Based Community Palliative Program Nancy Guinn, M.D. Medical - PowerPoint PPT Presentation

Building an Integrated Team- Based Community Palliative Program Nancy Guinn, M.D. Medical Director, Home and Transition Services Presbyterian Healthcare System 1

Join us for upcoming CAPC webinars and virtual office hours Visit www.capc.org/providers/ webinars-and-virtual-office- hours/ ➔ Webinar: – Identifying the Right Patients or Specialty Palliative Care: Thursday, November 17, 2016 | 1:30 - 2:30 pm ET ➔ Virtual Office Hours: – Pediatric Palliative Care with Sarah Friebert: Wednesday, October 12, 2016 | 4:00 pm ET – Billing for Community-Based Palliative Care with Anne Monroe, MHA: Monday, October 17, 2016 | 12:00 pm ET – Building Effective Payer-Provider Partnerships with Tom Gualtieri-Reed, MBA and Kristofer Smith, MD, MPP: Tuesday, October 18, 2016 2:00 pm ET – Palliative Care Models in the Community with John Morris, MD, FAAHPM: Tuesday, October 18, 2016 | 3:00 pm ET – Ask a Program Leader with Andrew Esch, MD, MBA: Wednesday, October 18, 2016 | 2:00 pm ET 2

Building an Integrated Team- Based Community Palliative Program Nancy Guinn, M.D. Medical Director, Home and Transition Services Presbyterian Healthcare System 3

Objectives ➔ At the conclusion of this seminar, the learner will be able to: – List two measurements that keep health plan CEOs up at night – Identify how home-based palliative care programs can address these issues – Describe one value-based way to pay for palliative care 4

Presbyterian HealthCare  Largest not-for- profit healthcare system in New 108 years in New Mexico Mexico  Serving one in  Health Plan three New Mexicans  Delivery System  755,387 unique  Medical Group customers (March 2016) 11,000 employees New Mexico’s largest private employer Confidential | 5

Focus on Values-based Care  Triple Aim is centerpiece of  Health Plan started in 1986 care model at Presbyterian  Medicare Advantage Plan since 1998  Accountable for • Largest Medicare Advantage Plan in the state the total cost of care  In New Mexico  Approximately • One in three covered by Medicaid 470,000 • Ranked 51 st in nation for percentage of residents members receiving health insurance through an employer statewide • More Medicare and Medicaid lives and fewer commercial lives than other health insurance markets Confidential | 6

Presbyterian Delivery System and Medical Group  8 hospitals in 7 communities; opening a new medical center in Santa Fe in 2018  800 employed providers  9,000 contracted providers  30+ Multi-specialty clinic sites  1.8 million visits in 2015  All Primary Care Sites are PCMH Confidential | 7

Presbyterian Home and Transition Services Advance Care Planning Hospice Physicians Hospital at Home House Calls Palliative Care Complete Care: Inpatient An Advanced Illness Clinic Management Home Program Health Risk Assessments 8

Presbyterian Home and Transition Services Complete Office Care Hospital at Home Palliative Care 2005 2010 2014 2008 2013 2015 Inpatient House Calls Restructure Inpatient Palliative Care and Palliative Team to Home Palliative remove focus on Team FFS providers

Inpatient Palliative Services ➔ Started in 2005 ➔ Demonstrated decrease in variable costs after consultation in 2007-2008 ➔ 2014: Developed multi-disciplinary approach using equal ratios of social work and medical providers ➔ 2,000 consults/year in 3 Albuquerque hospitals/SNF – 30 day readmission rate tracked monthly: 5-8% – 75% of patients complete Advance Directive within 30 days ➔ Available 7 days a week ➔ Team: 3 APRNs, 1 MD, 3 Social Workers, 1 Chaplain, 2 RN’s ➔ Integrated with Inpatient Hospice Team 10

Community-based Office Palliative Care ➔ Office/Clinic Pilot in 2012-2013 – Demonstrated dramatically reduced total cost of care for patients seen in clinic ➔ Expanded to 5 primary care and 2 oncology clinics ➔ Continues to demonstrate: – Low hospitalization rate (<8%) – Advance Directives (80% within 30 days of initial visit) – High percentage of patients receive hospice care prior to death ➔ Clinic: 1 NP, assistance from 2 MDs – Integrated with Oncology, Social Work, and Psychology – Integrated with Home Palliative Team 11

