community-based chronic care management

Community-based Community-based Chronic Illness Management:Chronic Illness Management:

Strategies and Tools to Reduce Strategies and Tools to Reduce Costs and Improve OutcomesCosts and Improve Outcomes

Community-based Community-based Chronic Illness Management:Chronic Illness Management:

Strategies and Tools to Reduce Strategies and Tools to Reduce Costs and Improve OutcomesCosts and Improve Outcomes

Steve H. Landers MD, MPHSteve H. Landers MD, MPHDirector, Cleveland Clinic Center Director, Cleveland Clinic Center for Home Care and Community for Home Care and Community

RehabilitationRehabilitation

landers@ccf.orglanders@ccf.org

April 5, 2010

Brent T. Feorene, MBABrent T. Feorene, MBAPresident, House Call SolutionsPresident, House Call Solutions

bfeorene@housecallsolutions.combfeorene@housecallsolutions.com

Today’s AgendaToday’s Agenda

• Welcome and Introduction

• Current trends

• What is on the table?

• Future tense

• Programs that hold promise

• CCF: Today and Tomorrow

• Q&A

Powerful Trends Impact Medical Practice

Powerful Trends Impact Medical Practice

Aging Population

Chronic Illness

Economic PressuresConsumer Expectations

Technology

Demographic ImperativeDemographic Imperative

Administration on Aging. A Profile of Older Americans: 2007. Accessed at www.aoa.gov

Activity LimitationsActivity Limitations

Administration on Aging. A Profile of Older Americans: 2007. Accessed at www.aoa.gov

Chronic Illness EpidemicChronic Illness Epidemic

Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update

Aging + Chronic IllnessAging + Chronic Illness

Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update

Costly Costly

Congressional Budget Office

2005 MCR FFS stats from MedPAC DataBook June 2008

“High Risk” “High Risk”

Johns Hopkins University, Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing Care, A Chartbook. September 2004 Update

Jencks SF et al. N Engl J Med 2009;360:1418-1428

Readmissions

Half of Medicare Patients Rehospitalized Without Seeing Doctor After Discharge ~60% of

Rehospitalized HF patients hospitalized due to another problem

“Train Wrecks” “Gomers”

Frustration with the complexity, communication barriers, and administrative burdens…

Adams WL, McIlvain HE, Lacy NL, et al. Primary Care for Elderly People: Why Do Doctors Find it So Hard? The Gerontologist. 2002;42(6):835-42.

Adams WL, McIlvain HE, Geske JA, et al. Physicians’ Perspectives on Carring for Cognitively Impaired Elders. The Gerontologist. 2005;45(2):231-9.

Physician Frustration

Quality ConcernsQuality Concerns

• “suffering in spite of spending”• “silo care” “no care zone”• avoidable readmissions• hospital acquired conditions• the “hidden patient”• frustration

•Patient Centered Medical Home•Bundled Payments •Penalties for Re-hospitalizations•“Accountable Care Organizations”

What’s On the Table?

Chronic Care is DifferentChronic Care is Different

• Engaging community• Self-management support• Advanced information systems/

tracking

Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. Jama 2002;288(15):1909-14.

‘New Model’ Primary Care‘New Model’ Primary Care

• Practice “Redesign”

• Team Approach

• Advanced Information Systems

• “Patient-Centered”

• “Healing Relationships”

14. Martin JC, Avant RF, Bowman MA, et al. The Future of Family Medicine: a collaborative project of the family medicine community. Ann Fam Med 2004;2 Suppl 1:S3-32.

Patient-Centered Medical HomePatient-Centered Medical Home

• Whole-Person

• Team Based

• Accessible

• Advanced Information Systems

• NCQA Certification Process

Kellerman R, Kirk L. Principles of the patient-centered medical home. Am Fam Physician 2007;76(6):774-5.

The Case of Mrs. JonesThe Case of Mrs. Jones

• 82 year old woman, h/o HF and OOP

• “Tired and weak and swollen ankles x 5 days”

• Walker, Oxygen, Son’s Assistance

Bringing Home Medical Home?Bringing Home Medical Home?

• Highest risk patients may not be able to access offices

- Permanent

- During time of vulnerability

• Accessibility and whole person approach enhanced when care is done at home

• Scalability of team

Landers SH. The other Medical Home. Jama 2009;301(1):97-9.

