08/04/2014. Tim Hogan, RRT, PhD Primary Care Home Health Director. University of Missouri Health Care Department of Family and Community Medicine

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1 Tim Hogan, RRT, PhD, Primary Care Home Health Director Joan Asbee, RN, BSN, CWOCN, Nurse Care Manager Karli Urban, MD, Assistant Professor of Clinical Family and Community Medicine University of Missouri Health Care Department of Family and Community Medicine August 16, 2014 Tim Hogan, RRT, PhD Primary Care Home Health Director 1

2 MO HealthNet Health Home Medicaid Health Home 2 year* CMS I demonstration project Awarded to Missouri State Medicaid (MO HealthNet) 1,000 enrollees high risk, high utilization PMPM ($60.00) to embed PCMH team into primary care: Nurse Care Manager Behavioral Health Consultant Care Coordinator Project Manager State wide Collaborative Training in PCMH processes Required NCQA PCMH Recognition Quality reporting 17 measures Leveraging Information Technology to Guide High Tech High Touch LIGHT2 3 year CMS I demonstration project Awarded to MU SOM 10,000 enrollees Medicare + Medicaid $13.2M to embed NCM and support for primary care: Nurse Care Manager Health Information Analysts (3) Technical support Other resources Training in care coordination processes EMR solutions to manage populations Risk stratification of patients (quasi) Provider/NCM dashboards MO HealthNet State Wide Primary Care Health Home Initiative 43,385 persons total served (includes Dual Eligibles) Cost Decreased by $51.75 PMPM Total Cost Reduction $23.1M Source: Joe Parks, Director MHN, June 2014 Grand Rounds presentation 2

3 Number of ER Events By Month Since Enrollment PCHH ER Events Linear (PCHH ER Events) Source: Joe Parks, Director MHN, June 2014 Grand Rounds presentation Months in Health Home (0=Admission Month) Primary Care Health Homes CMHC Healthcare Homes Joan Asbee, RN, BSN, CWOCN Nurse Care Manager 3

4 A collaborative process between patient, physicians, and care team which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual s health needs through communication and available resources to promote quality and cost effective outcomes Care Management Plus; Oregon Health and Science University and Intermountain Health The Ts : What we do: Teaching: More in depth and patient centered; Engage patient and validate understanding Transitions: Across the health care continuum; follow patient with EMR; contact outside providers; provide insight and make follow up calls with each transition; align with community resources Triage: RN utilizes critical thinking skills by assessing, problem solving and collaborating More Ts : How we do it: Touch: Face to face, clinic/ home visit, Follow up Time: Take more time to review, educate, go over the details, validate understanding Trust: Develop a therapeutic relationship based on recognizing the patient and their preferences Technology: Use of EMR, MUHealthe, Powerchart messages, Phone, Inter office instant messages 4

5 High Utilizers, Hospital, ER Medically Complex Frail/Elderly Chronic Disease Management Diabetes Asthma/CHF Hypertension Depression/Mental Health Identify a Physician Champion Meet patient at clinic appointment, explain role Keep goals consistent with Physician Provide education, teach back Follow up, clinic appointments, home monitoring, ER, Hospitalizations Be familiar with Community Resources (lots of social work) Be available 84 year old male with past medical history of Parkinson's, dementia, CAD, gout, glaucoma, hypothyroidism, severe visual and auditory impairment Complicating factors: poly pharmacy, multiple specialists, wife does not read, could not manage meds and anticoagulation therapy 5

6 NCM role: In 2011 consolidated all meds to one pharmacy, with NCM as point person, transitioned to prepackaged med packages Physician stopped Coumadin, changed to ASA Patient contacts NCM for any questions, calls have gradually decreased to 1 2 x month. One planned Hospitalization (joint replacement) and one ER visit since Still at home with wife. 91 year old female with past medical history of CHF, CAD, A Fib, HTN, Hx CVA, ulcerative colitis, erosive gastritis, osteoarthritis Complicating factors: Multiple specialists, increasing symptoms and complications from CHF and Ulcerative Colitis with 7 hospitalizations in 2013 NCM role: NCM served as primary contact person for patient and family. Frequent phone follow up and availability of NCM has helped her stay in home with family and in home services. Patient monitors weight and reports change in symptoms to NCM. Between NCM, PCP and Cardiology input, have helped to manage CHF without any ER or Hospitalizations in

