A Population-Based Perspective on the Care of Complex Patients: - PowerPoint PPT Presentation

A Population-Based Perspective on the Care of Complex Patients: Knowing When to Intervene C. Annette DuBard, MD, MPH SVP, Informatics and Evaluation UNC Cancer Outcomes Research Seminar April 14, 2015

CCNC Population Health Management Approach Key Ingredients:  Connecting patients to a primary care medical home; providing those medical homes with support  Care management model that uses analytics to target highest need beneficiaries in the appropriate settings  Practice support model that provides resources to medical homes to provide higher value care  Assisting DHHS/DMA in effectively deploying programs (e.g. pharmacy initiatives, clinical policy changes)  Shared informatics platform for data integration, analytics and reporting, and clinical applications

CCNC Footprint Statewide  1.3 million Medicaid Patients  300,000 Aged, Blind, Disabled  5,000 primary care providers  150,000 Dually Eligible  1,800 Practices  22,000 uninsured in HealthNet  90% of PCPs in NC programs; >20,000 privately insured All 100 NC Counties 14 Networks Each network averages:  1.4 Medical Directors, 1.0 Psychiatrist  42.8 Local Care Managers  1.8 Pharmacists  Multiple disciplines: RN, LCSW, RD, …

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Informatics Center Data Sources and Applications Care Management Information System  2,300 active users, embedded locally in  Weekly payer claims, monthly primary care practices, hospitals, local eligibility/enrollment data health departments, and other settings  Real-time Admission/Discharge/  >140,000 patients/month with recorded care Transfer data from >60 hospitals management activities  Pharmacy claims via ESI, PharmaceHome Surescripts transactions, Medicare  1,100 active users of shared medication Part D management platform,  Lab results (Labcorps, Solstas,  >13,000 patients/month with medication UNCH) reconciliation activities  Behavioral Health-MCO encounter Provider Portal  2,500 active users; 40,000 patient records data accessed per month  Other DHHS data: birth certificate, Reports and Pop Health Management Tools immunizations  secure web-based reports distribution  PCP Electronic Health Records  member, cost, and utlizaiton dashboards;  Patient data recorded in user predictive modeling and opportunity applications analysis; disease registries; geomapping; quality and performance measurement

System Resources Population Needs

CCNC Care Management Evolution Disease Care of Complex Patients Management Focus on High Focus on Most Impactable Cost/High Risk Right sizing of intervention to One Size Fits All maximize ROI

Among Medicaid Beneficiaries with Chronic Disease, Multiple Chronic Conditions is the Norm “The near universality of comorbidity across these index conditions highlights the need for care management strategies that explicitly acknowledge this clinical complexity.” Data Brief | Clarifying Multimorbidity Patterns to Improve Targeting and Delivery of Clinical Services for Medicaid Populations. Boyd et al. CHCS, December 2010

Beneficiaries with 6 or more Chronic Conditions account for 70% of ALL Medicare readmissions Source: Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chart book: 2012 Edition Baltimore, MD. 2012.

Targeting Patients At Risk For Readmission Cross-state traffic: Complex Medicaid patients admitted to UNC from 80 counties • 190,000 NC Medicaid recipients are admitted to the hospital every year, and 31,000 have multiple hospital admissions. – Nearly one in ten admissions represents a readmission within 30 days of a prior discharge – Cross-hospital traffic is common: 23% of 30-day readmissions occur in a different facility. 10

Real-time notification of hospital admission. Priority flagging based on overall risk profile using historical claims. 11

Typical patient identified as high priority for CCNC Transitional Care 58 year old man with severe diabetes, kidney disease and Hepatitis C  Earlier in the year: Two ED visits at Duke and Durham Regional; Two UNC hospitalizations with uncontrolled DM and hyperosmolarity coma  Recently hospitalized at Duke with hepatic encephalophathy and aspiration pneumonitis/ acute respiratory failure  Re-hospitalized at UNC with c diff colitis and hepatic coma  Primary care provider is in a Duke-affiliated practice

Medication Review 20 medicines in patient’s possession based on prescription fill history. Additional 10 (unmatched) medicines listed on hospital discharge summary.