“Secret Weapons”“Secret Weapons”

Enhances view of patient and caregivers

Reduces barriers to care

Strengthens patient relationships

Avoids hazards of hospitalization

Costs less

Desired more

Enabling technology emerging

Workforce EstimatesWorkforce Estimates

• Annual FFS MCR HHA Visits > 110,000,000

• Medicare Home Health FTEs >250,000

• Annual FFS MCR Physician Visits < 2,000,000

• Home Care Physician and Mid-Level FTE’s ?

• Total Primary Care Physician FTEs ~270,000

Role for Home HealthRole for Home Health

Home health is likely the (only) truly scalable infrastructure for improving quality and access for the low-mobility, high risk Medicare beneficiaries who drive the majority of program expenditures and suffer the most---1st step in impacting quality for this group may be conceptualizing home health as THE central architecture/ platform to deliver transitional, post-acute, and primary care/ chronic care management for these individuals

Programs that hold promisePrograms that hold promise

• Transitional Care

- Multi-level targeting patients with the right provider at the right time

• House call programs

- Reserved for the frailest, most complex patients

Technology in the form of EMR/EHR and telehealth among others is not an absolute necessity, but has proven itself to be an excellent

enabler to improve productivity, reduce costs and enhance outcomes.

HealthCapacity

A Role for Chronic Care Management

Time

Disability

RiskFactors

Death

NormalAging

Chronic Care Management

• Hip fracture• Stroke• CHF• COPD

• Hypertension• Rapid weight gain/loss• Hyperglycemia

• Incontinence• Dementia• Caregiver burnout• IADL/ADL decline

• Obesity• Tobacco and alcohol• Environmental

Cumulative, inter-related risk factors require ongoing, coordinated care interventions.

PublicHealth

PrimaryCare

AcuteCare

Long-termCare

High

Accelerated Loss of Health

Acute Event

Disease Management

Adapted from, “The Glide Path” Kyle R. Allen, DOMedical Director, Post-Acute and Senior ServicesSumma Health System

Transitional CareTransitional Care

• Goal- Ensuring a smooth transition for the

patient from one site or level of care to another that meets goals of care

• Why?- Limits of traditional disease and case

management in preventing adverse events and unnecessary utilization/costs

Rates of Rehospitalization within 30 Days after Hospital Discharge

Jencks SF et al. N Engl J Med 2009;360:1418-1428

Who to target?Who to target?

• Community dwelling• Admitted for ambulatory sensitive

conditions, such as COPD, CHF, Diabetes, Pneumonia and Dementia

• Frequent flyers – two or more admissions in the past six months to one year

• Individuals currently enrolled in case management

Patient Factors Contributing to Poor Post-Discharge OutcomesPatient Factors Contributing to Poor Post-Discharge Outcomes

• Multiple conditions/therapies*• Functional deficits• Emotional problems • Poor general health behaviors• Poor subjective health rating*• Lack of support • Cognitive impairment**• Language, literacy and culture

Level ILevel I

• A health coaching model using RNs- 25 – 30 patients per coach- Not a “doing” model

• Lowest-intensity, lowest-cost model• Target thirty day duration• Enroll patients who are able to be

“coached” to effectively self-manage through the transition

Level ILevel I

• Five Principals

- Medication self-management

- Nutrition management

- Patient health record

- Physician follow-up

- Red flag awareness

Level IProcessLevel IProcess

• Health coach visits while I/P - Introduce the program and gain acceptance- Prepare patient and family for follow-up

• Home visit- One visit within 48 – 72 hours of discharge- Structured

• Review the program in detail• Environmental scan• Medication reconciliation• Review discharge instructions• Introduce PHR • Discuss physician follow-up• Educate on red flags

Level IProcessLevel IProcess

• Key follow-up phone calls- 2 – 3 calls as needed- Ensures compliance and continuity- Modify plan

• Plan to call after major post-acute events- Physician visit- Home health/therapy- Change in Rx regimen- Graduation

Level IILevel II

• Use RNs in a more active model of care

• RN must balance “coach” and “do”

- Patient capabilities

- Support systems

• More extended time frames up to 6 months

• Criteria are the same as Level I, but add

- Significant ADLs/IADLs

- Psycho-social concerns

Level IIProcessLevel IIProcess

• Builds on Level I activities

- RN visits while I/P

- Initial home visit within 48 – 72 hours of discharge

- Key follow-up phone calls

• Coaches and provides care

• May need additional home visit(s)

• Graduation date can be extended based on situation

Level IIILevel III

• Highest level of intensity and care provision using NPs and/or PAs

• A hybrid model, but weighted more toward medical than nursing

• SNF-level patient able to remain community dwelling- Geriatric syndromes- ADLs/IADLs- Polypharmacy

