir Sinha, MD DPhil Clinical Panel Christophe Bula, MD Ellen Burkett, MD Len Gray, MD PhD Marie Jeanne Kergoat, MD Don Melady, MD Fredrik Sjostrand MD PhD Walter Swoboda MD 11

12 HNHB DIVERT Pilot Project: Using the DIVERT Scale to Develop better Chronic Disease Management

13 HNHB LHIN Source: Action A Call To IntegratiON Now HNHB Strategic Health System Plan

14 HNHB DIVERT Pilot Project Purpose: To start to understand what type and intensity of chronic disease management services and coordination are effective in home care. OBJECTIVES: 1. Pilot Practices Purpose: To explore the feasibility new and sustainable chronic disease management strategies.. Pilot Evaluation Purpose: To test methods for using existing data sources for pragmatic trials. 1

15 HNHB LHIN 1

16 Clinical Partnerships An Inter professional Panel derived from: HNHB LHIN primary care leaders HNHB LHIN Family Health Teams HNHB LHIN geriatricians (McMaster Division of Geriatrics) HNHB LHIN cardiologists Key primary care practitioners and specialists were engaged through prior work with Ontario Cardiac Care Network Heart Failure Guidelines 16

17 Demographic and Caregiver Variables, by DIVERT 100% 90% 80% 70% 60% 0% 0% 0% DIVERT 1 DIVERT DIVERT DIVERT DIVERT DIVERT 6 0% 10% 0% Female Married 0+ hrs informal Caregiver Shows care* signs of Distress Better off** Deteriorated*** 17

18 Problem Conditions Physical Health, by DIVERT 100% 90% 80% 70% 60% 0% 0% 0% DIVERT 1 DIVERT DIVERT DIVERT DIVERT DIVERT 6 0% 10% 0% Chest Pain Dizziness Edema Shortness of Breath Daily Pain (Moderate to Severe) 18

19 Health Status Indicators, by DIVERT 100% 90% 80% 70% 60% 0% 0% 0% 0% DIVERT 1 DIVERT DIVERT DIVERT DIVERT DIVERT 6 10% 0% Unintended weight loss Poor Self-Rated Health Unstable Conditions Flare up of a chronic condition Treatment Changed (due to new acute condition) 19

20 Medications, by DIVERT 100% 90% 80% 70% 60% 0% 0% 0% DIVERT 1 DIVERT DIVERT DIVERT DIVERT DIVERT 6 0% 10% 0% Antipsychotic/ Neuroleptic Use Anxiolytic use Antidepressant use Hypnotic/ Analgesic use 9+ Medications 0

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22 DIVERT Project Higher Intensity ~ 70 patients Lower Intensity ~ 0 patients

23 DIVERT Subgroup 1 Summary: Medically complex, well defined, unstable, poor prognosis Interventions: RRTT Checklists/Patient Action Plans/Telemonitoring CAD, HF, COPD Primary care notices/resources/checklists/meetings CREMS and EMS registration Advanced Care Planning CDM Patient Self Management Pharmacy meds check/rrtt RT visit **Home based primary care/health care connect?? **Specialists. geriatrics, cardio??

24 DIVERT Subgroup 1 Summary: Medically complex, undefined, unstable Interventions: RRTT Checklists/Patient Action plans/ Telemonitoring Primary care notices/resources/checklists/meetings CREMS and EMS Registration CDM Patient Self Management Pharmacy meds check **Home based primary care/health care connect?? **Specialists. geriatrics, cardio??

25 DIVERT Subgroup 10 Summary: COPD/CAD, dyspnea, fairly stable, well managed Interventions: Primary care notices/resources/checklists/meetings CREMS and EMS Registration CDM Patient Self Management Pharmacy meds check/rrtt RT visit **Specialists. geriatrics, cardio??

