Frontier Extended Stay Clinic Demonstration Project

1. Frontier Extended Stay ClinicDemonstration Project Report on 12 Months Data Presented by: Alaska Center for Rural Health – Alaska’s AHEC December 2006

2. General Observations • Data collection period for ARMC, CRMC, and IFHS: 3/15/05 – 3/14/06. • Data collection period for IIMC: 9/15/05-9/14/06 (due to later start in project). • Year’s data captures seasonal variations (fishing season, tourist season). • Data submitted by clinics of very high quality – required minimal “data cleaning.” • Clinics reported a remarkably similar number of FESC encounters – no need to weight/adjust the data.

3. Key Findings • Each clinic is a distinct blend of geographical challenges, material & human resources, and community/culture. • Consequently, the data show that there is no “typical” participating FESC clinic. • Overall project means/averages hide these distinctions. • However, there is considerable “common ground.”

4. Key Differences and Common Ground • Key differences: • Mon Ob/Transfer patient breakdown • Patient disposition breakdown • Length of encounters • Percentage of Medicare-reimbursable encounters • Key common ground: • High percentage of after hours encounters • FESC-related staff stress (esp. after hours) • Clinics’ ability to quickly diagnose, stabilize and • medevac Transfer patients (weather permitting).

5. Number of FESC Encounters • Clinics reported very similar numbers of FESC encounters. • Consequently no need to weight/adjust data.

6. Type of FESC Encounter • FESC encounter type breakdown is highly variable from clinic to clinic – a key indicator of the conditions unique to that clinic.

7. Disposition of FESC Patients • Disposition of patients is highly variable from clinic to clinic - closely tracks Mon Ob/Transfer breakdown (most Mon Obs are discharged home, nearly all Transfers are medevaced).

8. Disposition of Mon Ob Patients • In all clinics, large majority of Mon Ob patients are discharged home. • Similar smaller percentages are referred for non-urgent follow-up care.

9. Mean FESC Encounter Length • Mean encounter length extremely variable (range: 1.42 – 17.07). • Transfer encounters generally shorter than Mon Obs (exception: IFHS, due to weather-caused medevac delays).

10. Median FESC Encounter Length • Median encounter lengths also highly variable (range: 1.25 – 10.25). • Median reduces effect (statistical “noise”) of very long “outliers.” • Relatively short Transfer median lengths show clinics’ ability to quickly diagnose, classify, and medevac Transfer patients.

11. Maximum/Minimum FESC Encounter Length • Minimum encounters were all Transfers: clinics can accomplish medevacs extremely rapidly under right conditions. • Maximum encounters nearly all Mon Obs [exception: IFHS, due to a prolonged weather delay].

12. Maximum Encounter Length – Mon Obs vs. Transfers • Maximum encounters highly variable – range: 4.00 to 99.50. • Transfer maximums quantify longest medevac delays (due to bad weather, lack of daylight, waiting for transport, stabilizing patient).

13. Distribution of Encounter Length – All Encounters • No clinic with “typical” distribution matching overall project. • Few encounters >12 hours, very few >24 hours [exception: CRMC].

14. Distribution of Encounter Length – Mon Obs • No clinic with “typical” Mon Ob distribution matching overall project. • Few encounters >12 hours or >24 hours [exception: CRMC].

15. Distribution of Encounter Length – Transfers • No clinic with “typical” Transfer distribution matching overall project. • Very few Transfer encounters >12 hours or >24 hours [exception: IFHS, due to medevac weather delays].

16. After Hours Encounters • More common ground: similar percentages of encounters occurring outside of normal clinic hours (“after hours”) – project mean: 47%. • Represents FESC work and stress loads of after hours/on call staff.

17. Frequency of Project Top 5 Diagnoses at Discharge • No “typical” clinic (IFHS close) – diagnoses vary significantly. • Common ground - incidence of top 2: injury and cardiovascular.

18. Frequency of Project Top 5 Mon Ob Diagnoses • Again, no “typical” clinic [ARMC is close]; diagnoses vary. • IFHS: substance abuse most common; IIMC: injury most common; CRMC: renal-urinary high incidence. • Common ground – high incidence of gastrointestinal (esp. CRMC).

19. Frequency of Project Top 5 Transfer Diagnoses • Highly variable – only IIMC approaches overall project pattern. • Common ground: injury and cardiovascular top 2 for all clinics.

20. Top 10 Diagnoses at Discharge for Each Clinic • Highly variable – only IFHS approaches overall project pattern. • Common ground: injury, cardiovascular, gastrointestinal.

21. Medicare/aid Eligibility for Reimbursement • Medicare/aid-eligible FESC patients range from 7% (IFHS) to 55% (IIMC). • High percentage “filtered out” by 4 hour encounter length criteria (esp. IIMC). • Net Medicare reimbursable encounters range from 4% (IFHS) to 19% (CRMC). • Most clinics will receive minimal financial boost from CMS reimbursements.

22. Time Distribution Medicare/aid-Eligible Encounters • Time distribution of Medicare/aid eligible FESC encounters highly variable • Total numbers of eligible patients also highly variable • Potential reimbursements thus variable, from high (CRMC) to very low (IIMC)

23. Time Distribution Medicare-Eligible Encounters • Time distribution of Medicare eligible FESC encounters highly variable • Total numbers of eligible patients also highly variable • Potential reimbursements thus variable, from high (CRMC) to very low (IIMC)

24. Clinic Thumbnails • ARMC – Short encounters (all types); rapid medevacs; low percentage medevaced; high percentage discharged home; many Medicare eligible patients but few Medicare-reimbursable encounters. • CRMC – Very long Mon Ob encounters; rapid medevacs; low percentage medevaced; high percentage discharged home; many Medicare-eligible patients and many Medicare reimbursable encounters.

25. Clinic Thumbnails • IFHS – Long encounters; otherwise rapid medevacs prolonged by distance/bad weather; median percentages medevaced and discharged home; very few Medicare eligible patients and very few reimbursable encounters. • IIMC – Very short encounters (all types); very rapid medevacs; high percentage medevaced; few discharged home; many Medicare-eligible patients but very few Medicare-eligible encounters.

26. Key Variables

27. Key Qualitative Findings • Staff cite stress and turnover due to both FESC-related and unrelated causes (or causes beyond clinic control). • Main FESC-related causes cited: - Stress of after hours/on-call FESC encounters - Disruption of daytime routine - Lack of space for FESC patients - Demands on skills (urgent care) - Sporadic nature of encounters (anticipatory stress) - Community expectations for after hours/urgent care

28. Key Qualitative Findings • Unrelated/uncontrollable causes cited: - Medevac weather delays - Personal/family/spousal issues - Professional isolation/lack of educational opportunities - Call schedule/sleep loss/call remuneration - Administrative issues - Staff issues: staff turnover/poor hires • Clinics that added after hours staff/providers reduced staff stress. New/additional equipment also helped. • Most staff positive and optimistic about FESC project, and recommend project participation.