Bridge Team Innovation: New Approach to Care Management for Sickle Cell Disease: Mauvareen Beverley, M.D. Associate Executive Director Queens Health Network November 5, 2010 Healthfirst 2010 Fall Symposium: Making Care Accountable - innovations in Care Coordination and Quality 1
Queens Health Network The Queens Health Network (QHN) is a member of New York City Health and Hospital Corporation (NYCHHC) and affiliated with Mount Sinai School of Medicine. QHN comprised of 2 acute care facilities : Elmhurst Hospital Center (545 beds) Queens Hospital Center (261 beds) Thirteen community-based health centers Six school-based health centers QHN is a unique health care provider serving the largest and most ethnically diverse communities in New York City In 2007, Dr. Mauvareen Beverley was hired to develop a Network Care Management Department 2
Care Coordination Model Care Management for patient with multiple admissions and LOS 7 days by bridging the gap between inpatient and outpatient, reduce LOS,ED visits and 30 day readmission Inpatient Complex Case Bridge Team Individual Patient & Family Outpatient Care Management Expand current chronic disease management programs to include additional patients with Diabetes and other chronic diseases including prevention Develop a system of care management at the point of service entry that will better coordinate care between ED and outpatient dept and the community resources. Emergency Department Care and Case Management Community Based Organizations, Home Care, Private PCPs, Mental Health, And Housing Organizations) 3
Care Management Training Program Core Beliefs Recognition that the attitudes of Health Care providers positive or negative can affect patient care and subsequent health outcome. Recognition that the Disease is not the sum total of the individual Progressive understanding that the word patient does not fully address the complexity of the individual. Historical Baggage can affect patient beliefs and responses. Example: Tuskegee Study Use of negative words such as non-compliant, frequent flyer, high utilizers and drug seekers creates a culture of callous disregard 4 for patients.
Innovation: The Bridge Team The Complex Case/Bridge Team Initiative was implemented at Queens Hospital Center in January 2009 with the following objectives: To focus on the needs of patients with complex diagnoses by improving communication with patients and families and eliminate gaps in care coordination. To provide patients with appropriate quality care and information during transition in and out of the hospital setting. To improve patient experience and reduce readmissions through the interdisciplinary care management process. Patients with Sickle Cell Disease were identified as a population in need of Care Management. 5
Key Problem Key Problems Readmission rate Patient dissatisfaction with care and staff attitude in the ED and Inpatient service Lack of PCP follow-up post discharge Transition of care from adolescent to adult services Key population... Predominantly Patients of African Ancestry male and female from all countries Evidence of the problem... 7% of 30 day readmission in Queens are Sickle Cell Patients Impact of Problem. Financial cost to the system Potential for poor HCAP (Healthy Communities Access Program) scores Possible less than optimal health outcomes
Bridge Team Care Coordination Process All patients admitted with Sickle Cell Disease are referred to the Complex Case/ Bridge Team, composed of a Social Worker, a RN Care Manager and a support staff The Bridge Team works closely with the patients and their families and is an integral part of the interdisciplinary care team The RN Care Manager provides education, medication reconciliation, assistance in filling prescription, and follow up appointments The Social Worker provides psychosocial as well as family and community support post discharge. Empowers the patient to advocate for their health and well-being 7
Bridge Team Innovation: Identify and Build on Facts not Myths Agreed upon Core Beliefs Instituted Adult Sickle Cell patient registry Care Management Training Program Developed and implemented a patient survey that identified patient needs and concerns Collaborated with ED, Inpatient and Ambulatory Department Medical Directors to improve care for Sickle Cell patients Sponsored a comprehensive Sickle Cell conference that included clinical experts, a patient panel and a dad, for the Network and the community 8
