Care Coordination. The Embedded Care Manager. Presented by Thomas Decker, MD Mary Finnegan, BSN, M.Ed

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1 Care Coordination The Embedded Care Manager Presented by Thomas Decker, MD Mary Finnegan, BSN, M.Ed

2 Goals of Care Management The goals of care Management are consistent with the Triple Aim: Improve population health Enhance patient satisfaction Cost efficiencies Coordination of patient care through out the continuum Involve the patient and family in establishing goals for their care plan

3 Beginning the Care Manager Program Pilot began January 2011 at Strafford Medical Associates Focus was to decrease readmission rates for Congestive Heart Failure Patients Care Manager position created Began with a panel size of patients August 2011 expanded to include other chronic diseases

4 Structure Senior Director Quality / Nursing Clinical Staff Care Manager Provider

5 Care Coordination Team

6 Coordination with Project RED WDH Case Manager WDH Discharge Advocate Embedded Care Manager

7 Staffing and Training Registered Nurses Motivational Interviewing Health Coaches Certification Seven Embedded Care Managers covering all PCP practices

8 Role of Care Manager Manages chronic care Instrumental in preventative health Telephone contact with patients within 48 hours of hospital discharge Medication Reconciliation Comprehensive Care Planning Social Service Referral Care Coordination, patient navigation

9 Role of Care Manager Cont d Assessment of patient health status Health coaching and teaching Telephonic and face to face interactions Management of patients with multiple chronic care needs Assessment of patients ability for self management

10 Role of Care Manager cont d Role in transition of care Member of the collaborative care team Development of individual care plans Follow up with hospital discharges

11 Role of Care Manager cont d Assists the patient in the development of selfmanagement goals Medication reconciliation Referral to community agencies Follow up between office visits Patient/family education Documentation in Electronic Medical Record

12 Role of Care Manager cont d Member of the patient care team Collaborative relationship with providers Communicates with staff in practices, hospital, Home Health agencies, Skilled Care Facilities, Acute Rehabilitation Hospitals and numerous community agencies

13 Panel Composition Patients with chronic disease: Congestive Heart Failure Cardiovascular Disease Chronic Obstructive Pulmonary Disease Diabetes

14 Panel Management Call every hospital discharge within 2 business day Review of hospital discharge summary provides information relative to potential patients Provider will discuss patients to include on panel Panel size over 600 patients contacted Intensive follow up of patients

15 Measures of Success Consistency with hospital mission and vision Consistency with Triple Aim Continuum of Care Committee Decrease readmission rate Patients are self motivated Reduction of duplication of services Patient satisfaction

16 Measures of Success for Practices Medication compliance Huddles maximize care planning Getting the big picture in real time Maximizes provider time Care Manager available to accompany patient at time of visit

17 Metrics Process Measures Telephone contact with in 2 business days of discharge in high risk patients Telephone follow up with in 14 business days of discharge in high risk patients Self management goals recorded in Care Plan for high risk patients Palliative Care referral for appropriate high risk patients

18 Metrics Process Measures Cont d Completion of POLST for high risk patients

19 Outcome Measures Rate of readmission with in 30 days for high risk patients Days between readmission for high risk patients Mortality among patients not referred for Palliative Care Symptom Control Survey results ---average cumulative score

20 Outcome Measures Cont d Symptom Control Survey: Pain control Index (Numerical) Energy/ Activity Level Index (numerical) Overall Index (numerical) Breathing Index (numerical)

21 Updated 11/8/12 Comparison of Readmission Rates Full Year 2010 to March 2011-February 2012 Source: MIDAS (Rebecca Collins) PCP Group # of Acute Care Readmissions January- December 2010 March 2011-February 2012 # of Acute Care Admissions % 30 Day Acute Care Readmissions # of Acute Care Readmissions # of Acute Care Admissions % 30 Day Acute Care Readmissions Strafford Medical Associates % % Dover Internal Medicine % % Dover Family Practice % % Primary Care of Dover % % Adult & Children's Medicine % % Hilltop Family Practice % % Durham Health Center % % Lee Family Practice % % Bellamy Health Center % % Barrington Health Center % % South Berwick Family Practice % % Marshwood Family Care % % Great Bay Family Practice % % Seacoast Integrative Medicine % % Other 245 2, % 236 2, % Total 742 6, % 661 5, %

22 Comparison of Readmission Rates Pre- and Post- Care Manager Implementation Updated 11/8/12 Shared CM hired: 11/11 Panel size: 400+ Shared CM hired: 11/11 Panel size: 400+ Shared CM hired: 11/11 Panel size: 400+ CM hired: 11/11 Panel size: 400+ Shared CM hired: 11/11 Panel size: 400+ CM hired: 01/11 Panel size: 600 Comparison of Readmissions 25.00% Number of Readmissions 20.00% 15.00% 10.00% 5.00% 0.00% Strafford Medical Dover Internal Dover Family Primary Care of Adult & Children's Hilltop Family Durham Health Lee Family Practice 2010 (Jan-Dec) 14.19% 16.95% 12.01% 15.20% 10.77% 15.96% 15.31% 17.13% 9.26% 13.99% 12.62% 6.15% 23.73% 10.00% 9.44% 2011/2012 (Mar-Feb) 10.49% 11.24% 14.50% 12.71% 11.38% 17.52% 14.62% 11.64% 12.35% 16.55% 18.69% 15.28% 12.07% 0.00% 9.35% WHP Practice Bellamy Health 2010 (Jan-Dec) 2011/2012 (Mar-Feb) Single practices assigned a Care Manager: Strafford Medical; Dover Internal and Geriatric Medicine Barrington Health South Berwick Marshwood Family Practices assigned a shared Care Manager: Dover Family Practice & Adult and Children s Medicine; Great Bay Family Practice & Durham Health Center Great Bay Family Seacoast Integrative Other

