Care Management Programs to Improve Outcomes in Value Based Payment: Early Lessons from PCDC s Integrated Care Planning Collaborative

Transcription

1 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations Care Management Programs to Improve Outcomes in Value Based Payment: Early Lessons from PCDC s Integrated Care Planning Collaborative Karla Silverman, MS, RN, CNM Primary Care Development Corporation October 18, 2015 Slide 1

2 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations Primary Care Development Corporation (PCDC) Founded in 1993 Nonprofit organization dedicated to transforming and expanding primary care in underserved communities to: Improve health outcomes Reduce healthcare costs and disparities. Slide 2

3 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations PCMH Recognition and Transformation PCDC s Experience Care Coordination and Care Management Workforce Training and Curriculum Development Clinical Operations and Quality Improvement Integrating HIV, reproductive health, and behavioral health services into primary care Slide 3

4 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations Objectives Identify best practices that support coordinated care and an integrated care planning process for patients Describe effective integrated team processes that support improved patient engagement and outcomes Slide 4

5 Slide 5 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations A story FQHC #1 is also a NY State lead Health Home provider. This make sense as they are a safety net provider who has always cared for many patients with complex social service needs, many of whom also have high risk medical conditions. FQHC #1 will now have care managers and, as opposed to the old case management system, many more types of patients will receive care management, and the FQHC/Health Home can get paid for these care coordination and care management services.

6 Slide 6 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations A story The Health Home care managers will collaborate closely with the primary care and behavioral health staff to provide an interdisciplinary, coordinated approach to meeting the needs of patients with multiple chronic conditions. Clinicians will feel supported by the care managers, relieved that some work is being taken off their plate. The mental, physical and social service needs of patients will be addressed in an integrated way. Care will improve. Patients will get better. Someone will save a lot of money.

7 Slide 7 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations What do we mean by an integrated care planning process?

8 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations An example of when an integrated, team based care planning approach was needed 25 year old G6P2 First two children had previously been with social services Past pre-tem delivery at 32 weeks with baby in NICU for 8 weeks Past hx substance abuse Hx of depression Referred to the high risk OB hospital clinic but never went Came to visits at our community health center, but erratically Slide 8

9 Slide 9 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations For patients with complex medical and social conditions, the care planning process needs to be integrated and coordinated. To provide an integrated care planning process we need to understand how to deliver care as a team.

10 Slide 10 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations The Integrated Care Planning Initiative: A PCDC Learning Collaborative

11 Slide 11 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations Communication, collaboration, Integrated care planning process Medical providers Patient Care management providers Behavioral health providers

12 Slide 12 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations BrightPoint Health Participating Organizations Organization Community Healthcare Network Institute for Family Health Mount Sinai Hospital Community Health Services of Upstate Cerebral Palsy

13 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations What we found Medical, behavioral health and care management departments in siloes Doctors who did not know what the care management program was, which of their patients were in it, and how it could be useful Care management enrollment numbers that were low and didn t include all eligible patients Uncoordinated administrative and IT systems that don t support team based, integrated care Lack of process or uncoordinated and erratic processes for follow up after emergency room and inpatient discharges Slide 13

14 Slide 14 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations Common issues that the organizations are working on Increasing the use of the care management program Sharing information more effectively between departments Establishing interdisciplinary case consult meetings Care plans with input from medical, behavioral health and care management Clear processes for patient follow up after is discharge from hospital

15 Slide 15 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations Best Practices Increase the use of the care management program Warm hand offs Co-location of care managers in primary care offices Or presence of care manager at the primary care office at regular intervals Discussion with doctors about its value and soliciting of their input In service all departments about the program

16 Slide 16 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations Best Practices Share information effectively between departments Build one care plan template with tabs that different departments can update Update EMR/IT system so that care team is identifiable to all Someone must be accountable for updating plan-usually care management Create liaisons that interface with doctors, behavioral health

17 Slide 17 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations Best Practices Establish interdisciplinary case consult meetings Risk stratify care management patients Don t discuss too many patients Have dedicated time for any department to bring difficult cases to Use meetings to review patients who are frequently in the hospital or in crisis

18 Slide 18 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations Best Practices Care plans with input from medical, behavioral and care management An integrated care plan is the end point of an integrated care planning process Creating a care plan accessible to all does not create a process for completing it and delivering an integrated message to the patient

19 Slide 19 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations Best Practices Clear processes for patient follow up after is discharge from hospital Is there a process now? Who knows about it? How do you know it is being followed? Can t just be care management that is following up Different processes for different types of patients

