September 19, 2012 PCMH-ACO Roundtable Discussion After a hiatus for the summer, the September Roundtable began with a welcome by Dr. Fred Brancati and Dr. Scott Feeser Our first speaker was Amy Deutschendorf MS, RN ACNS-BC Sr. Director Utilization/Clinical Resource Management. "Johns Hopkins Community Health Partnership (J-CHiP)" Committing to Best Practice What are we doing as a health system to prevent avoidable readmissions? The New England Journal article by Stephen Jenks on Rehospitalizations set the stage with findings that are now well-known: https://docs.google.com/open?id=0b-oym53-04zldjj5sexsrmtcrnm 70.5% rehospitalized for a medical condition but can be readmitted after surgery 10% planned readmissions (American Hospital Association bundles planned readmissions in with unplanned) It is hard to look at current methods and say that risk adjusters are good risk adjusters The Cost: 17.4 billion dollars Surgical and medical patients are very different. (Surgery colorectal and hepatobiliary surgery outcomes and readmissions article) 2009 JHHS Readmissions Initiative: Causes of readmissions During hospitalization At discharge Post discharge Causes of readmissions patient characteristics demographic/socioeconomic/access to community resources disease progressions failure of ambulatory environment (primary reason for readmission is wound infection at Hopkins) Current themes on readmissions Focus on transitions and access to care Partnerships between providers payers and community agencies Strategies for all patients
Strategies for high risk patients Emphasis on: risk screens, individualized patient education, self-care management, medication management, red flags, healthcare provider support Example: COPD population at Bayview; the severity of illness of COPD is higher at Johns Hopkins downtown, but Bayview patients with COPD had more comorbidities, and risk models did not take this into consideration. High utilizers: our biggest ability to impact for cost reduction are those people who come back once or twice. Patient care delivery transition: Continuity of care, collaboration between all team members. We need to improve our transdisciplinary team. Transdisciplinary care coordination model: Realigns daily care processes around the needs of all hospitalized patients Maximizes workforce synergies to increase accountability for outcomes Selection of evidenced based bundle of strategies based on risk Patient and family engagement in responsibility for healthcare outcomes (this is critical, but not seen in CMS documentation) Recent evidence focuses on the bundle Inverse relationship between 20-day mortality and readmissions Strategic decision points: Emergency Department Admission During hospitalization Discharge Post-acute (where big commitment from physicians comes in) Interdisciplinary care planning: every patient every day Questions: B. Cook: At what point, especially in patients with multiple comorbidities, is the PCP informed? A. Deutschendorf: At Hopkins, notficiation of PCPs is terrible. Our plan is for patients to leave with an appointment already scheduled with their PCP in 1-2 weeks, to send the d/c summary, and the PCP gets a communication with a request for information and information on outcomes. S. Feeser: Is there attention to discharge summaries? A. Deutschendorf: We can t get past the 30-day mark at Johns Hopkins; at Bayview they are moving to 48 hour turnaround for discharge summaries. D. Trautman: In how many units are there indterdiscplinary rounds? A. Deutschendorf: In 8 units currently. The hospitalist unit (Halstead 6) was the first in which it was implemented.
Care Coordination bundle (Provider handoffs): PCP identified during hospitalization d/c summary within 5 days PCP apt within 7 days Pilot units at Johns Hopkins and Bayview HAL 6 hospitalist service: 18% relative reduction in readmissions with full plan rollout GI Surgery there is no teaching before surgery, which isn t helpful. F. Brancati: Has the reduction in readmissions affected the hospital census? A. Deutschendorf: The beds in the hospital are full, this is probably from a several prominent reasons. No payers are paying for 1 day stays, and the larger new Emergency Department has increased the volume on medicine services. Volume on surgical services is down. JChiP: Based on care coordination work in the inpatient and community settings Improved health and healthcare delivery and reduced cost Submitted $30 million proposal in response to a 3 year CMMS funding award In May, JHMI was given 72 hours to reduce $30 to $20 million proposal June 15 th received award o Acute care: $10 million over 3 years o Community side: $10 million over 3 years Goals: Improve care coordination Reduce disparities Improve health and healthcare delivery Reduce cost Target population: 40,000 adult patients discharged annually from Johns Hopkins and Bayview Medical Center Underserved, high risk East Baltimore population Primary components of care continuum Acute/post acute care Ambulatory community care SNF D. Trautman: What do you think has been our greatest improvement? A. Deutschendorf: Bayview has been doing this for a long time. At Hopkins, we re getting lots of physician champions. Engagement from providers. S. Fitzpatrick: I m used to integrated care teams, I m a psychologist, things seem behind to me here. How will EPIC be integrated into this?