26 DIVERT Subgroup 9 Summary: CAD, fairly stable, well managed Interventions: CM Checklists/Patient Action Plans Primary care notices/resources/checklists/meetings CDM Patient Self Management Pharmacy meds check

27 Practice Changes for DIVERT Caseloads 1. Improved CCAC Interprofessional Communication Goal to establish a better communication between RRTT and CMS, where roles are defined and clinical and supportive care integrated in care plan = ACHIEVED. Improved CCAC Continuity of Care Goal: Ensure clinical care providers are consistent among DIVERT patients to improve chronic disease management = ACHIEVED

28 Care Pathways Higher Intensity Lower Intensity Care Lead: DIVERT Rapid Response Nurse CCAC Care Manager Common Elements: High Intensity Only: Community Meds Check Primary Care & Specialist Communication Protocols Chronic Disease Self Care and Caregiver Support Information Pneumonia and flu vaccine Enhanced CCAC continuity practices Dedicated DIVERT support hotline Weekly case rounds with team 1 week ( visits/ phone) schedule HF and COPD Action Plans Advanced Care and Goal Planning Nurse Practitioner Support RRTT Clinical Pharmacist Consult (if needed) ED Transition Package 8

29 RRTT CLINICAL CARE PATH (1 WEEK PROCESS) visits in total (one initial assessment and follow up visits) telephone follow up reassessments PRN telephone consultation (hotline) THE SCHEDULE FOR PLANNED CONTACTS: Week 1 In Home Initial Assessment (1) Week In Home Reassessment () Week Telephone Reassessment (1) Week In Home Reassessment () Week Telephone Reassessment () Week 6 In Home Reassessment () Week 7 Telephone Reassessment () Week 8 Week 9 Week 10 Week 11 Telephone Reassessment () Week 1 Week 1 Week 1 Week 1 Telephone reassessment/disengagement ()

30 CHF Action Plan

31 Heart Failure Weight and Zone tracker DAILY WEIGHT TABLE NAME: MONTH/YEAR: PLEASE NOTE: IF YOU GAIN TWO () LBS IN ONE DAY OR FIVE () LBS IN ONE WEEK, PLEASE CALL YOUR DOCTOR TODAY. TODAY S DATE TODAY S WEIGHT WHICH HEART FAILURE ZONE ARE YOU IN TODAY?

32 Planning Interventions were initiated on 7 CCAC patients each week for 16 weeks Start date: February 01 Duration : 11 Days June A 1 Week Clinical Care Path is being completed on all ~10 patients Start Date: Feb 01 Duration: 17 Days Sept

33 Communication with Primary Care Level 1: Patient Status Update Jointly developed, efficient two way communication tool using the Institute for Health Improvement SBAR format. Level : Additional document request Rapid Response Nurse Initial Assessment COPD/CHF/Dyspnea Action Plans PHP (RAI Assessment Summary)

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35 Evaluation Non randomized Matched Evaluation DIVERT Caseloads DIVERT Score (RAI HC) DIVERT Interventions + Regular Care 6 months Outcomes + Cost Match by DIVERT & demographics Regular Caseloads DIVERT Score (RAI HC) Regular Care 6 months Outcomes + Cost

36 DIVERT Project Acknowledgements Clinical Panel Andrew Costa, PhD (Chair) Dilys Haughton, RN, MHSc Colleen Lackey, RN, BScN Beth Dube, BScPT Anne Pizzacalla, RN, BScN Wendy Renault, RN Alison Shields, RN Bob McKelvie, MD, MSc George Heckman, MD, MSc Karl Stobbe, MD Ainsley Moore, MD, MSc Jennifer Everson, MD, MSc Operations Committee Tom Peirce, MBA (Chair) Beth Dube, BScPT Colleen Lackey, RN, BScN Dilys Haughton, RN, MHSc Irene Wilson, PhD Jane Blums, MHSc Gail Riihimaki, BScPT Andrew Costa, PhD Barb Busing, BScPT 6

37 Questions? Comments? 7