Barb Simons, RN Cate Ranheim, MD October 2010

1. Barb Simons, RN Cate Ranheim, MD October 2010 Madison, WI

2. Overview: • The Need • The Program • The Patients • The Analysis

3. Defining the Needs for a Solution: • PATIENTS: ED is not the right care for increasing chronic care management needs • CLINICIANS: under or over-treating ED patients • PAYORS: insurance premiums rise in response to hospitals increasing costs to cover bad debt and uncompensated care • HOSPITAL: capacity constraints in ED require targeting avoidable ED admissions • we began with those who, upon intake, stated homelessness, provided shelter addresses, or did not give an address

4. Overcoming Barriers to Good Health in the Medically Underserved • Retrospective, medical record review • 330 homeless and unstably housed patients in MADISON, WI seen in ED or hospitalized at Meriter Hospital between 1/07-10/08 • manually reviewed to identify and evaluate barriers to good health: -Housing -Literacy -Lack of primary care provider -Transportation -AODA -Medications -Mental Illness - Insurance

5. Where Should We Focus Our Resources? Housing Lack of primary care provider AODA* Mental Illness* Medications Insurance Literacy Transportation *Each identified in 15% of population

6. HEALTH Patients Meriter Medical Record Numbers Program patients sought Meriter emergency services 138 times in the 10 months before the program started. Over $86K COST savings potential from these visits alone*. *Based on Medicaid reimbursement for ED visits of $0.13/$1.00 charge

7. November 2009 Helping Educate and Link the Homeless (HEALTH) Program is born: • Four outreach locations open in an effort to overcome identified barriers to good health • One outreach clinic/week, four alternating sites, volunteer-staffed • Funded with $250,000 grant from Meriter Foundation for 2010

8. The “Hut”

9. HEALTH Program Timeline

10. HEALTH Program Logistics

11. HEALTH Volunteers Facility, 22 n=75

12. HEALTH Volunteer HoursJan-Sept 2010 ~ 718 hours Facility

13. HEALTH Volunteer Hours (Estimated Value)Jan-Sept 2010 ~ $25,000* Facility * Madison market -based

14. HEALTH Program Donations 7,300 + 1 *Direct expenses only: value of HEALTH Hut building or utilities not included **Time frame = 6 months

15. The Patients

16. n=185

17. HEALTH Patients Housing Status

18. HEALTH Patients Payer Status /No Coverage

19. HEALTH Program Data • Program patients Nov 2009 – Aug 2010 • 185 unique patients 393 visits PRIMARY DIAGNOSIS CATEGORY: Cardio- Respiratory 36% Endocrine 2% Mental Illness 21% Other 15% Musculo- Skeletal 17% Infection 9% 1% unknown

20. HEALTH Patients Medical Diagnoses by Bucket • Most cardiorespiratory patients have a secondary cardiorespiratory diagnosis • Mental Illness: secondary diagnosis prevalence is only 2% higher than primary diagnosis prevalence Secondary Diagnosis Group Primary Diagnosis Group

21. HEALTH Patients Co-morbidities n=185

22. HEALTH Patients Number of “Hut” Visits per Patient Total Visits: 393

23. The Analysis

24. HEALTH Patient Patterns • Top 5 diagnoses represent just 22% of all diagnoses: Hypertension, Depression, Anxiety, Type II Diabetes • Transitionally-housed patients made more repeat visits to the Hut per person, on average, than those reported as homeless or permanently housed.

25. Patient Pathways Value: avoiding unnecessary ED visits, reducing need for I/P admissions

26. Where do the underserved go for care? Control Group HEALTH Program Participants ED C, D F E ED A, B D H G E I/P I/P Before After

27. Measuring Value

28. How It Works Costs = total direct expenses only (salaries, supplies, bus passes, equipment) and excludes building depreciation, overhead, etc. Average Inpatient cost of care is specific to diagnosis bucket (i.e., Service Line) The greater the ALOS and Median Inpatient Cost of Care the greater the avoided cost opportunity: analyze your current volumes to estimate your potential savings *all patient and cost data listed here is fictitious

29. Quick and Dirty ROI Recipe 1. Gather ingredients from Finance Department: • Cost per Medicaid ED visit: (total direct costs *Medicaid % payor mix)/N Medicaid patients • Number of ED admits from either local shelters or no address in one year: assess common ED diagnoses by service line • Average I/P costs = total direct expenses for Service Line/N patients (use 1 year of data at least) 2. Calculate your current costs for these patients to date using the above data 3. Use the formula presented to determine your cost reduction potential • Sample at least 30 patients: estimate probability of ED avoidance through record review • Use Elixhauser comorbidity values (see supplemental) • Assume a indigent care program estimated cost per patient: we used $50 4. If the cost of program startup – donations is less than #3, consider implementing an off-site indigent care program like HEALTH.

30. Thank you to our donors! Meriter Foundation St. Vincent de Paul UCC-Memorial Church Meriter Hospital Masimo Corporation Association of Spiritual Caregivers Wisconsin Medical Project Dr. Bernie Micke Dr. Jack Kenney Nicole Heide, RN Mandy McGowan, RN McGovern & Sons Jo Hoffman/Ellen Boyce John Warden Home Depot Hometown Flooring Sherwin-Williams Meriter Medical Staff Office www.healthprogram.us

31. A special thank you to our friends and colleagues, Heidi Kimble and Melissa Strayer, for data analysis and volunteer time! www.healthprogram.us

32. SUPPLEMENTALS

33. Supplemental A: Slide 4 Calculations

34. Supplemental B: Elixhauser Comorbidity Index Source: Effects of Specific Comorbidities on Outcomes Controlling for Demographic, Insurance, and Other Clinical Factors of Adult, Nonmaternal Patients Who Were Hospitalized in California in 1992 (n = 1,779,167) Elixhauser, Anne; Steiner, Claudia; MD, MPH; Harris, D; Coffey, Rosanna. Comorbidity Measures for Use with Administrative Data. Medical Care. 36(1):8-27, January 1998.