A Comprehensive Strategy for Coordinating the Care for Patients with Coronary Artery Disease (CAD) and Other Chronic Medical Conditions Presented at the Integrated Healthcare Association Meeting Los Angeles, CA / September 20, 2012 Robert F. DeBusk, M.D. Professor of General Medical Disciplines, Emeritus Department of Medicine Stanford University School of Medicine Stanford, California DeBusk@stanford.edu 650.380.3792
Healthcare Delivery Settings at Present HOME ER Hospital Clinic
Healthcare Delivery Settings in the Future HOME ER Hospital Clinic
How the Care Management System (CMS) Coordinates Clinical Care Patient (home) Phone CMS Phone, Computer Phone, Computer Phone, Computer ER Hospital Clinic
Closed-loop System For Patient Triage and Surveillance Email Monitoring & Surveillance of symptoms and medications Telephone Triage of Symptoms INBOUND Patient CMS Staff OUTBOUND Telephone Coordination of care with Patients MD s Email Monitoring of Symptoms & Optimization of Drug Rx
Telephone Triage for Suspected ACS (Ischemic Chest Pain) Algorithm 1 Patient calls to report symptoms Ischemic chest pain/discomfort present? ACS Yes No Prolonged (>20min) ongoing pain at rest? Yes CMS advises patient to call 911, calls ED to provide current medical data. No Complete symptom check list for non-ischemic chest pain. Prolonged (>20 min) angina at rest, during the past 3 days, now resolved? Nocturnal angina during the past 3 days? New-onset limiting angina during the last 2 weeks? (Activity limited to walking 1-2 blocks or 1 flight of stairs.) Yes CMS advises patient to visit Same-Day Clinic, calls Same-Day Clinic to provide current medical data No Increased frequency, severity or duration of angina during the past 2 weeks? Angina provoked at lower threshold of physical activity during past 2 weeks? New-onset angina during the past 2 weeks? Angina-Non ACS Yes CMS advises patient to stay at home, contacts patient s physician regarding followup No Complete symptom check list for CHF, stroke/tia, syncope
Integrated Strategy for Care Coordination Protocols Tools Staffing Outcomes assessment Business Analytics
Protocols: How is care coordinated? Email and telephone links to patients at home for ongoing surveillance and acute triage Email and telephone/text links to healthcare providers to coordinate care in ED, clinic and hospital settings
Tools: How are healthcare decisions formulated? Online decision support system (DSS) to translate patients symptoms into provisional diagnosis and risk categories Email-telephone communication with patients healthcare providers to finalize patients clinical disposition (stay at home, clinic visit within 24-72 hours, call 911, visit ED)
Staffing: Two-Tiered Approach Care Coordination Healthcare teams composed of MD s, RN s and others serve as air traffic controllers Hands-on Care Practicing physicians in clinic, ED and hospital settings provide on-site care
Outcomes assessment: Does care coordination yield superior outcomes? Clinical processes Frequency, duration, and content of patient-initiated telephone interactions with healthcare teams and patients physicians Advice provided to these parties Hands-on care subsequently provided to patients Clinical Outcomes Death, acute MI, emergency coronary revascularization, etc. Satisfaction Patients and physicians satisfaction with the care coordinated by the healthcare team
Business analytics: Is care coordination financially sustainable? Incentive payments to physicians based on reduction in total costs of care (TCC)* Gross savings based on reduction of TCC Net savings based on gross saving minus programmatic costs *professional, pharmacy, hospital and ancillary costs
Emergency Department Visits: Treatment Group (n=90) Visits 37 Clinic Hours Calls 23 After Hours 14 Cardiac 11 N-Cardiac 12 Cardiac 10 N-Cardiac 4 Tel Call 9 No Call 2 Tel Call 7 No Call 5 Approp. 9 Elect. 0 Approp. 2 Elect. 0 Approp. 4 Elect. 3 Approp. 4 Elect. 1 Approp. 6 Elect. 4 Approp. 2 Elect. 2 11/11 approp. 100% 8/12 approp. 75% 19/23 approp. 83%
Emergency Department Visits: Usual Care Group (n=84) 25 Visits Clinical Hours 16 After Hours 9 Cardiac 7 Non-Cardiac 9 Cardiac 6 Non-Cardiac 3 Approp. 2 Elect. 5 Approp. 2 Elect. 7 Approp. 3 Elect. 3 Approp. 1 Elect. 2 2/7 approp. 28% 2/9 approp. 22% 4/16 approp. 25%
Patient-Initiated Call Center Contacts 88 Calls* Chest Pain 21 Dyspnea 3 Syncope 2 Other 62 Home 7 Home 1 Home 1 Home 53 Home 51 ED 2 ED 6 ED 1 ED 0 ED 3 Hosp 6 Home 1 Home 2 Hosp 1 Clinic 8 Clinic 1 Clinic 1 Clinic 6 Home 6 ED>Hosp 2 Home 1 Home 1 Home 5 ED 1 *43 patients: 21 1 call / 12 2 calls / 10 3+ calls Admin and other questions 19, Meds 22, Non-Card Symptoms 21
