The I PiCC Program (Integrated Patient Centered Care)

1. The I PiCC Program(Integrated Patient Centered Care) Karyn Rizzo RN, CHPN, GCNS

2. " 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: Medicare. It's a multitrillion-dollar 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

3. 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

4. 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

5. 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)? Questions: How to know when a patient is admitted? Does the practice have enough admits to support project ramp up? Ongoing RN and PCC support; PharmD support as needed Ongoing RN and PCC support; PharmD support as needed Extending PCPs reach via IPiCC Pilot

6. 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 ex. med was left off discharge summary ex. Discharged with med but no Rx ex. dosage was changed ex. Did not fill Rx, refuses to take med ex. warfarin and coumadin ex. instructions not understood, can't afford meds

7. 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

8. Project Timeline and Ramp-Up Schedule Concept and operations development Outcomes measures and tracking systems Patient data collection Data analysis / program evaluation Staff hiring and training Kick-off Service delivery Outcomes and recommendations Implementation strategy Sep. 08 Jan. 09 Feb. 09 Sep. 09 May 10 Patient Ramp-Up Schedule

9. Measuring clinical outcomes

10. 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

11. Value proposition: selling complex patient management to payer and provider groups under risk contracts 40,000 Medicare Advantage members Top 5% of highest cost / highest risk patients 2,000 patients qualify for services 50% accept services 1,000 patients enrolled in program Patient Identification 2000 admissions / 1,000 among patient group per year 1,000 patients in program will have 2000 admissions ($10,000 each-AHRQ) $20M problem ($41.66 pmpm) Size of Problem 1,000 patients enrolled for 4 months each ($450 per month) $1.8M program cost ($3.75 pmpm) Program Cost 12% reduction in admissions = $2.4 M avoided cost [+600K) 15% reduction in admissions = $2.25M avoided cost [+$3M] 25% reduction in admissions = $3.75M avoided cost [+$5M] ROI

12. Questions / Discussion