Transitional Care Team in Action • RN care manager and health educator visited patient’s home 2 days after discharge – Noted chaotic household; patient was “completely confused” about hospital events; unaware blood sugar had been >1000 at admission; “absent - minded” – CM worked with patient & family to develop a person-centered plan of care • Follow-up PCP visit CM accompanied patient to medical home – • Team-based care – Follow-up home visit by health educator and registered dietician – Patient/family education on “red flags” and use of glucometer Nutritional assessment – baseline habits and knowledge – – Provided bus pass to endocrinology appointment • Network pharmacist consultation – Clarified active med list – Corresponded with patient’s endocrinologist to simplify insulin regimen for better manageability, and switch to pen due to visual impairment

Peer-reviewed research Transitional Care • 20% reduction in readmissions for patients with multiple chronic conditions • Benefit persists far beyond the first 30 days • One hospital readmission avoided for every 6 interventions – strong ROI

Time to First Readmission for Patients Receiving Transitional Care Vs. Usual Care Lighter shaded lines represent time from initial discharge to second and third readmissions (Significant Chronic Disease in Multiple Organ Systems, Levels 5 & 6; ACRG3 = 65-66) Survival Function 1 1 1 0.9 0.9 0.9 Proportion still out of the hospital 0.8 0.8 0.8 0.7 0.7 0.7 0.6 0.6 0.6 0.5 0.5 0.5 0.4 0.4 0.4 0.3 0.3 0.3 0.2 0.2 0.2 0.1 0.1 0.1 Transitional Care (N=1,966) Usual Care (N=1,035) 0 0 0 0 0 0 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 6 6 6 7 7 7 8 8 8 9 9 9 10 10 10 11 11 11 12 12 12 Months since discharge from the hospital

Time to First Readmission for Patients Receiving Transitional Care Versus Usual Care Lighter shaded lines represent time from initial discharge to second and third readmissions (History of Significant Acute Disease, all severity levels ; ACRG3 = 20-25) Example of an ACRG with a LOW risk of readmission that didn’t benefit from transitional care. Survival Function 1 0.9 Proportion still out of the hospital 0.8 0.7 0.6 0.5 0.4 0.3 0.2 Transitional Care (N=1,747) Usual Care (N=2,451) 0.1 Months since discharge from the hospital 0 0 1 2 3 4 5 6 7 8 9 10 11 12

Which Patients Benefit the Most from Transitional Care Management? 50% Reduction in Readmission Risk When Managed High Risk 40% Higher is better 30% Medium Risk Low Risk 20% 10% 0% -10% -20% *Size of bubble reflects the number of hospital discharges

Most Cancer Patients Have Complex Care Needs Comorbidities Among Current NC Medicaid Recipients with Cancer Diagnosis (n=26,827) 3 or More Chronic Conditions Severe and Persistent Mental Illness Chronic Kidney Disease Chronic Neurologic Cardiovascular/Ischemic Vascular Chronic Obstructive Pulmonary Disease Chronic Gastrointestinal Disease Diabetes Mental Health Condition Hypertension 0% 10% 20% 30% 40% 50% 60% 70% 80%

NC Medicaid Cancer Patients Discharged from UNC Hospital Home addresses of cancer patients discharged from UNC Hospital Apr 2012 to Mar 2013 20

NC Medicaid Cancer Patients Discharged from Duke Medical Center Home addresses of cancer patients discharged from Duke Medical Center Apr 2012 to Mar 2013 21

NC Medicaid Cancer Patients Discharged from Five Major Medical Centers Home addresses of cancer patients discharged from all five major medical centers from Apr 2012 to Mar 2013 22

Time to Readmission for Patients Receiving and Not Receiving Any Transitional Care (Adults with “Dominant, Metastatic, and Complicated Malignancies”) Survival Function 1 Proportion still out of the hospital 0.9 0.8 0.7 0.6 0.5 0.4 0.3 Yes (N=445) 0.2 No (N=248) 0.1 0 0 1 2 3 4 5 6 Months since discharge from the hospital *Includes non-dually enrolled Medicaid patients with an initial discharge in SFY2011 (excluding obstetrics, newborns, malignancies, burns and traumas) who were CCNC enrolled at time of discharge or month after. Significant group differences: Wilcoxon (Gehan) statistic = 25.68, p<.0001

Time to Readmission for Patients Receiving and Not Receiving Any Transitional Care (Children with “Dominant, Metastatic, and Complicated Malignancies”) Survival Function 1 Proportion still out of the hospital 0.9 0.8 0.7 0.6 0.5 0.4 0.3 Yes (N=74) 0.2 0.1 No (N=91) 0 0 1 2 3 4 5 6 Months since discharge from the hospital *Includes non-dually enrolled Medicaid patients with an initial discharge in SFY2011 (excluding obstetrics, newborns, malignancies, burns and traumas) who were CCNC enrolled at time of discharge or month after. Significant group differences: Wilcoxon (Gehan) statistic = 7.73, p<.01