A. Deutschendorf: Initially, this whole grant was about leveraging EPIC. It is very difficult to tell a patient story from the medical record right now, but EPIC will help solve some of that. However, we have to be cautious to not let our documentation system to dictate our practice. F. Brancati: I think we can make a more coherent plan on the inpatient side because there is so much detail. Our second speaker was Bruce Sherman, MD, FCCP, FACOEM, who is currently Consulting Corporate Medical Director, Walmart, and the Medical Director, Employers Health Coalition of Ohio, as well as an Assistant Clinical Professor, Dept of Medicine, Case Western Reserve University School of Medicine "Employer Perspectives on PCMH-ACO Models of Care" Because we ve always done it that way If employers knew more about PCMH, they would be more interested From an employee perspective, combination of wages and benefits, as time goes along, increases in benefits are detracting from wage growth. Patient-Centered Primary Care Collaborative (PCPCC) released the latest outcomes data: http://www.ajmc.com/publications/issue/2012/2012-9-vol18-n9/impact-of-medical-homes-on- Quality-Healthcare-Utilization-and-Costs Boeing Intensive Outpatient Care Program: Program target o 740 people with highest predicted healthcare costs intensive outpatient care program Implemented with 3 practice groups o 20% reduction in healthcare costs o Reductions in hospital admissions o Improvement in cognitive function o Lower number of workdays missed Why should employers care about PCMH? Improved coordination of healthcare Enhanced quality of care Better clinical outcomes Improved patient satisfaction with healthcare Center for employer engagement: http://www.pcpcc.net/center-employer-engagement Triple Aim: Better health, better care, Lower healthcare costs, Improved productivity Cost to employer for primary care is 4-6% QuadMed comprehensive primary care
Aligning objectives: Employers and PCMH/ACOs Many metrics being reported from PCMH are clinical, and these don t resonate with employers one of biggest barriers. Employers want to know about COST, productivity Employers are only focused on cost and they need to learn that it is a lagging indicator - we can see improvement in medication adherence, preventive care services first Healthways is starting to contribute to this. F. Brancati: What degree of labor stability would an employer need to make instituting a program like this beneficial to the employer B. Sherman: Flu shots and smoking cessation can be implemented for high-turnover industry. These are the only services that can show difference in 1 year. 2 components to PCMH: an individual may have a relationship with an employer, but the relationship with PCMH will transcend this. F. Brancati: Employers are making an investment in the model. Does Walmart have the stability to invest in this? B. Sherman: Not a simple question to answer. People who are sicker would benefit first and they tend to stay with the employer because they can t afford to give up benefits. People who are healthier wont derive as much benefit. T. Boonyasai: If the Affordable Care Act makes it easier to leave a company and keep medical care despite pre-existing conditions, would it be strategically wiser for a large company to hand off healthcare? Is there a cut-off number for how long a company should have an employee before they should invest in their healthcare? B. Sherman: Waiting periods for benefits eligibility is now 60 days with healthcare reform this forces the hands of the employers. But once someone is employed, the lion s share is still paid by employer. There is another interesting element there was an engagement survey done globally looking at why employees stays with employers. The #1 reason cited by employees is that my employer cares about my well-being. F. Brancati: That will help a company recruit new talent. B. Sherman: And that s where the metrics get broader B. Cunningham: Do they look at subpopulations within the overall work force? Executive level vs work on the floor or is it an aggregate? B. Sherman: This is all over the map. Executive physicals is one extreme. The other side is looking more critically from a healthcare standpoint. Are there vulnerable populations that need more help? Some employers subsidize more for people earning less than $50K. Vendors sell program, employers need strategies. Problems with PCMH: There is no new money. Reallocate money from disease management programs for PCMH B. Cooke:
EHP had a robust health program for 3-4 years. I wonder if EHP has data that obesity, etc. has dropped with that intervention? Answer from audience: No demonstrable differences because we struggle to get people to participate in programs. We tried an incentive program which people didn t take up. Uptake is low. F. Brancati: Is the evidence base is sufficient to convince smart executives? Lots of wellness programs have no trials underlying their motives. We see that there is often low engagement, but this presumes that the program is efficacious. We need RCTs, then we can tackle underengagement, and RCTs to look at who is engaged and who isn t. The people who don t need the programs are engaged. Healthcare practicioners are a big problem, as they often think they are healthy and do not need such an intervention. Workplace clinics have greater interaction Stephen Atlas looked at patient-practitioner connectedness. When present, uptake was greater: 200 physicians treating diabetes had wide variance of ability to control the condition in their patients. Nothing identified could explain this. Probably communication. If doctor sat with patient, this generated greater patient satisfaction. And patients overestimated amount of time in contact. Those who are engaged have better outcomes. F. Brancati: How much evidence do the execs want before putting down money? They used to invest in disease-management, but this was disproved when CMS made them do RCTs. Do they want to see trials? B. Sherman: I think they have enough data, especially if they want to expand PCMH. S. Feeser: What are these linkages between the corporate and medical worlds how do we tap into this? B. Sherman: Employers haven t looked critically on the supply side (most looked at demand). JHU has done well with centers of excellence (Pepsi and Hopkins direct contract). Why can t there be direct contract with employers in the context of an ACO? We need to clearly articulate the value proposition to employers in a way they understand. This concluded the discussion for the September Roundtable. Our next PCMH-ACO Roundtable is scheduled for Wednesday, November 14 th from 1-3pm. We will have lunch available from 12:30pm onwards. Please contact Meghana Gadgil at mgadgil2@jhmi.edu with any further questions, would like to join our GoogleGroups forum, or if you are interested in presenting at a future Roundtable.