Care Coordination: Facilitating patient engagement and quality in healthcare

1. Care Coordination: Facilitating patient engagement and quality in healthcare Julie Shepard Administrative Coordinator of care coordination May 20, 2014

2. Presentation Outline Overview of Care Coordination Patient Engagement Quality Improvement

3. Overview of Care Coordination

4. Patient Win Cancer Patient PAST assistance provided for multiple social service barriers homeless MULtiple ER visits and hospitalizations due to the rapid progression of her terminal illness and uncontrolled symptoms did not want to receive any further life prolonging measures and wanted a hospice referral Staff had multiple conversations with the oncologist advocating the patient’s wishes and he eventually approved the hospice referral. family relationships mended due to receiving hospice services This provided her with a month to say her apologies, her goodbyes, and to find peace again.

5. 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: • Improve the experience of care • Improve the health of populations • Reduce the per capita cost of care

6. Care Coordination Initiation • 2006: Access Health Adams County was initiated to provide 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.

7. 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

8. 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

9. Target population • Patients with uncontrolled chronic disease/or those newly 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

10. Health Assessments • Health Impact Assessment (Service Navigation only) • Disease Specific Clinical Assessment (Chronic Disease only) • Patient Activation Measure (PAM) Survey – measures the concept of patient activation and self-confidence toward self-management. • SF-12 Quality of Life Survey

11. Staffing

12. Program Components

13. Care Coordination Activities • 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

14. Patient Engagement

15. Patient win 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 hasstated frequently that it was the impetus which saved her and changed her life forever for the better.

16. Population Engagement • Case Finding is important! • Relationship Building • Assess readiness to change by using PAM (Patient Activation Measures) survey • Additional Assessments to determine patient area of focus • Motivational Interviewing • Teach Back • Behavior Change Theory

17. PAM/CFA Basic Concepts Helps determine a patient’s perception of his/her 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

18. CFA Tool Overview • The Coaching for Activation tool is based on three changeable attributes: • Knowledge • Skills • Confidence

19. Theories of health behavior DiclimenteTranstheoretical Model Social cognitive theory Health belief model Theory of reasoned action Knowledge-attitude behavior model

20. 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.

21. Quality Improvement

22. Program Outcomes • Satisfaction • Patient • Internal Customer • Provider • SF-12 Quality of Life • PHQ-9 • Clinical • Cost • Emergency Room Usage • Inpatient Hospitalizations • Readmissions • ROI

23. First Year Findings • 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

24. First Year Findings • Reduced unplanned hospitalizations in chronic disease clients 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

25. Improvement Opportunities • Systems Integration • Consistency in data collection, data storage and 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

26. Patient Win • Mid 30Year 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

27. Thank you for your participation! • Julie Shepard: Julie.Shepard@blessinghealthsystem.org • 217.223.8400 ex. 5561