23 Comparison of Discharge Disposition Rates 2010 Readmission Rate Readmission Rate Comparison of Discharge Disposition Rates 25.0% 20.0% Readm ission Rate 15.0% 10.0% 5.0% 0.0% Home, Self Home Health Skilled Nursing Transfer to Rehab Other Short Hospice Medical Against Medical 2010 Readmission Rate 10.3% 17.6% 14.1% 5.3% 7.0% 4.0% 20.7% 7.3% 8.1% 14.3% 4.2% 0.0% 0.0% 0.0% 0.0% 0.0% Readmission Rate 9.2% 14.9% 14.2% 6.0% 13.8% 0.0% 20.6% 3.2% 18.9% 7.8% 6.7% 0.0% 0.0% 0.0% 0.0% 14.3% Hospice Home Discharge Disposition Intermedi Structur Transfer Discharg Discharg Transfer Trans to ate Care ed/ to Psych e/ e/ to Desig Other

24 Comparison of Discharge Disposition Rates Full Year 2010 to March 2011-February 2012 Source: MIDAS (Rebecca Collins) January- December 2010 March 2011-February 2012 Discharge Disposition Disposition of Encounter prior to Readmit Total Acute Encounters 2010 Readmission Rate Disposition of Encounter prior to Readmit Total Acute Encounters Readmission Rate Home, Self Care 340 3, % 267 2, % Home Health Service 232 1, % 209 1, % Skilled Nursing Facility % % Transfer to Rehab Facility % % Other Short Term Hospital % % Hospice Medical Facility Inpatient % % Against Medical Advice % % Hospice Home Care % % Intermediate Care Facility % % Structured/ Assisted Living % % Transfer to Psych Facility % % Discharge/ Transfer to Court/ Law Enforcement % % Discharge/ Transfer to Federal Hospital % % Transfer to Specialty Hospital % % Trans to Desig Canc Cte or Children's Hospital % % Other % % Total 742 6, % 661 5, %

25 Medicare Care Coordination Two billing codes and Moderate and complex Specific criteria which includes identified time frames for patient contact Two business days after discharge for Care Manager to contact patient Office visit within 7-14 days Documentation requirements Thirty day episode from date of discharge

26 Lessons Learned Identify types of patients to include at onset Embedding the Care Managers in the practices has been very valuable for patients and staff Involving Pharmacist in medication management would be very beneficial Social Service involvement on a regular basis would help with agency referrals and financial counseling

27 Challenges Information Technology---Documentation, Care Plans Numerous medications Medication Reconciliation---no uniform list Staff resources Limited community resources Complexity of patient and family issues Balance of success and impact on bottom line

28 Case #1 Scenario A 64 year old male with Cardiovascular Disease, Chronic Obstructive Pulmonary Disease, Type Two Diabetes, Hypertension, Hyperlipidemia, Back Pain and Obesity. Number of medications = 13 Challenges Medication identification was a challenge due to illiteracy.

29 Case #1 Scenario Cont d He had difficulty remembering to take his medications. Established Self Management Goals Weekly meetings with the Care Manager to develop a system to identify his medications and assist him in setting up his AM and PM medications. Patient developed a system with the pharmacist for when he picks up his new medications or refills.

30 Case #1 Scenario Cont d Location of his medications to enhance compliance Began seeing a Certified Diabetes Educator Outcome Patient confidence in his ability to self manage Improvement in HbA1C now 5.2 down from 7.2 in October 2012

31 Case #1 Scenario Cont d LDL down fro 165 to 101 BP down from 152/77 to 118/66 Angina decreased

32 Case #2 Scenario A 64 year old male patient with congestive heart failure, diabetes, chronic obstructive pulmonary disease and ulcerative colitis. Number of medications = 32 Challenges Numerous hospitalizations and ED visits Illiterate, low socio-economic lifestyle Numerous physicians

33 Case #2 Scenario Cont d Depression over chronic conditions and wheelchair disabled. Established Self Management Goals Understanding of disease, medications, weight management Arranged wheelchair van service Work with significant other for medication management Referral to Community Service for depression Working closely with social service and healthcare agencies.

34 Case #2 Scenario Cont d Outcome Ability to now manage own care Medication compliant Office visit compliant Reduction in hospitalization and ED visits

35 Case #3 Scenario 63 year old Male with Type Two Diabetes and hyperlipidemia Number of medications = 7 Challenges Discharged from previous Primary Care Provider 5years ago for non-compliance and missed appointments Diagnosed with Diabetes in 2007 with no care for five (5) years HbA1C of 10.5

36 Case #3 Scenario Cont d Established Self Management Goals Understanding of chronic disease Understand medications Consistent meetings with Primary Care Provider, Care Manager and Certified Diabetes Educator (CDE)

37 Case #3 Scenario Cont d Outcome HbA1c from 10.5 to 6.3 Maintaining ongoing visits with Care Manager and CDE.

38 Case #4 Scenario 94 year old patient with Hypertension, memory loss and spinal stenosis. Number of medications = 2 Challenges Memory loss No family or friend to help patient forgetting to pay bills, not answering the phone, resistant to accepting help

39 Case #4 Scenario Cont d Outcome After working with independent healthcare organization to assess patient home care situation we were able to obtain placement in high level assisted living facility.

40 Questions?

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