20 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations Lessons learned so far Organizational commitment from leadership for team-based care delivery is critical Empanelment Use data to understand who a team s patients are, what their needs are and how they are doing Strategically show doctors how care management can help their patients and them Work towards IT systems that are integrated or at a minimum can show who is on a patient s care team and how to contact them Slide 20

21 Slide 21 PCDC Integrated Care Planning Initiative Funded by the Altman and Blaustein Foundations Contact: Karla Silverman, MS, RN, CNM Director, Clinical and Training Initiatives

22 ED Diversion Through Co-Location of Care Management: A Collaboration Between a FQHC and a Community Hospital Avi Silber, MD, FAAP: Chief Medical Officer Jesse C. Sarubbi, MA: Sr. Director of Care Management & Health Education

23 FACULTY DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. The faculty in a position to control content for this session have indicated they have no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

24 The Greater Hudson Valley Family Health Center

25 Who we are Federally Qualified Health Center Joint Commission Accredited PCMH Level 3 23,000 patients with 171,577 units of service in clinical sites plus a mobile van including health care for the homeless, Center for Recovery, dedicated dental, and audiology Locations in Newburgh, New Windsor, Highland Falls, Goshen Coming Soon. New Access Point: Binghamton, NY - collaboration with Housing Authority Innovative DSRIP partnerships

26 Patient Race/Ethnicity Project Community: Newburgh, NY KFP Site Race Composition KFP Site Ethnicity Composition 8, 0% 60, 2% American Indian or Alaska Native Asian 91, 2% 102, 3% Hispanic or Latino 2411, 64% 1005, 27% 15, 0% Black or African American Native Hawaiian or Other Pacific Islander Patient Declined 1409, 38% 2135, 57% NON-HISPANIC Patient Declined UNREPORTED/REF USED TO REPORT 103, 3% 135, 4% Unspecified White

27 Patient Language Composition Project Community: Newburgh, NY Spanish, 1431, 38% English, 2272, 61% Arabic ASL Chinese Creole Dzongkha English French Hindi Korean Mandarin NULL Panjabi; Punjabi Polish Spanish Urdu Vietnamese

28 Our Services Internal Medicine Urgent Care Pediatrics OB/GYN Behavioral Health Dental Audiology Subspecialty Care Healthcare for the Homeless Center For Recovery (Out-patient chemical dependency treatment) Care Coordination Positive Choices (HIV/AIDS Care and Care Coordination) Women, Infants, and Children (WIC) Services Enabling Services Health Education

29 Care Management Department 1 Care Coordinator at ED SLCH 1 RN Care Transitions Case Manager for admitted patients at SLCH 6 Care Coordinators at Newburgh Site 2 Health Home Dedicated 2 IM High Risk 1 Pediatric 1 DSRIP Project 3 Preventative Health Care Coaches (one CMA and 2 AmeriCorps Volunteer2) Outreach and enrollment for above (includes street outreach) Asthma Improvement project Post-natal follow-up Pap and Mammogram care coaching Colon Cancer Screening coaching Other special projects as needed for instance will begin doing home visits for asthma, and for some families showing up in the ED 1-2 Interns as support for all above

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31 Emergency Services at SLCH The Kaplan Center for Emergency Medicine at St. Luke s Cornwall Hospital s Newburgh campus remains one of the most frequently visited Emergency Departments in the Hudson Valley. In 2014, SLCH averaged just under 5,000 patients per month at the Newburgh Campus. Newburgh campus Cornwall campus

32 The Partnership: The Greater Hudson Valley Family Health Center & St. Luke s Cornwall Hospital GHVFHC Care Coordination SLCH ED referrals ED Diversion

33 The Partnership How it all began: Discussions began in 2012, as both GHVFHC and SLCH Providers noted frequent inappropriate use of ED by GHVFHC patients By 2013 we had a shared vision of co-location Both partners performed ongoing collection to support project development GHVFHC Care Coordinator began at SLCH in March 2014

34 Project Goals Reduce Potentially Preventable Emergency Room Visits (PPVs) Redirect care to the most appropriate setting by providing supportive patient education care coordination service (re-engage in primary care) Collect reliable Data/Information to inform project development Sustainability (self-fund) Appointments made Engagement Gain sharing agreements (Affinity) DSRIP initiative

35 Scope Care Management services are provided at the SLCH Emergency Department to GHVFHC patients, and SLCH ED patients who are referred by SLCH staff Referral based off Emergency Severity Index (ESI) Patient need not have PCP 30-day return to ED Patients are seen by GHVFHC Care Coordinator upon discharge from SLCH ED Care Coordinator follows up with patients who are in need of low-level of care in ED or who have repeat visits in a 30 day period