• Risk loss of functionality and/or exacerbation of chronic condition(s)

• Most likely to bridge “at-risk” period successfully with effective, coordinated care

Level IIIProcessLevel IIIProcess

• Builds on concept of Levels I & II• Initial visit within 48-72 hours of

discharge from SNF or hospital• Key follow-up phone call(s)• Typical 30 days enrollment to

graduation - Back to office-based practice- Enrollment in house call program

House Call ProgramHouse Call Program

• Provide a patient-centered medical home to frail, low-mobility elderly

• Physician and NP serve as the patient’s in-residence PCP- Primary care house calls

- Urgent care visits

• Collaborate with hospitalists on IP care• Coordinate specialty care, ancillaries and other

health services, as needed• Offer counseling and social service coordination

for patient and family/caregivers

House Call ProgramsHouse Call Programs

• Typical profile- Difficulty getting to/from the PCP office- Have not seen PCP in 12 -18 months- ED most likely access point for healthcare

services- 2+ deficiencies in ADLs- Complicated, chronic medical conditions and

polypharmacy not likely responsive to other programs

• Disruptive to PCP office flow- Physical/facility issues- Time and resource intensive- Difficult to meet the full spectrum of patient’s

needs

What are the outcomes?What are the outcomes?

• Community-based chronic illness management programs have demonstrated positive outcomes- Reduced utilization- Lower costs- Improved outcomes

• Health• Quality of life/Goals of care

Transitional CareTransitional Care

• Eric Coleman, MD• Randomized controlled trial of a Level I

program• Outcomes

- Reduced readmissions- Lower costs

• In use by over 135 health systems nationally

House CallsMontefiore Medical Center House CallsMontefiore Medical Center

Pre-HCPInitial Six

Mos.Absolute Change % Change

CMO HCP Patients 112 112Member Days 12,936 12,936Total Hospital Days 820.0 503.0 (317.0) -38.7%Total Admits 102.0 59.0 (43.0) -42.2%Hospital Admit PPPY 2.9 1.7 (1.2) -42.2%Hospital Avg. LOS 8.0 8.5 0.5 6.0%Total SNF Days 2,148.0 703.0 (1,445.0) -67.3%Total SNF Admits 41.0 17.0 (24.0) -58.5%SNF Admit PPPY 1.2 0.5 (0.7) -58.5%SNF Avg. LOS 52.4 41.4 (11.0) -21.1%

Results for Medicare Advantage Enrollees

How are these programs paid?Managed Care/Payer PerspectiveHow are these programs paid?Managed Care/Payer Perspective

• The economic incentives are aligned and the programs produce positive ROI

- Montefiore

- Summa Health System

- Inspiris

- United

How are these programs paid?Medicare FFS environmentHow are these programs paid?Medicare FFS environment

• Programs’ downstream benefits - Capacity management

• Avoided admission• Reduced ALOS• Less pressure on ED

- Fewer re- admissions- Increased market share

• Provider professional billings- Partial contribution- MDs, NP & PAs

• Community agencies

Cleveland ClinicCenter for Home Care and Community Rehab

Today: Gaining a beach head

Cleveland ClinicCenter for Home Care and Community Rehab

Today: Gaining a beach head • System-wide recognition

- Oversight and Strategy Board- Department of Home Care Physicians

• Services- Mobile physician services

• Geriatric consults• PCP

- Home care, hospice, home infusion, etc.• Expansion of MPS

- First to a specific CCF member hospital in development for 2010

Cleveland ClinicCenter for Home Care and Community Rehab

The future: Strategic tool for CCF

Cleveland ClinicCenter for Home Care and Community Rehab

The future: Strategic tool for CCF

• Seamless delivery and coordination of care- Regardless of location - Regardless of age/time in life

• Care transitions• New roles for home care staff• Use of telehealth and remote technologies

Transitional Care ResourcesTransitional Care Resources

• Eric Coleman, MD

- www.caretransitions.org

• National Transitions of Care Coalition

- www.NTOCC.org

• Better Outcomes for Older adults through Safer Transitions (BOOST)

- www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm

House Call ResourcesHouse Call Resources

• American Academy of Home Care Physicians

- www.aahcp.org

• American Geriatrics Society

- http://www.americangeriatrics.org/products/positionpapers/housecall.shtml

Thank YouThank You

“The future belongs to those who believe in the beauty of their dreams”

- Eleanor Roosevelt