Observatory Venice Summer School 2015 "Integrated care: moving beyond the rhetoric" 26 July 01 August 2015, Isola di San Servolo, Italy
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1 Maria Chiara Corti Regione del Veneto USING ACG (ADJUSTED CLINICAL GROUPS) TO IMPROVE EQUITY AND CARE COORDINATION Observatory Venice Summer School 2015 "Integrated care: moving beyond the rhetoric" 26 July 01 August 2015, Isola di San Servolo, Italy Giunta Regionale Area Sanità e Sociale
2 Multimorbidity and Population Health Management Multimorbidity is the norm in our population. Care for these persons is fragmented and expensive Disease management programs fail, when many chronic conditions are coprevalent Risk stratification is a key component for case finding and case-mix adjustement.
3 Population Health PALLIATIVE CARE, CARE COORDINATION CASE MANAGEMENT CARE COORDINATION End of life Multimorbidity and complexity Management HOME, HOSPICE COUNTRY HOSPITAL, OUTPATIENT COUNTRY HOSPITAL, DISEASE/CASE MANAGEMENT DISEASE MANAGEMENT Single complex disease, Multiple simple conditions Single non-complex condition OUTPATIENT HOSPITAL OUTPATIENT DIAGNOSIS HEALTH PROMOTION SCREENING HEALTH MANAGEMENT TOOLS Symptoms development In good health Giunta Regionale Area Sanità e Sociale PRIMARY CARE HOME POINT OF CARE
4 WAHT IS THE ACG SYSTEM? ACG = Adjusted Clinical Groups USED FOR RISK ADJUSTMENT: IT S A POPULATION GROUPER: Developed by Johns Hopkins University, Baltimore (USA)
5 3 key goals from our regional Plan Stratify the population and their risk. Integrating data to integrate professionals in primary care Improve care coordination for persons with multimorbidity.
6 Scaling up with ACG in VENETO Pilot : 2 LHU (1 mln inhabitants) Database building Statistical validation Integration with GP diagnoses : 6 LHU (2 mln inhabitants) Retrospective analyses : Focus on specific chronic diseases depressione, diabetes,. Hospital admission predictive modelling ACG Interface with business intelligence systems : 21 LHUs (5 mln inhabitants) All LHUs are involved Regional database is now available Case management program in primary care
7 Disease registries (ICD9) Person centered data collection Hospital discharge data ( ICD9CM) Emergency Room (ICD9CM) Nursing homes Hospice (ICD9CM) Person Home care (International Classification for Primary Care-ICPC) Mental Health Database (ICD10) Rare disease registry (ICD 9) Drugs (ATC) Costs & tariffs ( DRGs, tariffs, drug costs) Giunta Regionale Area Sanità e Sociale
8 ACG Actuarial Cells Reflect the Constellation of Health Problems Experienced by a Patient Time Period (e.g., 1 year) Treated Morbidities Visit 1 Visit 2 Visit 3 Clinician Judgment Diagnostic Codes Code A Code B Code C Code D Clinical Grouping Morbidity Groups ADG10 ADG21 ADG03 Age and gender 93 ACG Categories 6 RUBs categories
9 The risk pyramid: Resource Utilization Bands PALLIATIVE CARE, CARE COORDINATION CASE MANAGEMENT CARE COORDINATION 5= End of life = 1% 4 = Multimorbidity and complexity = 3 % WEGHT 10,2 WEIGHT 5,1 DISEASE/CASE MANAGEMENT DISEASE MANAGEMENT DIAGNOSIS 3 = Single complex disease, Multiple simple conditions = 17% 2 = Single non-complex condition 16% 1 = Symptoms development = 44 % WEIGHT 2,4 WEIGHT 0,9 WEIGHT 0,3 HEALTH PROMOTION SCREENING HEALTH MANAGEMENT TOOLS 0= In good health= 18% Giunta Regionale Area Sanità e Sociale WEIGHT = 0 LOCAL WEIGHT
10 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Population vs cost % distribution by RUBs 3,7 17,7 18,7 40,7 19,2 Veneto Population 21% 28,0 45,0 75% 71 % 56,0 16,0 17,0 12,0 12,0 Total costs Giunta Regionale Area Sanità e Sociale 15,0 Drug costs High/ Very High Moderate Low Healthy user Non user
11 Health care resources : % cumulative distribution MORE THAN 60% OF RESOURCES ARE USED BY 8% OF THE TOTAL POPULATION BEST TARGET FOR CASE MANAGEMENT PROGRMS
