Intensive Outpatient Care Program CARE Connect Pat Brydges RN, MHA, ACM Regional Vice President, Care Integration Elisol McKim RN, BSN, CCM Care Manager, Care Connect Misty J Rydelski, MD Internal Medicine, Utilization Medical Director 1
St. Joseph Health St. Joseph Health Mission: To extend the healing ministry of Jesus in the tradition of the Sisters of St. Joseph of Orange by continually improving the health and quality of life of people in the communities we serve. SJH serves communities in Northern California, Southern California and West Texas/New Mexico • 16 hospitals, • 2 home health agencies • Integrated physician groups in every market • Discharges 155,400 • ER Visits: 537,800 2
St. Joseph Hoag Health Orange County, CA • 9 Hospitals • 26 Urgent Cares • 10 Physician Networks – • 475 Primary Care Physicians • 1,250 Specialists 3
Population Health Health Status & Cost Breakdown of our Full Risk Populations Complex Health Status Cost Breakdown Care High Risk 43% Complex 8.1%/8.3% Chronic/Episodic 40% 14%/18.6% Medium -Risk 17% Healthy – Low Risk 77.7%/73.3% Almost 50% of our costs are on less than 10% of our patients %=Medicare Advantage and BSC Commercial 4 4
Population Health Management Programs developed to help meet Triple Aim Improve Health, Enhance Patient Experience, Reduce Costs • CARE Connect/Regional Care Management • Transitional Medical Clinic (TMC) • Post Discharge Phone Calls • Regional Palliative Care • Tele-Monitoring • Standardized Clinical Protocols • Tele- monitoring • Diabetes Education • Nurse Advice Line • New Member On boarding • Centralized Prescription Refill • Patient Portal • Wellness/Weight Management • Preventive Care • Tele-Medicine 5 5
What is Care Connect? • A team of Specially Trained Care Managers, Health Advocates and Social Workers managing Medically and Socially complex patients • Support team of Clerical Staff and access to a Pharmacist • Embedded in PCP Offices – are members of the PCP team • Perform Motivational Interviews, Patient-Centered and Patient Driven Shared Action Plans Goals • Provide home visits, see patients in office, clinic, hospital, skilled nursing facility • 24/7 access for patients through Nurse Advice Line • Develops strong trusting relationship with patient and family • Provide coordination of care across the healthcare continuum • Technology/Documentation – Patient Identified as “Care Connect” with Care Manager Name/Phone Number in Allscripts Touchworks (EMR) – Documentation in Allscripts Touchworks (EMR) 6
Patient Selection/Processes • Risk Stratification using Verisk – Likelihood of hospitalization – Concurrent Risk – Predictive Risk • Other Reports: Readmission, ER Visits, LACE Reports • Referrals from Providers, Hospitals, Transitional Medical Clinic) Care Managers • Focus on Full Risk Patients (Medicare Advantage) and Domestic Full Risk (Commercial) • Criteria – Diagnosis, Cognitive, Understanding Condition, Meds, Self management skills, Overall Health Status – Frequent PCP, ER, Hospital visits – Living Situation, Care at home, depression, hopeless feelings • All information is shared with PCP in selection of patients 7
Care Connect Program Regional Program - All networks Southern California 14 Care Managers and 8 Health Advocates 1,858 patients enrolled since April 2013 - >900 Active patients 132 Participating PCPs 8
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Care Connect - Financial Outcomes Patients enrolled between April 2013 thru December 2014 - 954 patients) Estimated 90 days prior to 90 days post Events and enrollment enrollment Spending Avoided Inpatient visits 278 204 74 Estimated inpatient Spend (using $11K as $3,058,000 $2,244,000 $814,000 average cost per visit) ED visits 315 212 103 Estimated ED spend (using $1354 as average $426,510 $287,048 $139,462 cost per visit) 11
A Care Manager Perspective Elisol McKim RN, BSN, CCM 12
How the Physicians Introduce CARE Connect to Patients • The CARE Connect Team (RN/LVN Care Manager, Social Worker, and Healthcare Advocate) are here to help me take care of you. • The CARE Connect Team is your “Disneyland Fast Pass to me (Physician)” • The CARE Connect Team is your “GPS to the healthcare system” 13
This is a CARE Connect Doll 14
Initial Super Visit Nurse/PCP/ Nurse/Patient Nurse/Patient Patient Visit Visit Visit 15-20 minutes 15 minutes 20-30 minutes • Relationship • Team approach • Assessments and • Patient agreement building with patient goal setting • Ask then listen • PCP introduce PAM • What bothers you VR-12 nurse as a member PHQ -9 most? of care team • Where do you want • Non-stethoscope to be in a year? visit 15
