Preventing “Tipping Points” in High Comorbidity Patients: A Lifeline from Health Coaches Co-PI: Mary Charlson, MD (Weill Cornell Medicine) PI: Jonathan N. Tobin, PhD (CDN/The Rockefeller University) Funding: PCORI Award #IHS-2017C3-8923 With support from: AHRQ Grant #P30-HS-021667 NYC-CDRN (INSIGHT) PCRF Award #20171205 CAPriCORN PCRF Award #20171205
Conflicts Mary Charlson MD: Cornell University has filed a patent for the use of the enhanced comorbidity index to predict future costs.
Team in Attendance • Mary Charlson • Guillerma M. Martinez • Andrea Cassells • Shelly Sital
Partners PCORnet Clinical Directors Network New York City Clinical Data Research Network (NYC- CDRN/INSIGHT) Weill-Cornell Medicine Chicago Area Patient-Centered AllianceChicago Outcomes Research Network (CAPriCORN)
Federally Qualified HC Partners Chicago • Erie Family Health Centers ( Red ) • Friend Family Health Center ( Yellow ) New York • Family Health Centers of NYU Langone ( Purple ) • Community Healthcare Network ( Blue )
Backg kground Patients with Multiple Chronic Diseases: • Increased mortality and morbidity • High risk for destabilization, including hospitalization, ER visits and increased disability • Excluded from clinical trials because they have worse outcomes, confounding results • Almost no guidelines for the care of such patients • Experience social and psychosocial challenges – “Tipping Points” – that may lead to destabilization
Charlson C Comorbidity Index: x: A Adults Condition Points Condition Points Myocardial infarction 1 Depression 1 Congestive heart failure 1 Warfarin 1 Peripheral vascular disease or bypass 1 Inflammatory bowel disease 1 Stroke 1 Excluded: Hemiplegia 2 Dementia or Alzheimer’s 1 Chronic pulmonary disease/ asthma 1 Metastatic solid tumor 6 Diabetes 1 HIV or AIDS 6 Diabetes with end organ damage 2 Any transplant: renal; heart; liver; bone marrow; lung 6 Renal disease 2 Schizophrenia or bipolar 3 Mild liver disease 2 Bipolar disease 3 Severe liver disease 3 Taking antipsychotics or medications for bipolar disorder 3 Gastric or peptic ulcer 1 Drug or alcohol addiction 3 Cancer (lymphoma; leukemia; solid tumor) 2 Rheumatic or connective tissue disease 1 Hypertension 1 Skin ulcers/ cellulitis 2
Backgroun und d
Design • Cluster randomized clinical trial • Predominantly low-income, black and Latino/a adult patients with multiple chronic diseases (defined by Charlson Comorbidity Index of >4 ) • Conduct recruitment, assessment and intervention at 4 FQHC networks through designated, trained Health Coaches • Engage 4 FQHC sites in each Health System with at least 500 patients who have high comorbidity at each Health System ( total=16 FQHC sites )
Charl rlson Comorb rbidity Index x by Network rk FQHC Total # of Adult Total # of % of Patients Network/Health Patients* Patients with CCI with CCI ≥4 System ≥4 Health System 1 35,141 1,949 5.6% Health System 2 23,819 1,888 7.9% Health System 3 12,839 2,984 23.2% Health System 4 11,521 2,199 19.1% Total 83,320 9,020 10.8% *This total is for only the 4 recruitment sites at each health system (n=16 sites)
Interve vention PCMH: Patients will receive their usual care at their health center per Patient-Centered Medical Home (PCMH) guidelines (Control) PCMH+coaching: Patients will receive their usual care at their health center per Patient-Centered Medical Home (PCMH) guidelines plus health coaching (Experimental)
Site Recruitment & Randomization Design: 4 FQHC Networks, 16 FQHC sites, N = 1920 Patients
Tippi ping ng P Points - Inter erven ention on Experimental Arm Includes: • Setting life goals and self-management goals with Health Coaches to engage patients • Coaching toward self-management goals shared with patient’s primary care clinician and Health Coach to work with patient to develop an action plan for when they should contact their clinician • Emotional and tangible support for life stresses Patients in the PCMH+ coaching intervention will be able to contact the Health Coach if they need help because of new life events, psychosocial challenges, new diagnoses or deterioration in their current social or clinical status. The Health Coach can help to mobilize family and friends to provide support