Patient Survey How often during the year, do you have pain requiring an emergency room visit? Do you think that the care you receive in the emergency room addresses your needs? How effective does the staff control your pain in the ED? How many times per year do you get hospitalized? During your ED visit or hospitalization do you feel the doctors listen to you? Have you ever been called Drug Seeker? How did it make you feel? Do you have a primary care physician? Are you followed in the pain management clinic and hematology clinic? Do you feel depressed Do you receive on going mental health counseling? 9
Patient Survey cont d PATIENT INFORMATION Did you finish High School/College/Other Are you employed? Do you have children with sickle cell disease? What is your country of birth What is your parent s country of birth Language spoken? English Spanish French Other Recommendations to Hospital staff including physicians. Optional: Name: Contact Number 10
Sickle Cell Registry Data Patient Demographics Total Adult patients 41 Birthplace Male 21 USA 41% Female 20 Jamaica 17% Guyana 15% Age Africa 7% Age Range 19 to 65 yrs Trinidad 7% Average Age 32 yrs Haiti 5% Average Age Male 35 yrs Surinam 2% Average Age Female 28 yrs St. Vincent 2% Hondurus 2% 11
Sickle Cell Registry Data Patient Demographics Parent Data Sibling Data Parents with SC Trait (SCT) 88% Parents with SC Disease (SCD) 2% Unknown 10% Sibling with SCT 10% Sibling with SCD 19% Sibling with SCT or SCD 61% Unknown 10% Registry Expansion with addition of pediatric patient Pediatric Patients Total patients (Adult & pediatric) 51 92 12
Myth Sickle Cell Patients have a higher degree of drug addiction than the general population 13
Fact The data regarding opioid addiction in patients with sickle cell disease provides less evidence for addiction than popular opinion would suggest. Prevalence estimates for opioid addiction among patients with sickle cell disease range from 0.5% to 8% vs 3% to 16% in patients with other chronic pain syndromes, and in the general population Behaviors often described in patients with sickle cell disease, such as requesting a specific dose of opioid or requesting that the opioid be administered intravenously, may be normative in patients who have experienced a history of under treatment of pain. Treatment of Sickle Cell Pain Fostering Trust and Justice William T. Zempsky, MD JAMA. 2009;302(22):2479-2480. 14
Quotes and Insights From Our Patients The pain is like a sledge hammer constantly hitting me up and down my spine. Yes, I am a drug seeker. I need drugs to relieve my pain. I am not someone just seeking drugs. If you have a cure for my disease, come in and talk to me. If you don t, stay out of my room. When I m in crisis, the pain is so severe that I really want to die. When I m home and feeling better, these thoughts go away. 15
Quotes and Insights From Our Patients cont d Doctors and Nurses do not teach me about the disease; the disease teaches me. I often ask myself Why me, God and realize there are no answers. I have goals and aspirations despite this disease. I have 50% chance when admitted that someone will be nice to me. Why did it take the hospital so long to recognize us. Is it because of who we are? 16
What We Learned Improving patient trust is crucial to improving the lives of Sickle Cell patients. Trust starts with a patient engagement philosophy that is non- judgmental Effective Transition of Care process is important to patients and their families. Partnering with community based organizations is crucial to helping the patients in the broader context of the individual SCD like other chronic disease does not have to control ones life. Patients should make every attempt to control the disease and not have the disease control them. 17
Bridge Team Innovation: Next Steps Expansion of content of registry beyond demographics to include disease complications, medications and current treatment plans Adding pediatric patients to registry Collaborative with QSCAN and other community based organizations as well as health care institutions 18
Bridge Team Innovation: Summary Queens Health Network Care Management Department believes that the key to addressing the challenges of SCD, first and foremost, starts with patient engagement eliminating negative language and labels and in addition partnering with SCD patients, families, medical providers and community organization to improve health outcomes. 19
Thank You Difficult patients are not just born, they are in part, created by their passage through the medical system. Not only has this system failed to cure, it may have done unpleasant things to make matters worse. (Disorders of Hemoglobin Steinberg at al 2001-Pg 697) (Hartrick and Pitcher, 1995 ) It is more important to know the person who has the disease than the disease who has the person (Hippocrates) 20
Contact Information For more information, contact: Mauvareen Beverley, MD Associate Executive Director Care Management Queens Health Network (718) 334-1693 beverlem@nychhc.org 21