Kick-off Meeting November 11-13, 2015

Transcription

1 Kick-off Meeting November 11-13, 2015 Cornerstone Health Care Heart Function Program Carolina Cardiology Cornerstone

2 Cornerstone Health Care Founded in 1995 as a Physician owned and led Multidisciplinary Organization 85 Practices 36 Specialties, including 6 Cardiology Office locations 201 Physicians, 127 Advanced Practice Providers Serving approximately 242,000 Patients

3 Heart Failure Program Team Presenting: Thomas Folk, MD, FACC -Medical Director of The Heart Function Program Providers: Thomas Folk, MD, FACC Steven Rohrbeck, MD, FACC Ursula Grant, MSN, FNP-C Multi-Disciplinary Team: Dave Tofanelli, MBA, PhD, FACHE- Practice Administrator Sharon Hanes, RN, BSN-Clinic Manager Kyle Nifong, MBA-Director of Clinical Quality Dale Green, MD, MHA -Chief Medical Information Officer Jaime Glover, Clinical Data Analyst Shannon Parrish, RN, BSN-Director of Care Coordination Julie Smith, RN, BSN-Health Navigator Marybeth Kindley, CMA-Patient Engagement Coordinator Faith Yow, RD, LDN- On Site Dietitian Larry Young, PhD-Psychologist Nellie Garcia, RMA-HFP Medical Assistant

4 HF Goals & Objectives As an ACO We Strive for the Triple Aim: Improve Quality of Care Improve Patient Experience Reduce Overall Cost of Care HF Goals : Targeting Hospital Admissions/Readmissions/High Risk Patients Telemanagement for Detection of Signs/Sx for Early Intervention Enhanced Medical Management Through Multidisciplinary Team Where Are We Now? Three Years into Outpatient Multidisciplinary Program Embedded in the Main Cardiology Practice Care Delivery Process Evolving in Hopes to be Replicated Throughout the Health System

5 HF Intervention & Population Baseline Target HF Population: Systolic Heart Failure with an Ejection Fraction of less than or equal to 45% Diastolic Dysfunction HF Registry: 315 active patients Behind the Scenes: Development of Dedicated Team Defined Roles and Workflows

6 HF Intervention & Population Baseline Technology : Obtained and Reviewed Analytics to Determine High Risk Patients Registry Development to Track Active Participants Staff Involvement: Daily Screening of: Office Schedules Inpatient Hospital Lists and Portals Referrals from Providers and the Health Navigators Methods to Change Physician Practice: Identification of Physician Champions

7 Improvement Interventions Close Telemanagement for Early Sign and Symptom Identification Robust Transition Of Care Support: Health Navigation Pharmacy Support Enhanced Patient Educational Materials Resource Allocation: Cardiac/Pulmonary Rehab Sleep Apnea Referrals Behavioral Health Referrals

8 Measures Used National Clinical Standards: American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Data sources, data collection processes, measures, and results: For the AMGF Collaborative: EMR Optum One Cornerstone Heart Function Program: Heart Function Program Registry and Analytics Heart Function Program Report Cards

9 Challenges or Obstacles Biggest Challenges: Specialty Copays Transportation Identification of Heart Failure Patients Appropriate for Program Patient Engagement Lack of Benefits for Medical Nutrition Therapy

10 Outcomes and Successes Key Elements for Success: Enhanced Care Coordination and Patient Support Provided By: On Site Multidisciplinary Team Nurse Practitioner Behavioral Health Nutrition Health Navigation Team Off Site Multidisciplinary Support Social Work Pharmacy Results: Increased Efficiency of Care Delivery Decreased Utilization of Acute Care Decreased Costs of Care Improved Patient Outcomes Increased Patient Satisfaction

11 Future Steps Next Steps: Continue to Increase Enrollment of Patients in HF Program Development of Medication Management Protocol/Process Enhance Transition of Care Support Implement Quality of Life Monitoring Tool We Hope to Achieve: Improvement in Quality of Life Better Patient Self Care Management Practices Standardization of Care Continued Health Care Savings

12 Lessons Learned Lessons Learned: Be Flexible-It s OK to Revise, Revise, Revise! Patient Engagement is Essential

13 Questions