Innovations in Clinical Care Delivery Models that Integrate Care Across Settings to Improve Outcomes, Access, and Value

Transcription

1 Innovations in Clinical Care Delivery Models that Integrate Care Across Settings to Improve Outcomes, Access, and Value 2014 Integrating Quality Webinar Series July 7, 2014

2 Welcome & Introductory Remarks Submit your questions and comments to the Panelists using the Chat feature on the right side of your screen The recording and presentation slides will be made available within one week of this web conference at At the completion of the webinar, please complete the brief evaluation to provide feedback on today s program and suggestions for future topic areas

3 Clinical Care Innovation Challenge This program recognizes AAMC member teaching hospitals and medical schools that have implemented or are developing programs to address clinical care innovations, including new delivery, payment and training models, which integrate education and research to improve value and quality. Challenge Award Winners Cleveland Clinic University of Missouri School of Medicine University of Colorado School of Medicine LSU Health Sciences Center Vanderbilt University Pilot Project Winners University of Illinois College of Medicine at Peoria and UnityPoint Health Methodist Cincinnati Children's Hospital Medical Center University of Minnesota NYU School of Medicine Massachusetts General Hospital Awardee profiles are available at

4 2014 IQ Webinar Series July 22, 2014, 12:00-1:00 p.m. ET Aligning Maintenance of Certification (MOC) and Performance Based CME with On-Going Quality Improvement August 4, 2014, 12:00-1:00 p.m. ET Overcoming Obstacles to Research During Residency

5 Presenters: Leveraging Information Technology to Guide Hi-Tech, Hi-Touch Care (LIGHT 2) Development, Evaluation, and Refinement of an Offsite Clinical Pharmacist Service within a University Family Medicine System Jerry C. Parker, PhD Associate Dean for Research, MU School of Medicine; Co-Director, MU Institute for Clinical and Translational Science University of Missouri Joseph P. Vande Griend, PharmD Assistant Professor University of Colorado, School of Pharmacy and Medicine

6 Leveraging Information Technology to Guide Hi Tech, Hi Touch Care Jerry C. Parker, PhD Lori Popejoy, PhD, APRN, GCNS BC Eduardo Simoes, MD Michael LeFevre, MD Robert Lancey, MD Anne Fitzsimmons, MD Bryan Bliven Clayton Hicklin

7 The Award

8 The Opportunity Hire, train, and deploy workforce Implement a care coordination program Explore strategies for population health Develop workflows and technologies Explore costs, savings, and sustainability

9 The Stakeholders

10 The Teams OPERATIONS GROUP HI TOUCH TEAM ANALYTICS COORDINATING COMMITTEE ADVISORY BOARD Stakeholder Board ADMINISTRATIVE TEAM EVALUATION COORDINATING COMMITTEE Hi Tech Team TRANSITIONS AND IMPLEMENTATION TEAM PI GROUP STEERING COMMITTEE INNOVATION AND CARE TEAM HIA TEAM

11 The Beneficiaries

12 CMS Enrollment Dual 1,592 17% Medicare 6,021 63% Medicaid 1,892 20% dual Medicaid Medicare

13 Age Distribution Number of LIGHT 2 Members by Patient Age and Gender Female Male % 56% Number of Patients Less than 65 yrs old Greater than 65 yrs old

14 CMS 27 Chronic Conditions Hypertension Hyperlipidemia Depression Acquired Hypothyroidism Anemia Chronic Obstructive Pulmonary Disease and Bronchiectasis RA/OA (Rheumatoid Arthritis/Osteoarthritis) Chronic Kidney Disease Diabetes Ischemic Heart Disease Atrial Fibrillation Asthma Stroke / Transient Ischemic Attack Heart Failure Female/Male Breast Cancer Cataract Glaucoma Prostate Cancer Osteoporosis Benign Prostatic Hyperplasia Alzheimer's Disease and Related Disorders or Senile Dementia Colorectal Cancer Hip/Pelvic Fracture Acute Myocardial Infarction Lung Cancer Endometrial Cancer Percent of Patients

15 Risk Stratification (50%) Number of Patients (27%) 1422 (15%) (8%) 0 Tier 1 Tier 2 Tier 3 Tier 4 Tier 1 = Healthy (no CMS chronic condition) Tier 2 = Chronic condition, but stable (low utilization) Tier 3 = Chronic condition, but unstable (moderate utilization) Tier 4 = Complex care (high utilization)