7 44 year old female with past medical history of asthma, dysuria, generalized anxiety disorder, obsessive compulsive disorder, dermatitis, muscle spasms. Use of services: ER visits 2008: 11, 2009: 2, 2013: 2 Physician visits 2009: : : : : : 30 NCM role: 2009 established care with current PCP; 2011 Medicaid Medical Health Home started PCP has involved NCM and Behavior Health Coach. Used planned visits with follow up phone contact to address anxiety & frequent clinic visits. Continue to increase follow up calls & planned visits with NCM and BHC Karli Urban, MD Family Medicine Board Certified Geriatric Medicine Board Certified 7

8 Broadens the network of support Safety net Patients more inclined to call NCM rather than general clinic phone line More aware of patient history, social aspects of care Improved continuity of care with patients My time with the patient is more focused Patients receive quicker responses regarding test results and change in medication Smoother transition for home health services Arranging PT/OT Respiratory supplies (supplemental oxygen, nebulizer) Assistive devices (wheelchair, walker, cane) Improves transitions of care Hospital independent living Skilled nursing independent living Outpatient inpatient geriatric psychiatry care Review of medical goals of care, patient goals Medication reconciliation Patient and family education Awareness of discharge plans Anticipating need for follow up 8

9 She is great. I think she is wonderful. I know that I can always call her and she can help me find out the answer to a little question that I have had on my mind. I don t know what I would do without her. It s so nice to have her available. Recognize the potential benefits for you and your practice Where can they provide the patients the most benefit Identify priorities: Seeing patients in clinic Calling patients to follow up Home or SNF visits Patient and family education Patient checks in at front desk Roomed by nurse vital signs, chief complaint Notify NCM when patient is ready to be seen Physician sees patient Physician and NCM create treatment plan NCM provides summary to physician, discusses concerns NCM provides follow up phone call NCM sees patient 9

10 56 year old female with past medical history of DM type 2 (poorly controlled), HTN, HLD, congestive heart failure with cardiomyopathy, history of CVA with residual left foot drop and prolactinoma Complicating factors: poor insurance coverage, limited financial assets, minimal family support Admitted to the hospital July 25 th with new lower extremity DVT. Discharged the following day on Coumadin and Lovenox. NCM role: Called to follow up on her and learned I m not taking the Lovenox, I can t afford it Patient unaware of plans for INR on July 28 th. NCM informed her of this appointment and provided a taxi pass for free transportation During the visit to clinic for lab draw, NCM met with her: Provided Coumadin education Reviewed how Coumadin works Diet precautions NCM role (cont.): Learned patient was living in an unsanitary environment. She was staying with her brother in law, a bilateral amputee. There was no clean water and no usability of the toilet or bath. Also noted that the sewers were backing up Patient had contacted Salvation Army but dietary and sleeping restrictions did not work for her She was on the public housing list #28 NCM contacted our SW who provided an additional list of housing opportunities in Columbia NCM wrote a letter from the clinic in support of urgent clean housing in an attempt to move her up on the wait list We provided information regarding DHSS hotline regarding unsanitary living conditions 10

11 98 year old male with past medical history of Alzheimer s disease, congestive heart failure, chronic renal failure and colon cancer Patient presented to the ER on 5/11/14 with dyspnea for suspected CHF exacerbation. Clinically improved and discharged home to care of daughter. NCM role Called daughter 5/12/14 who reported symptoms were improved with treatment provided Noted f/u appointment from ER visit had not been made coordinated scheduling this appointment Clinic visit 5/16/14 with covering physician NCM reviewed patient s symptoms, patient s goals of care and the desire of the family to keep him home as long as possible. Discussed possible benefits of initiating hospice which the patient and family wished to pursue NCM contacted hospice intake coordinator and provided needed admission information to hospice agency NCM role 5/19/14: NCM called hospice agency and family to inform them that I will be serving as the primary medical provider under hospice 5/21/14: NCM called patient s daughter to follow up on initiation of hospice services current on symptom control 5/22/14: NCM contacted by hospice nurse who reported increased agitation, sleep disruption and increasing lower extremity edema. NCM arranged for appointment the following day in clinic 11

12 A collaborative process between patient, physicians, and care team which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual s health needs through communication and available resources to promote quality and cost effective outcomes Tim Hogan, RRT, PhD, Primary Care Home Health Director Joan Asbee, RN, BSN, CWOCN, Nurse Care Manager Karli Urban, MD, Assistant Professor of Clinical Family and Community Medicine University of Missouri Health Care Department of Family and Community Medicine August 16,