12 348 7,0 3,4 1,7 0,9 0,9 Costo Totale medio , % assistiti % Population and costs by N. of chronic conditions Costo Totale medio % assistiti Più di n. Chronic conditions 5 0
13 What type of intervention did we need? Population focused Evidence based Adapted from the Guided Care Model Comprehensive Personalized Intersectorial approach Granting continuity
14 The paradigm of Congestive Heart Failure Heart
15 The paradigm of Congestive Heart failure N. of patients with CHF in 2013 in Veneto N. of patients with CHF in 2014 in Veneto
16 The paradigm of Congestive Heart failure
17 The paradigm of Congestive Heart failure
18 Evidenze cliniche in Veneto Combined Outcome : all cause mortality and CHF hospital admissions) 70% 60% Δ=-30% Δ=-24% 50% Δ=-40% % 40% 30% Δ=-51% p = 0,007 p = 0,03 p = 0,05 Intervento Controllo 20% p = 0,003 10% 0% 3 mesi 6 mesi 9 mesi 12 mesi Follow up
19 What type of intervention did we need? Population focused Evidence based Adapted from the Guided Care Model Comprehensive Personalized Intersectorial approach Granting continuity
20 About the Guided Care Model Specially-trained RNs are based in GPs Medical Homes The nurse collaborates with 2 GPs in caring for high-risk older patients with chronic conditions and complex health needs (CHF). The nurse partners with the patient for the rest of their life; it is NOT a one episode solution. Boyd et al. Gerontologist 2007
21 Care Manager Nurses Assess patient needs & preferences Create an evidence-based Care Guide and Action Plan Monitor patient proactively Support patient self-management Smooth transitions between sites of care Coordinate with all providers: Hospitals, EDs, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies Educate and support family caregivers Facilitate access to community services Regularly updates care and action plan with GPs. Boyd et al. Gerontologist 2007
22 How are patients selected? CARE MANAGEMENT LISTS OF PATIENTS WITH CHF GENERATED BY ACG + INTEGRATED WITH OTHER CHF PATIENTS IDENTIFIED BY GPs WITH ADDITIONAL COMPLEXITY (SOCIAL BURDEN, OTHER FRAILTIES)
23 Integration of data to integrate care Population Disease : Diagnoses (EDC, major EDC) Drugs (RxMG, major RxMG) Diagnoses Drugs -Costs -Resource use -Treatments Person centered ACG System Disease burden ADG (Aggregated Diagnosis Groups) ACG (Adjusted Clinical Groups) RUB (Resource Utilization Bands) Future use of resources Future cost prediction Probability of high cost Probability of hospital admissione (unplanned)
24 Case finding of high risk patients ACG care management tools ACG 1. Care Management Lists 2. Patient Clinical Profile Report Giunta Regionale Area Sanità e Sociale
25 Patient Id Age Sex Care Management list (1) Total Cost Rescaled Total Cost Resource Index Probability High Total Cost Probability IP Hospitalization ,74 22,85 0,95 0, ,03 18,97 0,95 0, ,49 20,87 0,95 0, ,75 23,35 0,95 0, ,54 24,50 0,95 0, ,02 21,61 0,95 0, ,42 19,32 0,95 0, ,04 18,64 0,95 0, ,28 19,75 0,95 0,46 Giunta Regionale Area Sanità e Sociale
26 Single Patient Clinical Report Giunta Regionale Area Sanità e Sociale
27 Recruitment status at July 1, 2015 N. GPs involved (2 each LHU) 42 N. Nurses involved (2 each LHU) 42 N. of patients with CHF among the 42 GPs Elegible CHF patients 525 Contacted CHF patients 225 Recruited CHF patients 152
28 DRIVERs for change Outcome measurement Administrative data Training GPs CM Nurses Evaluation ICT HOW Inpatient days ER and outpatient episodes costs 32 Credits 52 Credits with certification GP, nurse, patient satisfaction Web based integrated platform for GPs and Nurse WHEN Fall 2015 Spring 2016 Fall 2016 Fall In progress
29 Giunta Regionale Direttore Generale Area Area Sanità Sanità e Sociale e Sociale Regione del Veneto 29 mariachiara.corti@regione.veneto.it
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