Download Julie Shepard

Care Coordination: Facilitating
patient engagement and quality in
healthcare
JULIE SHEPARD
ADMINISTRATIVE COORDINATOR OF CARE
COORDINATION
MAY 20, 2014
Presentation Outline
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 Overview of Care Coordination
 Patient Engagement
 Quality Improvement
Overview of Care Coordination
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Patient Win
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C A N C E R PAT I E N T
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PA S T A S S I S TA N C E P R O V I D E D F O R M U LT I P L E S O C I A L S E R V I C E
BARRIERS
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HOMELESS
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M U LT I P L E E R V I S I T S A N D H O S P I TA L I Z AT I O N S D U E TO T H E
RAPID PROGRESSION OF HER TERMINAL ILLNESS AND
U N C O N T R O L L E D S Y M P TO M S
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D I D N O T WA N T TO R E C E I V E A N Y F U RT H E R L I F E P R O L O N G I N G
M E A S U R E S A N D WA N T E D A H O S P I C E R E F E R R A L
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S TA F F H A D M U LT I P L E C O N V E R S AT I O N S W I T H T H E
O N C O L O G I S T A D V O C AT I N G T H E PAT I E N T ’ S W I S H E S A N D H E
E V E N T U A L LY A P P R O V E D T H E H O S P I C E R E F E R R A L .
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F A M I LY R E L AT I O N S H I P S M E N D E D D U E TO R E C E I V I N G H O S P I C E
SERVICES
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T H I S P R O V I D E D H E R W I T H A M O N T H TO S AY H E R A P O L O G I E S ,
H E R G O O D B Y E S , A N D TO F I N D P E A C E A G A I N .
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Why Care Coordination?
• Improve health status and quality of life
• Reduce healthcare costs to the health system and clients
• Prepare for healthcare reform environment of the future
• Maintain high standards of care and service
• Perform as a single multi-disciplinary team
• Improve provider and client satisfaction
• Prepare for health care reform/value based environment
This aligns us with the IHI Triple Aim:
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Improve the experience of care
Improve the health of populations
Reduce the per capita cost of care
Care Coordination Initiation
• 2006: Access Health Adams County was initiated to provide
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care coordination and access to care for the uninsured
population.
July, 2011: Blessing Health System developed a pilot care
management program in the BPS outpatient setting to serve as
a bridge to acute care and the community.
October, 2012: Programs were combined and formed the Care
Coordination Department of Blessing Hospital.
January, 2013: Program was expanded to all ambulatory care
clinics including BPS Quincy, Hamilton/Warsaw, Palmyra, East
Adams Clinic, Community Outreach Clinic and the Diabetic
Center.
January, 2014: Program target population was expanded to
employees of the health system.
Guiding Principles Principles
•Multidisciplinary approach
•Embedded or co-located services
•Client empowerment
•Mutually set goals with client and their family
•Shared information across provider network
•Collaboration and communication
•Focus on transitional planning
•Program developed in collaboration with ABC community
planning and organization structure
•Facilitate the use of appropriate resources at the right
time and in the right setting
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Case Finding
Early identification of clients is key!!
Claims data (high volume, high cost)
 Diagnosis and medical expenditure thresholds
 Health impact assessments
 ED use
 Hospitalization Census
 Readmission risk
 Provider referrals
 Self referrals,
 Ancillary provider referrals
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Target population
• Patients with uncontrolled chronic disease/or those newly
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diagnosed (diabetes, hypertension, high blood lipids, CHF)
Patients with excessive inappropriate Emergency Room usage
Patients who have been hospitalized within the past two
weeks and who have risks for readmission (polypharmacy,
lack of social support, two or more chronic conditions,
cognitive decline or depression, three or more
hospitalizations within the past year, readmission within 30
days)
Patients transitioning from one setting to another
Behavioral Health Issues
Extreme Social Service Needs
Patients who need a PCP or dental services
Health Assessments
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Health Impact Assessment (Service Navigation
only)
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Disease Specific Clinical Assessment (Chronic
Disease only)
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Patient Activation Measure (PAM) Survey –
measures the concept of patient activation and
self-confidence toward self-management.
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SF-12 Quality of Life Survey
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Staffing
Position
Description
Qualifications
Nurse Care Manager
Provides RN Care Management services
designed to improve well-being to a
specified/targeted patient group.
RN/BSN degree
Social Worker
Address the psychosocial needs of the
targeted population by providing social
work evaluation, counseling, and advocacy.
LCSW
Case Worker
Conducts care navigation activities to those
who are seeking primary care services.
(Will carry a caseload of clients identified
as needing on-going support
BSW or related field
Referral Navigator
The Referral Navigator has overall
responsibility for administratively
coordinating referrals requested by the
Care Managers and other program staff as
appropriate.
Minimum of high
school graduate or
equivalent. Medical
Assistant, Certified
Nurse, preferred.