Care Management Interventions • Disease Education and Coaching • Advise, educate, and support Caregivers • Home Safety evaluation as necessary • Social Work referral for multiple psychosocial stressors or abuse/neglect concerns • Medication Reconciliation & Adherence • Referral Management and Education • Advance Directive Discussion • Coordination of overall care across continuum • Provide community resources 16
Patient Success • 71 year old male with CHF, DM Type II, A-Fib., CAD, CKD, HTN, Hx. CVA, Hemiplegia, Recent MI • Elisol met with the patient in physician office on 07/2013 17
On going support • Connected the patient with specialists (cardiology, endocrinology) • Medication reconciliation • Medication Education • Home visit to evaluate barriers to patient’s self care. • Educate patient regarding symptom management and when to call the health care providers. • On going communication with the health care providers to ensure continuity of care. 18
Outcome • Hgb A1c- 9.7 upon enrollment to CARE Connect – Current Hgb A1c-7.5 • Inpatient or ED admission – None in 2013 – 1 inpatient admission in December 2014 – 1 inpatient admission in September 2015 • Patient and family are engaged in taking care of their health. • Patient and family are appreciative of nurse relationship • Call or text nurse with appropriate questions or concerns 19
A Physician Perspective Misty J. Rydelski, MD 20
How do we move from current state to future state? We do it through Population Health Management (PHM). In PHM, we use information to look proactively at our population and develop programs to better meet the needs of those population. Different from the “old” way of waiting for patients to be sick and seek care. We measure success in Population Health Management in terms of the Triple Aim: Improving community health, enhancing the patient experience and reducing costs. 21
PHM is defined as using information to manage the outcomes of groups of individuals. We have broken down our population into 4 segments and we are working to develop programs and services to meet the needs of each segment. Here are some examples: Complex care are very sick patient who need a nurse to call them on a regular basis to help them stay healthy and out of the hospital Case management are patients who have had an inpatient stay and need help transitioning back into their home. We help connect them to their provider of care. Disease management are patients with a chronic condition: diabetes, asthma or heart failure. Programs such as health education and the Center for Health Promotion serve these patients. Health promotion are the “healthier” patients who are not accessing care but we still care about them and want them to stay healthy. So we reach out to them for preventive screenings . 22
Management of the Patient with Complex Disease William H. • 94 year old with metastatic prostate cancer , diffuse atherosclerosis with cardiomyopathy, CHF, AICD, S/P stent, and CKD. • Lives with son and daughter in law who brings him to appointments. • Depression in past which has been managed well for 6 months • Came in feeling “more tired and depressed”. 23
How did Complex Care/Care Connect help William, his family and the “Triple Aim”? • The “fatigue” was found to be a hgb of 9.8 • Pt was able to make decision with family from his baseline of 13. We were able to to consider hospice. admit him just as he began to have hematemesis. • Hospice accepted a week after that office • This was an easy transition to hospital. No visit. Within 24 hours patient was set up ambulance or 911 services. The at home with hospice. hospitalist saw , treated and transitioned him back to the office setting. • William passed at home with his family • William and his family were able to get all within 4 weeks of that initial “fatigue “ the out patient supportive DME he visit. needed with the coordinated effort of • I talked to the family just after he passed. case management in the hospital and care Son sent his complements to the team connect in the outpatient setting. approach and all we were able to do for • In follow up at the office, we were able to him outside the hospital after the smooth have family meetings and discuss end of transition from inpatient. He asked if he life care, especially for the prostate cancer, and his wife could be patients. CHF and GI bleed. He did not want to go back to hospital or have more procedures. 24
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