16 High-Cost Episodes by Tier Average Number of Episodes Average Number of Episodes Emergency Inpatient Observation Tier 1 Tier 2 Tier 3 Tier 4 Tier 4 patients account for 51% of the inpatient, emergency, and observation episodes. Average Length of Inpatient Stay (days) Average Length of Stay/Patient (Days) Tier 1 Tier 2 Tier 3 Tier 4 Based on the past 365 patients visits data

17 Summary of 2013 Charges for LIGHT 2 Population 2/13 1/14 Number of Members: 9,266 Total charges: $175,766,433 Mean: $18, th percentile: $46,596 Median: $3, th percentile: $13,249 Minimum: $0 25 th percentile: $906 Max: $6,412, th percentile: $0

18 Charges by Tier Charges by Tier (March, 2013 February, 2014) % of Total Mbrs % of Total Charges Charges Per Mbr 60.0% $140, % 50.5% $119,434 $120, % 41.9% $100, % 27.3% 29.2% $80, % 19.9% $41, % $60,000 $40, % $6, % $8, % $20, % $0

19 Hi-Touch Negotiate responsibility Communicate Facilitate transitions Assess needs/goals Create a plan of care Monitor and respond to change Support self management Link to community resources Align resources with needs

20 The Original Protocol Coordination Domain Tier 1 Tier 2 Tier 3 Tier 4 Negotiate Responsibility Communication Facilitate Transitions Once only Once only Assess Needs & Goals Create a proactive plan of care Monitor and respond to change Support self-management Link to community resources x2 x2 x2 x4 x4 x4 Align resources with needs

21 Documentation of Care Coordination

22 Touches by Tier (Annualized) Touches by Tier (Annualized) 16, ,000 12,000 14, Total # of Touches 10,000 8,000 6,000 9, , Touches per Member 4,000 2,000 3, TIER (2,555 Mbrs) (4,690 Mbrs) (1,359 Mbrs) (679 Mbrs) 0.0

23 Time by Tier (Annualized) Time Spent by Tier (Annualized) 4,500 4,000 3,500 3, Total # of Hours 3,000 2,500 2,000 1,500 2, , Minutes per Member 1, TIER 3 4 (2,555 Mbrs) (4,690 Mbrs) (1,359 Mbrs) (679 Mbrs) 50 0

24 Touches by Domain (Annualized) Touches per Member (Annualized) LIGHT2 (Total) Communication Assess Needs & Goals Negotiate Responsibility Plan of Care Align Resources & Needs Facilitate Transitions Self Management Support Community Resources Change Response/Monitor Events

25 Time by Domain (Annualized) Minutes per Member (Annualized) LIGHT2 (Total) Communication Assess Needs & Goals Facilitate Transitions Self Management Support Negotiate Responsibility Plan of Care Align Resources & Needs Change Response/Monitor Events Community Resources

26 The Revised Protocol Coordination Domain Tier 1 Tier 2 Tier 3 Tier 4 Negotiate Responsibility Communication Facilitate Transitions Assess Needs & Goals Create a proactive plan of care Monitor and respond to change Support self-management Link to community resources Align resources with needs

27 The Attribution Strategy PCP Stayed the same PCP changed to same department PCP changed to other department PCP Undesignated PCP Not Eligible

28 Hi-Tech Data

29 Provider Dashboard Key Sections: Chronic Disease Care Preventive Care Screening Lower Cost

30 Providers and Care Coordinators: Health Risk Alerts

31 Providers and Care Coordinators: Patient Connections

32 Care Coordinator Worklist

33 Patient Dashboard

34 Patient Goal Editor

35 Institutional Integration: Operations Review

36 The Remaining Challenges Attribution management and workflow Optimizing physician engagement Optimizing patient engagement Optimizing institutional alignment Delivering targeted, electronic communications

37 Acknowledgement: CMS Health Care Innovation Award (1C1CMS331001)

38 Development, Evaluation, and Refinement of an Offsite Clinical Pharmacy Service within a University Family Medicine System Joseph Vande Griend, PharmD, BCPS, CGP 1,2 Assistant Professor, University of Colorado Co-Authors: Joseph Saseen, PharmD, 1,2 Debra Bislip, MD, 2 Gina Moore, PharmD, MBA, 1 Colleen Conry, MD, 2 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy, 1 and Department of Family Medicine, University of Colorado School of Medicine 2

39 Clinical Pharmacy and Family Medicine Collaboration at CU 3 pharmacist faculty (primary appointments in pharmacy, secondary in FM), pharmacy residents 1998: A.F. Williams Family Medicine Center (Medical Residency Training Clinic) 2000: University of Colorado Hospital (Inpatient Family Medicine Service) 2011: Park Meadows Clinic 2013: Boulder Clinic 2014: Westminster Clinic

