Re-Imagining the DOC : FY14 Report on Implementation

1. Re-Imagining the DOC:FY14 Report on Implementation August 25, 2014

2. Agenda • Outcomes for FY14 • Review of Dashboard • Analysis of HomeBASE clinic-based complex care management program • Priorities for FY15 • Expanding capacity for population health management • Optimizing clinic operations • Discussion and Next Steps

3. Brief recap • DOC provides primary care to ~4300* patients • Most underserved (~40% Medicaid incl duals, 15% uninsured; minority, low SES) • Main continuity clinic site for Duke IM Residency (70+ resids) • Historically, patients high utilizers of care • Frequent ED use; 30-day DUH all-cause readmit rate of 21% • High burden of chronic illness, plus co-morbid mental health (MH), substance abuse (SA) • 83% of DOC pts w/ ≥3 hospitalizations had co-morbid MH/SA • Led to comprehensive redesign, starting in July 2014 • Added dually-trained medicine-psychiatry attending; APP • CCNC-funded clinic-based care manager • Stead-based resident clinic groups *Defined by 2 office visits in past 36 months, including 1 in the last 12 Source: Performance Services

4. Dashboard for FY14

5. Dashboard for FY14 (cont’d)

6. HomeBASE Evaluation of Impact on Healthcare Use Post-intervention annual encounter rate = (Number of encounters in evaluation period / Length of evaluation period) * 365 • Pre-intervention annual encounter rate: • PCP visits at DOC • ED Visits • Hospital Admissions • Inpatient Days Encounter Costs Based on average cost for DOC patients receiving care at DUH during FY13 and FY14. Source: Josh Worrell, Finance

7. Impact of HomeBASE on ED visits Average change = 6.7 fewer ED visits* per HomeBASE patient *annualized fewer ED visits more ED visits

8. Impact of HomeBASE on Inpatient days Average change = 0.8 fewer inpatient days* per HomeBASE patient *annualized fewer inpatient days more inpatient days

9. -0.8 -6.7 -0.5 -$58K -$120K -$1K

10. Duke University Health System Encounters

11. Priorities for FY15: Population health management • HomeBASE • Continuing to formalize HomeBASE process (e.g., care plans) • Broadening scope of clinic-based care mgmt to uninsured • Requires addt’l non-CCNC support ($16K) for DOC care manager (Marigny) to expand scope beyond Medicaid • Non-emergent patient transportation pilot • Early results promising • Transfer of donated van; recruitment of volunteer driver(?) • New formalized complex care evaluation option • Part of creation of add’tl stratified collaborative care interventions • For any high-need patient who meets criteria for HomeBASE but does not have Medicaid • Covering medication-related issues, psych, housing/food, etc. • Performed jointly by SW (Jan) & MH NP (Julia) • To help PCPs address needs, connect patients with resources • Ongoing analysis of HomeBASE impact

12. Stratified Collaborative Care Interventions Higher Intensity

13. Population health mgmt (cont’d): Uninsured DOC patients • Partner again w/ PADC to refer pts to exchanges • Did this in February of this year; affordability an issue • Referral by Pharmacy of Medicare Part D-eligible patients not enrolled/who qualify for addt’l assistance • Broaden role of SAM (Brandie) in coordination of coverage-related activities • Ultimately reducing costs of uninsured to DUHS • Possible pilot w/ DUH hospitalists to provide PCMH for selected complex uninsured pts discharged from DUH • Requires addt’l non-CCNC support for clinic-based care mgr • Could be good use of SOAR counselor (w/ dedicated time?); LATCH, too PADC = Project Access Durham County; SAM = Service Access Manager; PCMH = primary care medical home; SOAR = SSI/SSDI Outreach Access & Recovery

15. Population health mgmt (cont’d) • Mental Health-Primary Care (MH-PC) next steps • Collaborative care model expansion • Diabetes and depression management pilot (IMPACT model) • Treatment for alcohol abuse (@DOC: 39% SA; 8% EtOH) • Chronic pain • Cont’d involvement in leadership of DUHS Opioid Safety Taskforce (clinical pharmacists Holly/Ben, Larry Greenblatt) • Uniform policies, med safety, use of NC CSRS, etc. • Developing relationship w/ Duke Pain Medicine • Referral to AIM Health Services for addiction treatment; clinic-based suboxone treatment for selected patients • Social determinants of health • Tracking socioeconomic barriers faced by DOC patients (literacy, housing, food insecurity, transportation, adult maltreatment, hx of child abuse, ineffective self-mgmt)