Program Components
Intervention
Target
Activities
Staff
Service Navigation
No targeted chronic
condition; No complex
condition; Service
navigation needs
identified through intake
Assists clients in receiving
healthcare services or
meeting social service
needs
Case Worker
Chronic Disease
Management
At least one targeted
chronic conditiondiabetes, hypertension,
CHF, lipids
Assists clients in
managing their chronic
conditions
Nurse Care Manager
supported by Referral
Navigator
Transitional
At least one of the risk
factors for increased
readmission post
Assist clients in the
transition of leaving
inpatient treatment
Nurse Care Manager
Behavioral Health
Clients in care
coordination program
identified with risk for
depression or anxiety
Assessment for mental
health conditions, shortterm counseling and
assistance in obtaining
services
LCSW
ED Diversion
Clients who are high
utilizers of the
Emergency Room
Assessment to determine
client needs
Case Worker
LPN
Referral Navigator
Care Coordination Activities
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Connecting clients to community resources
Coordination of healthcare services
Follow-up with clients after medical appointments to encourage treatment
adherence
Assistance with applications for Medicaid, Med Assist, Community Outreach
Clinic, and other programs
Nursing care management services/disease education
Behavioral Health
Client advocacy
Care plan development
Medication reconciliation
Health and wellness coaching services
Assistance with end of life decisions
Primary and dental care access
Patient Engagement
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Patient win
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 Patient with multiple chronic diseases and social service needs
 Multiple unplanned physician and emergency room visits
 Facilitated referrals to the Diabetic Education program,
psychiatry (which is embedded into primary care), Physical
Therapy, and other specialists
 Outcomes at six months include: reduction in A1C level of 2.6
points to 6.8% (recommended level <7), weight loss of 20 pounds,
medications have been reduced, no unplanned visits to provider,
no emergency room visits, improvement in LDL (88 currently),
development of an acceptable sleep pattern, and knowledgeable
and compliant with her medications and provider
 Patient is very complimentary of the Care Coordination program
and has stated frequently that it was the impetus which saved
her and changed her life forever for the better.
Population Engagement
• Case Finding is important!
• Relationship Building
• Assess readiness to change by using PAM (Patient
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Activation Measures) survey
Additional Assessments to determine patient
area of focus
Motivational Interviewing
Teach Back
Behavior Change Theory
PAM/CFA Basic Concepts
 Helps determine a patient’s perception of his/her
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ability to self manage
Patient “activation level”
Administered at regular intervals
Coaching for Activation (CFA) tool works in
conjunction with the PAM tool to provide goals and
action steps based on the patient’s activation level
The “action steps” (goals/interventions) will be
reevaluated and changed as patient progresses
CFA Tool Overview
 The Coaching for Activation tool is based on three
changeable attributes:
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Knowledge
Skills
Confidence
Theories of health behavior
 Diclimente Transtheoretical Model
 Social cognitive theory
 Health belief model
 Theory of reasoned action
 Knowledge-attitude behavior model
Why is behavior change theory important?
 Interventions that are most likely to success are
based on a clear understanding of the targeted health
behaviors and their environmental context.
 Theory can help you think about the larger picture of
how to help individuals successfully make changes.
 Knowledge is necessary but not sufficient to produce
behavior change. Perceptions, motivation, skills and
factors in the social environment are also important.
Quality Improvement
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Program Outcomes
•Satisfaction
•Patient
•Internal
•Provider
Customer
•SF-12
Quality of Life
•PHQ-9
•Clinical
•Cost
•Emergency Room Usage
•Inpatient Hospitalizations
•Readmissions
•ROI
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First Year Findings
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Successful Program Launch in January 2013
1825 clients enrolled by the end of the program year.
86% of referrals made to primary care were completed.
Significant increase in perceived mental health well-being
(SF-12 survey) among clients enrolled in the care
management program.
LDL control in clients with diabetes exceeded baseline year
goal by 17.4 percentage points.
PHQ-9 scores improved by a reduction in PHQ-9
reassessment scores exceeding baseline year goal of 20%.
Program Year 1 Result: 47%.
100% of patients reported being satisfied or very satisfied in
all seven areas surveyed
100% of employees reported being satisfied or very satisfied
First Year Findings
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 Reduced unplanned hospitalizations in chronic disease clients
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participating by 27.5% with an estimated cost avoidance savings of
$88,000
Realized a predicted future year medical expenditure savings among
clients with diabetes of $91,650.00
85% of clients enrolled in inpatient care transitions did not have a
readmission within 30 days of discharge with an estimated cost avoidance
savings of $820,000.
9 percentage point reduction in utilization of the emergency department
transition clients during the first program quarter with an estimated cost
avoidance savings of $1,975.
10% reduction in Emergency Department utilization for other programs
with an estimated cost avoidance savings of $17,875.
98% of clients referred from the Emergency Department to the dental
transitions program did not return to the emergency department with an
estimated cost avoidance savings of $321,000
1:9 Return on Investment
Improvement Opportunities
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 Systems Integration
 Consistency in data collection, data storage and
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reporting
Enhanced utilization of IT for case finding
Enhanced collaboration with PCP offices
Focus on improving A1c and BP control among clients
with diabetes
Focus on reduction of clients who are obese or morbidly
obese
Increased focus on continuous quality improvement in
chronic care outcomes
Patient Win
•Mid 30 Year old Male
•Five Ed visits over a 60 day period
•No PCP due to a violation of narcotics agreement
•Assessment revealed: narcotics issues, marital issues, and although employed
at that time his job was at risk due to his health issues, legal issues
•Care Coordination found a medical home and social worker who provided
personal and family counseling
•Staff made contact every 48hrs during emotional upheavals then bi-weekly as
issues decreased
•Assisted the patient to possible employment opportunities
•Connected to resources for legal issues
•Results: one admission to hospital (electrolyte imbalance) and 2 appropriate
visits to Emergency Department in 18 months
•Patient states that Care Coordination is his “life line”, and is very appreciative
of the services
•Staff continue to monitor and work with this family
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Thank you for your participation!
Julie Shepard:
[email protected]
217.223.8400 ex. 5561
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