40 Development July 2011: Park Meadows Family Medicine Located ~ 15 miles from the main campus and is part of the University Family Medicine System EPIC electronic health record (EHR) 100 patient visits/week spread among 5.4 FTEs 3 family medicine physicians, 2 NPs, 1 PA Clinical pharmacist: Joseph Vande Griend, Pharm.D. Full-time faculty at CU 2 years post-graduate residency training (with specialty in Family Medicine)

41 Development Clinical Pharmacy Service Significant upfront onsite time investment: 1-2 half-days/week for the first 3-4 months 1. Prospective clinical pharmacy medication review Manual review of EHR for upcoming visits Targeted patients most likely to benefit from medication review (e.g. diabetes, or multiple medications) Performed comprehensive medication review (CMR) When drug therapy problem identified, Clinical Pharmacy Consultation note placed into the EHR prior to patient appointment 2. Provider consultation in person or via EHR

42 Evaluation: 1-year results 118 hours of clinical pharmacist time (60% onsite) 70% provided offsite during months 6 through Clinical Pharmacy Consultation notes (83% prospective) Demographics for patients receiving a Clinical Pharmacy Recommendation (n = 123) Mean age (years) 65.4 (+/- 10.8) Mean number of medications 10 (+/- 5.6) Type 2 Diabetes 41/123 (33%) Hypertension 98/123 (70.7%) Existing vascular disease 19/123 (15.4%) GFR < 60 ml/min 48/123 (39%)

43 Evaluation: 1-year results 315 medication recommendations (~ 70% accepted) Drug therapy problem (n) Additional therapy needed (151) Unnecessary drug therapy (35) Most common recommendations Vaccine Statin Diabetes agent Antihypertensive Triglyceride lowering not needed ER Niacin not indicated Ezetimibe not indicated n, % accepted 94, 52% 21, 95% 7, 14% 3, 66% 13, 85% 7, 100% 6, 100% Drug interaction (24) Simvastatin interaction 21, 100% Incorrect dose (22) Antihypertensive dose too 12, 75% high/low 5, 80% Diabetes drug dose too high/low

44 Evaluation: 1-year results 315 medication recommendations (~ 70% accepted) Drug therapy problem (n) Lab needed (22) Vitamin D DEXA Most common recommendations n, % accepted 9, 44% 4, 25% Cost savings (19) Brand-only switched to generic 14, 86% Inappropriate drug (10) Unsafe in patients > 65 years 10, 90% Adverse drug reaction (9) Variety identified 9, 89% Wrong drug (9) Red yeast rice when statin needed 1, 100% Duplicate therapy (7) Aspirin/clopidogrel, ACEi/ARB 4, 50% Other (7) Non-adherence, med reconciliation 4, 100%

45 Evaluation: 1-year results 49 new vaccines administered 23 chronic disease drugs started: statins (19) antihypertensives (2) bisphosphonate (1) diabetes agent (1) 24 major drug interactions resolved 31 unnecessary drugs discontinued: Niaspan (6), Lovaza (5), gemfibrozil (5), fenofibrate (5), Zetia (4), Vytorin (1) terazosin (1), Cymbalta (1), clopidogrel (1), Colcrys (1), triamterene/hctz (1) Annual Estimated Savings: $52,215

46 Family Medicine. 2014; 46 (5):

47 Refinement: CP2 Score Offsite Clinical Pharmacy Service expanded to the Boulder Family Medicine clinic Greater efficiency in identifying patients who would benefit from CMR by the pharmacist was needed CP2 Score developed by the research team: Programmed within the EPIC EHR Uses ICD-9 codes and patient-specific data Cross-section report of the upcoming week s appointments, with prioritized scores, generated each Friday

48 CP2 Score (range: 0-21 points) Example Criteria* Chronic Disease Diagnosis - e.g., Diabetes, HTN, vascular disease Age (years) Objective patient data including lab values/vitals Number of items on the medication list *Point allocation was developed based on several iterations by investigators. The process of validating this tool is ongoing.

49 Medication recommendation after CMR CP2 Score Total reviewed Recommendation Yes No There were no patients with a score of 16 or higher % *2/588 (0.3%) *37/358 (10.3%) *40/119 (33.6%) *22/42 (52.4%) *Chi-square = 236, DF = 3, p <

50 Acknowledgement: Funding Primary Care Strategic Funding Program University of Colorado School of Medicine, University of Colorado Hospital, and University Physicians, Inc. QI and Small Grants Program University of Colorado School of Medicine, University of Colorado Hospital University of Colorado School of Medicine

51 Questions?