Strategies for Enhancing Physicians Revenue in Managing ACS Shared Savings Models based on benchmark and quality scores: California P4P Accountable Care Organizations (ACO) Medicare Shared Savings Program
Economic Analysis of CMS Call Center 3,000 Patients with established CAD 2,100 (70%) of enrolled patients initiate 1+ telephone contacts per year 4,200 total patient-initiated contacts 1,000 chest pain calls (25% of total contacts)
Costs of Staffing CMS Based on 3,000 patient case load and 1000 chest pain calls annually Nursing Effort (1.0 FTE) $104,000 Operations Coordinator s Effort (0.5 FTE) $52,000 Triage Cardiologist s Effort (0.2 FTE) $44,000 Total $200,000
Costs of Managing Suspected ACS Costs of care for 1,000 patients undergoing ED evaluation of chest pain 500 patients sent home @ $1400 $ 700,000 500 patients hospitalized @ $2560 $1,280,000 Total $1,980,000 Costs of care for 1,000 patients reporting chest pain to CMS 150 patients referred to ED @ $1400 $ 210,000 100 patients hospitalized @ $2560 $256,000 250 patients triaged to same day or expedited clinic @ $250 $62,500 500 patients advised to stay home pending F/U visit > 72 hrs $ 1,500 Total $530,000
Economic Benefits of CMS Gross savings Costs of Usual Care $ 1,980,000 Costs of Coordinated Care Under CMS $ 530,000 Gross Savings $ 1,450,000 CMS Program Costs Nurse Care Manager(s) 1.0 FTE, Operations Coordinator 0.5 FTE, Cardiologist 0.2 FTE $200,000 Net Savings Gross Savings $ 1,450,000 Program Costs $ 200,000 Net Savings $ 1,250,000 Shared with provider $625,000 Retained by health plan $625,000
Return on Investment in CMS $625,000 net savings for 3000 enrollee caseload $200,000 program cost (1.7 FTE) 3.0 ROI
Advantages of Care Coordination Concierge Care for All Minimizes operational costs of care delivery: Facilities: real estate Operations: workflow Personnel: skills matching
Advantages of Care Coordination Concierge Care for All Enhances comprehensiveness of healthcare Immediate telephone triage of symptoms Ongoing email surveillance of medications and responses to non-urgent requests Expedited scheduling of visits and specialty referral Generation of periodic reports on healthcare status and treatments
Advantages of Care Coordination Concierge Care for All Fosters local control of healthcare delivery, based on evaluation of programmatic costs, clinical processes and clinical outcomes.
Organizational Benefits of Care Coordination Enhanced convenience of care for patients Greater efficiency in matching healthcare resources to patients needs Enhanced participation of patients personal physicians in their patients care Potential for generating shared savings (P4P)
Deliverable Components of a Comprehensive System of Care Coordination Printed manual: Methods for email surveillance and telephone triage Online tutorial: Instruction of patients in the methods of care coordination Instruction for healthcare professionals in methods of care coordination Database application that supports ongoing care coordination including online decision support Assessment of clinical processes, clinical outcomes and patients and physicians satisfaction with care coordination Assessment of programmatic costs, healthcare costs and reductions in TCC
Options for Scaling CMS to the Needs of Various Users Healthcare providers Outpatient clinic(s) Telephone hotline(s) Urgent Care Clinic(s) Emergency department(s) Practice-wide (multiple clinical settings) Disease management companies State-wide Region-wide Nation-wide Health Plans State-wide
Clinical Outcomes of MHI Study No deaths or ED admissions among low risk patients reporting cardiovascular symptoms who were classified as low risk and advised to stay home Higher rate of appropriate ED admissions during clinic hours in treatment patients than in UC patients 11/11 100% Cardiac DX Treatment 8/12 75% Non-Card DX Group 19/23 83% Total 2/7 28% Cardiac DX Usual Care 2/9 22% Non-Card DX Group 4/16 25% Total
Strategies for Reducing Total costs of Care (TCC) for Suspected ACS Triage point is the ED: Increase the efficiency of emergency care by new approaches such as the Chest Pain Clinic. Triage point is the patient s home: Identify lowand moderate-risk patients by telephone and provide them with lower-cost options such as same-day or expedited clinic visits in lieu of ED visits.