36 Project Planning Agreement on goals and procedure Interpretations of EMTALA o Able to work with patients at discharge Data sharing Space / Access to patients Connectivity Communication with GHVFHC clinical departments

37 Metrics Tracked GHVFHC patients served in ED based on discharge provided by SLCH SLCH referrals to CM provided by SLCH Existing GHVFHC patients seen/followed up with by CM New patients seen/followed up with by CM at SLCH Total number seen by CM Follow-up with those not seen by CM in ED Successful post-ed follow-up appointments Follow-up visit No Show rate 30-day re-visits to ED after seen by CM

38 Level of Care: ESI

39 The Facts About Potentially Avoidable Emergency Room Visits in Upstate NY (2011) Excellus a nonprofit independent licensee of the BlueCross BlueShield Association

40 The Facts About Potentially Avoidable Emergency Room Visits in Upstate NY (2011) Excellus a nonprofit independent licensee of the BlueCross BlueShield Association

41 Our own data

42 The Facts About Potentially Avoidable Emergency Room Visits in Upstate NY (2011) Excellus a nonprofit independent licensee of the BlueCross BlueShield Association

43 Total Referral to CM January July 2015 (n=3,581) Total Follow-up % Total Referred by SLCH 2,808 79%

44 Top Barriers to Using PCP: Patient Report ED List of Barriers: December July

45 Top Barriers to Using PCP: Patient Report Transportation 9% No insurance/em. Medicaid Wait inside 6% GHVFHC 3% Sent by UC 9% Barriers Unable to pay copay 2% Convenience of location 38% Wait too long for scheduling 9% Convenience of service 24%

46 Success by Appointment Type 700 January July % % 248 Total Made Kept 0 Total Appointments PCP Appt. 35% Sent to UC

47 352 Follow-up Appointment Success by Mode of Intervention February July Total Kept Percentage Face to Face Phone F/U Face to Face UC Phone UC

48 Addressing Challenges Communication Created ED Follow-up forms in EMR to communicate patient issues/needs with GHVFHC Clinical staff Monthly Quarterly, collaborative meetings Monthly communication between IT departments Access to Appointments (PCP and Specialty) Capacity in GHVFHC IM departments dedicated ED F/U appointment types daily/provider Same-day walk-in visits Behavioral health ongoing issue New co-location of BH in IM with community partner Expanding BH

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50 Addressing Challenges Transportation Established relationship with local taxi company Care Coordinator schedules transport for patients from ED to GHVFHC Provides business cards and instructions to call for transport assistance Set up medical transport for those with Medicaid for urgent visits Teach patients how to schedule medical transportation for scheduled visits Coached to call Care Coordinator if need assistance

51 Addressing Challenges Data collection Data utilized is from SLCH discharge report Due to updates and change of staff, report reliability has been inconsistent Not yet able to track decrease (or increase) of GHVFHC patients seen at ED Not able to provide true diversion at current Specialist follow-up an issue Many do not take Medicaid Cost or co-pays too high for many patients with or without insurance

52 Interesting Lessons Many patients use pre-paid phones and have limited minutes They report they do not want to waste minutes on making appointments over the phone Do not want to call Medical Transportation Perception is important (how do we change this?) Perception that wait is longer at PCP Perception all needs will be met at ED Some people go to ED to have their social or other needs met Company, interaction Turkey sandwich

53 Best Practices Face to face interventions are most effective! Connect with and establish trusted relationship with patients Sell value of primary and preventative care as well as convenience and value of Urgent Care Schedule Follow up appointments within 3-5 days if possible Communicate internally regarding patient needs and situation Be willing to change status quo (e.g. change scheduling template or appointment types) Follow up with frequent fliers

54 Best Practices Be willing to change status quo (e.g. change scheduling template or appointment types) Target marketing to ED users Offer information of services offered at GHVFHC ( on call physician, urgent care) Work to change misperceptions about care Location Location Location!

55 Successes 15% decrease in GHVFHC ED visits in first 6-months of project PCP appointments made and kept: 1,048 Urgent Care visits as ED Follow-up: 243 New patients engaged: 301 Best practices learned e.g. Importance of face-to-face interventions Strengthened Relationship with SLCH RN Care Transitions Case Manager Medical Village Learning from our patients Location (38%) Phone minutes

56 Next Steps Increase presence at ED Work to improve report / data exchange Secure more data on repeat users Maintain strong presence at hospital RN Care Transition Case Manager Proposed Medical Village through NYS DSRIP at SLCH will include ED Diversion into primary care

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59 Collaboration, Co-location and Care Coordination!