16. Diabetes and depression management

17. Population health mgmt (cont’d) • Advanced analytics to understand, respond to needs of important patient subpopulations • Updated (and updating) DOC primary care patient list • DOC database (of clinical, socioeconomic variables) • Has been built; will load DEDUCE/DSR, be annually updated • Use of visualizations • Including for planned chronic kidney disease (CKD) project • AAMC “hot spotting” project • AAMC-supported minigrant using Macarthur “Genius” award-winner Jeff Brenner’s Camden Coalition method for understanding high-need patients’ stories • Transition to Healthy Planet (when available, fully functional)

20. DOC DRH Main Lincoln

21. Priorities for FY15: Clinic Operations • Outreach to “lapsed” or “hard-to-reach” patients • SAM-led response to Six Sigma Green Belt project/CGCAHPS • Clarified routing to existing diabetes-related services • Continued elevation in level of care provided on-site • RNs completing certifications for placement of peripheral IVs • New Procedure Clinic (joint injects, cryotherapy, punch biopsy) • GIM Consultation Clinic • Revenue enhancement • TCM billing; initial barrier addressed w/ PRMO • Pharmacy billing for visits (new) • Quality of resident experience • Changed intern scheduling in clinic to full days • Renewed focus on clinic communications • Further refining role of Stead-based clinic groups • Participating in Transforming Primary Care Collaborative • including Joint Commission PCMH certification 21

22. Diabetes-related services Sheila White

23. Clinic Operations (cont’d):Optimizing use of clinical pharmacy capacity • End of FY14sawloss of 0.9 FTE PharmD • In FY15: • Efforts to improve process efficiency, task-skill match • e.g., modifying CII contract management process • Continued facilitation of group visits (w/ SW; diabetes, hypertension, chronic pain) • Face-to-face visits to include anticoagulation, diabetes/hypertension/hyperlipidemia, medication management, and pain medication (CII) mgmt • Targeting pharmacy post-discharge medication reconciliation encounters to needier patients • Goalfor FY15: 50% of all discharges • Billing for clinical pharmacist visits • Start date: September 1

24. Discussion and Next Steps: Requested FY15 investments • Support for possible pilot of providing PCMH to “medically homeless” complex uninsured patients • Cont’d support for/ dedicated time of SOAR worker to help uninsured DOC patients (plus addt’l social work needs) • Direct support for clinic-based care manager ($16K) • Would allow expansion of Marigny’s work outside Medicaid (e.g., “medically homeless” pilot) • Preservation of budgeted clinic staffing allocation • Non-emergent patient transportation • Van donated from DFC; cost of insurance ($110/mo) + fuel • Volunteer driver? • Support for participation in planned TPC Collaborative • Contribution req’d to cover both DFM and DOC ($20K)

25. FY14 Accomplishments • Reduced inappropriate ED and inpatient utilization • Avoided direct costs of $489K (and savings of $384K) • Successfully established clinic-based complex care management program, on-site mental health-primary care collaborative care model • Increased resident satisfaction • Rebecca Kirkland Award (DUHS PSQC) • It Takes a TEAM Award (DUH) • Podium presentation at Society for General Internal Medicine (SGIM) Annual Meeting • AAMC HotspottingMinigrant

26. Discussion

27. Additional Slides

28. OVERALL, how would you RATE the VALUE of your PRIMARY CARE CLINIC EXPERIENCE?

31. Complex Care Evaluation

32. Complex Care Evaluation

34. Alcohol abuse treatmentReferral for behavioral intervention plus algorithm guided medication management:

35. DOC Patients Disease Network

37. Diabetes care • Clarified referral paths, indications for in-clinic and outside diabetes-related services • Six Sigma Green Belt Project (Shah, Simo) • Finding “lapsed” patients • Implementing IMPACT model for 25 patients w/ uncontrolled DM

38. Premium support for exchange-eligible uninsured • NC decision not to expand Medicaid limited coverage gains to those >100% FPL who could afford to purchase exchange plans w/ subsidies. • However, many people eligible for exchange plans cannot afford even this, even w/ subsidies provided. • In March 2014, of 23 exchange-eligible patients at DOC referred to PADC navigator, only 6 were able to afford their offer of coverage and sign up. • A proposal is being developed that would provide premium support for selected medically needy exchange-eligible individuals to purchase coverage. • Follows prior precedent set when e.g., COBRA coverage was purchased by Duke on behalf of an uninsured hospitalized patient.

39. Additional factor to consider • We have recently seen a rise in patients who have obtained insurance through the Affordable Care Act requesting assistance with the cost of their meds • While uninsured, they qualified for assistance from the manufacturer (Patient Assistance Programs) • Once insured, copays may be as high as $150 or more for some medications (e.g. insulin) • If premiums are paid for insurance for patients, there may be a hidden cost through a rise in requests for hospital sponsored meds

40. Source: UHC Research Institute