PCM CMH v ver ersu sus s PC PCMH with Health Coaching Intervention Needs Identified by Patients PCMH Intervention alone (Control) PCMH plus Health Coach Domains of Health Education (Experimental) Impact Questionnaire Engagement in self-management Patient-centered care that supports Same as PCMH Positive and active engagement in patients in learning to manage their life own care Effectively communications with Comprehensive accessible care that Same as PCMH Skills and technique acquisition physicians meets each patient’s needs Navigating the health care system Coordinated care across all Same as PCMH Health services navigation elements of the health care system Providing emotional support Empathic listening Emotional well-being Assistance with handling life Mobilizing social support and Constructive attitude/approaches; stresses connecting with relevant Social integration and support community support services
Tippi ping ng P Points - Key D Demographics NY/Chicago FQHC Subgroup Sample Prevalence Rate (%) Size Total 1920 Race/ethnicity White 344 20.8% Black 1006 48.5% Hispanic 659 42.2% Insurance Medicaid 1169 62.3% Medicare 115 5.1% Other Private 13.3% 259 Uninsured 19.3% 376 SES <100% FPL 1649 80.8% <200% FPL 1837 94.5% Health Literacy Language other than English 394 23.6%
Ti Tipping P Points s - Outcome mes Primary Outcomes • Decreased unplanned hospitalization • Decreased disability (WHODAS) Secondary Outcomes • Decreased emergency department visits • Improved Patient-reported Outcomes: • Increased patient activation (PAM-13) • Increased self-management (HEI-Q) • Increased patient satisfaction (CAHPS) Assessments • Baseline; 6-months post baseline; 12-months post baseline; 24-months post- baseline
ClinvestiGator D r Database System • Web based complete data entry, reporting and statistical and graphical analysis system. o APACHE, PHP, MySQL • High levels of security HIPPA compliant; site specific and role specific access; full audit trail • Baseline and follow up data entered extracted directly from FQHC/Health Systems EHR data into ClinvestiGator and reviewed by Health Coaches • Real time and dynamic reports to track recruiting, follow-up and missing data • Integration of outcome data (hospitalizations and emergency dept visits) from PCORnet networks, Regional Health Information Organizations (RHIOs), and FQHC data alert partners.
Tippi ping ng P Points - Concl clusions • Most interventions have been focused on improving outcomes in patients with chronic disease using guidelines, protocols and process measures • BUT most interventions have not reduced hospitalization • Because patients with one chronic disease do not drive hospitalization rates • Patients with multiple chronic disease or “high comorbidity” do drive hospitalization • There are no guidelines for patients with high comorbidity • We need to give patients tools and support and the reason to believe that they can achieve their OWN life goals by learning to better manage their own multiple chronic diseases, and support them through multiple psychosocial crises they face
Tippi ping ng P Points – Resea esearch Tea eam Clinical Directors Network Weill-Cornell Medicine: AllianceChicago: (CDN): Fred Rachman, MD Mary E. Charlson, MD Jonathan N. Tobin, PhD Nivedita Mohanty, MD Co-Principal Investigator Roxane Padilla, MPH Principal Investigator mecharl@med.cornell.edu JNTobin@CDNetwork.org Erica Phillips, MD Andrea Cassells, MPH James P. Hollenberg, MD Shelly Sital, MPH Rosio Ramos, BA, CRCC Dena Moftah, BS Martin Wells, PhD TJ Lin, MPH Lewis L. Perin, MS
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