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The I PiCC Program (Integrated Patient Centered Care) Karyn Rizzo RN, CHPN, GCNS " Twice I have asked Alan Greenspan what he considers the greatest threat to the U.S. economy, and both times he has answered immediately with a single word: It's a multitrillion-dollar Medicare. problem that's about to get dramatically worse. In the next President's first term, Medicare Part A will go cash-flow-negative, and it's all downhill from there. As the country ages, Medicare and Medicaid will devour growing chunks of US economic output. Then by 2070, when today's kids are retiring, Medicare, Medicaid, and Social Security will consume the entire federal budget, with Medicare taking by far the largest share. No Army, no Navy, no Education Department – just those three programs. " Geoff Colvin, Senior Editor, Fortune Magazine March 4, 2008 A primary care system on the verge of crisis • • • • Annual US healthcare expenditures have grown to over $2 trillion per year, and are expected to double in 10 years Only 10% of patients account for nearly 70% of healthcare expenditures Shift away from PCP reimbursement, fewer MD’s moving towards primary care role Current PCP model does not meet the needs of the aging client The Drivers are Clear Admissions account for the majority of healthcare expenses • 13% of population is 65+, yet account for 36% of total healthcare expenses Re-admissions only exacerbate the problem • 1 in 5 are readmitted in 30 days • 75% are preventable and related to medications Chronic illnesses causing over-utilization and contributing to PCP crisis • 44% of total healthcare expenditures and second biggest driver of admissions • Medicare and private insurance companies are focused on preventing admissions and re-admissions – In 2009 Medicare is requiring mandatory reporting of readmissions and in 2010 is proposing hospital penalties – National payers are focused on incentives (PCMH, Transitions, Chronic Illness management) to reduce admissions and improve health management programs for complex patients – Tufts Health Plan (MA) is making discharge transition programs mandatory in 2009 Project “Setting”: Patient-Centered Medical Home Patient-Centered Medical Home (PCMH) model “accepted” by Medicare was developed by NCQA staff in concert with the ACP, AAFP, AAO and AOP as well as other stakeholders to address improvements by the development of specific standards in patient centered care The PPC-PCMH has 9 standards (see Appendix 4 of the NCQA document), each of which has multiple elements. Major principles of the Patient-Centered Medical Home • Personal MD for each patient • Physician directed, interdisciplinary teams of care • Whole person orientation – acute care, chronic care, preventive, end of life • Coordinated and Integrated Care – across all elements of health care system and community • Quality and Safety • Enhanced Access to Care • Reimbursement for added value provided to patients *Drawback of PCMH is that it is NOT patient centered *Very heavy focus on EMR Extending PCPs reach via IPiCC Pilot Faulkner Primary Care Rehab Opt. 1 Opt. 2 Complex Care Management Supporting patients between PCP visits Transition Services Supporting patients following discharge [month 1] [month 1] APN led (in-home assessment); focus on chronic illnesses mgt. and red flag awareness education. PharmD led (in-home assessment); focus on medication optimization and red flag awareness education [months 2-4] Ongoing RN and PCC support; PharmD support as needed Questions: How to measure outcomes (e.g. admits avoided)? Ongoing RN and PCC support; PharmD support as needed Ongoing RN and PCC support; PharmD support as needed Questions: How to know when a patient is admitted? Does the practice have enough admits to support project ramp up? Why Lead Transitions with PharmD? Dovetail outcomes (pharmacy intervention) Dovetail's focus on medications has reduced readmissions to less than 10% (N=100) Reconciliation Issues Med Adherence Issues 75% of Dovetail clients have medication reconciliation issues identified during initial pharmacy assessment 94% of Dovetail clients have medication adherence issues identified during initial pharmacy assessment Med Omission, 4% ex. med was left off discharge summary Syst emic Issue, 40% ex. Discharged with med but no Rx Dose Specif ic, 26% ex. dosage was changed Drug Specif ic, 70% ex. warfarin and coumadin Int ent ional, 56% ex. Did not fill Rx, refuses to take med Non-Int ent ional, 4% ex. instructions not understood, can't afford meds Project goals • Reduce overall healthcare expenses by focusing on the most common cost drivers (admissions and readmissions and chronic illness) • Increase patient satisfaction by offering personalized, targeted interventions to improve overall health from a consistent team of healthcare providers • Increase PCP satisfaction with their job overall as well as their ability to care for complex patients • Help primary care practices take steps toward Patient-Centered Medical Home accreditation by providing specific services identified in NCQA guidelines Project Timeline and Ramp-Up Schedule Concept and operations development Outcomes measures and tracking systems Staff hiring and training Implementation strategy Sep. 08 Kick-off Jan. 09 Patient data collection Data analysis / program evaluation Service delivery Outcomes and recommendations Feb. 09 Sep. 09 May 10 Patient Ramp-Up Schedule Feb. Mar. Apr. May Jun. Jul. Aug. Sep. 5 5 5 5 - - - - - 10 10 10 10 - - - - - 10 10 10 10 - - - - - 10 10 10 10 - - - - - 5 5 5 5 Monthly Total 5 15 25 35 35 25 15 5 Unique Total 5 15 25 35 40 40 40 40 Measuring clinical outcomes Measure Source Collected By Frequency Patient perception of health SF-36 (patient) Dovetail RN Initial and final visits Patient satisfaction Dovetail survey (patient) Dovetail PCC Prior to initial visit and within 30 days after final visit Physician satisfaction Dovetail survey (physician) Project Assistant Prior to initial visit and within 30 days after final visit Utilization (hospitalization, ED visits, PCP visits, specialty care, VNA, Falls, Dovetail interactions, etc) Patient/family/RN report; medical record review Dovetail RN With each patient interaction Healthcare costs Estimated based on average utilization costs; SF-36 analysis Project Assistant At end of project IT utilization (use by MD, client, Dovetail) Gateway System Project Director Monthly review NCQA PCMH Standards Met NCQA PCMH Standards Project Director Prior to Program/Post The clinical centered tool (CCT) • Collects interventions as well as outcomes • Embedded SF-36 for pre and post intervention data • TTM evaluation • Incorporates all areas of geriatric domain concerns • Has report functionality • Guides clinicians in using a strength based approach to in home coaching (“Framing the visit in the positive”) • Client centered • Excel spreadsheet database which allows for great flexibility in data collection and interpretations Value proposition: selling complex patient management to payer and provider groups under risk contracts 40,000 Medicare Advantage members Patient Identification Top 5% of highest cost / highest risk patients 2,000 patients qualify for services 50% accept services 1,000 patients enrolled in program 2000 admissions / 1,000 among patient group per year Size of Problem 1,000 patients in program will have 2000 admissions ($10,000 each-AHRQ) $20M problem ($41.66 pmpm) 1,000 patients enrolled for 4 months each ($450 per month) Program Cost $1.8M program cost ($3.75 pmpm) 12% reduction in admissions = $2.4 M avoided cost [+600K) ROI 15% reduction in admissions = $2.25M avoided cost [+$3M] 25% reduction in admissions = $3.75M avoided cost [+$5M] Questions / Discussion