Community-based Home Palliative Care ➔ Housed in Home Health agency – Sees primarily Presbyterian Health Plan patients – ADC 150-200 patients (about 1/3 of agency census) ➔ Team trained in Palliative Care – Integrated with House Calls, Home Palliative Care providers, strong social work component ➔ Hospital Readmission rate is always 8% or lower for this complex population. ➔ Home visits by 1 NP, with assistance from 3 MD’s ➔ Full-time Social Worker (as well as House Calls SW team) ➔ Team of RN’s from home health agency (therapists also) ➔ Just adding Chaplain 12

House Calls ➔ Founded in 2010 from Hospital at Home ➔ “Mobile” Patient -Centered Medical Home ➔ Team based approach – MD/NP/Social Worker/Support staff – Offers Primary Care, Urgent Care, Hospital at Home ➔ Tracks all Hospitalization/ED rates – (3-8% of total census monthly) ➔ Tracks standard primary care measures: vaccination rates – (100% given/offered) ➔ Presence of Advance Directive (MOST) – (75% of patients) ➔ 72 hour follow up following hospitalization (100%) – Now tracking 48 hours follow up and follow up after ED visits 13

Hospital at Home A Patient’s Day Outcomes Patient Population 100% Core Measures • Daily Physician visit • Heart Failure (Heart Failure & • Daily Nurse visit (min) • COPD/Emphysema Pneumonia) • ECG’s, lab x -rays • Pneumonia .05% Falls • Home Health Aide twice • Cellulitis 3.2 Average LOS daily • Deep Vein Thrombosis 2.47% 30 day • Medications/Medical • Stable PE Readmissions Equipment Provided • Nausea/Vomiting 7.4% 90 Day • Emergency visits as • Dehydration Readmissions needed (rare) • Complicated UTI

Complete Care ➔ Piloted 2015 – focused on 5% of Presbyterian Medicare Advantage members with most serious illness burden – Needs assessment: responsible for 64% of costs ➔ Will have enrolled 600 members by close of 2016. ➔ Uses alliance with health plan to fund non- reimbursed services in the home, including DME, in-home foot care, urgent RN and community paramedic care 15

Complete Care ➔ Accept the most complex patients from our health system ➔ RN in-home case management ➔ “One number to call” 24/7 ➔ Integrate with Palliative and House Calls – Community paramedic program ➔ Track numerous outcomes including every ED visit, hospitalization, falls, any urgent visits, enrollment in hospice 16

Complete Care ➔ Tracks total cost of care: – Initial reports show savings of $700-$1000 PMPM ➔ Readmission and hospitalization rate 50% of predicted in this population ➔ 85% of patients who die do so at home by their choice ➔ Hospice average LOS: 59 days 17

Urgent Visits (Complete Care and House Calls) Cost Avoidance: Jan 2015-June 2016 Ambulance, Emergency Room and Hospital Savings: 553 Urgent Home Visits with 372 directly avoiding an ED Visit Costs % Use Pt Count Cost Avoidance Average ED Cost $700 100% 372 $260,400 Average AAS Transport cost $300 90% 335 $100,440 Average hospitalization cost $8,000 90% 335 $2,680,000 $3,040,840 Total Other Savings: • Post-acute care cost avoidance (commonly 40-60%) • Complication cost avoidance (falls, hospital acquired infections, delirium, ADL decline) 18

Advance Care Planning ➔ Supports and manages the state POLST project ➔ Integrated with New Mexico “Conversation Project” ➔ Monthly reports on scanned AD’s throughout our system – by clinic, hospital, provider ➔ Training in every PHS setting on having conversations with patients ➔ Creating trained volunteer ACP Facilitators to support all providers 19

Integration in Presbyterian Healthcare PCMH: Care Hospital: for Complex Readmissions, Patients, assist Post-acute with difficult Care conversations Health Plan: Patients and Manage Families: Help Complex in the Home Patients and Clinic Palliative Care 20

Integration from the Patient’s perspective House Calls Provider and Social Worker They may only Home Community see 2 or 3 of Palliative Paramedic Provider these team members in Patient their home Home Hospice Palliative MD RN Complete Care 21

Patients for Programs are identified by: ➔ Direct referrals from case managers in clinics, health plan, hospital ➔ Diagnoses (lung cancer in Oncology) ➔ Intake staff in Home Health ➔ Annual Health and Wellness Assessments ➔ Epic Registries 22

Registry 23

Operations ➔ Each team/service has a lead provider ➔ Manager of Practice Operations • Pairs with lead provider • Scheduling, recruitment, help with technology • Tracks outcomes, assists with meetings ➔ Complete Care has a Program Manager • Oversees all RN case managers 24

Tools to Help: From Progress Note to Report 25

Tools to help: ACP notes