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Delivering Better Care at
Lower Cost for Complex
Patients
Jeffrey Brenner, MD
Executive Director
Camden Coalition of Healthcare Providers
What do these patients have in common?
• Homeless patient in Trenton, NJ with 450 visits in a year
• Dialysis patient in Allentown, PA with $1 million in
inpatient costs
• Frequently hospitalized wheelchair bound patient in San
Diego, CA
• Middle class patient in South Eastern, PA with 147 CT
scans
• Ventilator-assisted patient in Camden with $745,000 in
charges
• Dialysis patient with $2 million in inpatient costs found by
a group of student hotspotters
Camden Coalition of Healthcare Providers
Outlier patients in the long tail of data
Who are patients with ‘super-
utilization’?
• Homeless?
• Mentally ill?
• Addicted?
• Complex co-morbidity?
• Medication confusion?
• Transportation barriers?
4
ER Visits 102
Admissions 54
Total CT Scans 147
CT Scan-Head 73
Utilization at CKHS Hospital Utilization since 1996
Patient Case Presentation #1
55-yo Male, admitted for GI bleed and SOB (November
2011)
Dual coverage, Lives alone in high-rise apartment
6 months- 9 ED visits, 6 Inpt visits
12 Medications daily
www.camdenhealth.org
ESRD
Renal Carcinoma
Hepatitis B
Hypertension
Hyperlipidemia
Peripheral vascular dx
Asthma
Glaucoma (blind in one eye)
Sleep Apnea
Severe Back Pain
Patient Centered Care Coordination
Patient
Hospita
l #1
Sub-Acute Rehab
Hospita
l #2
Home
Nursing
Home
PT/OT
Durable Goods
Meals
Transport
Dialysis
Nephrology
Transplant
PCP
Urology Oncology
Surgery
GI
Cardiology
Optho
Pain
Mgt
www.camdenhealth.org
www.camdenhealth.org
Patient Case Presentation #2
52-yo Female, Spanish-speaking, admitted for SOB
Lives with family
6 months- 6 inpatient visits
Ventilator dependent and has tracheosotomy
Severe COPD
www.camdenhealth.org
www.camdenhealth.org
Camden Coalition of Healthcare Providers
Overview of CCHP • 85 full-time staff, $8 million annual budget
• Mix of foundation & federal grants, technical-assistance & care-coordination
contracts, & hospital support
• Membership organization with twenty-member board; incorporated non-profit
Camden Coalition of Healthcare
Providers
Health Information
Exchange
High Utilizer Outreach Team
Primary Care Redesign
Citywide Membership
Non-profit
Advocacy and Policy Change
Cross-Site Learning and
Workforce Development
Research and Performance Improvement
Camden Coalition of Healthcare Providers
Camden Health Data 2002 – 2011 with Lourdes, Cooper, Virtua data
• 500,000+ records with 98,000 patients
• 50 % population use ER/hospital in one year
50% of population use the
ER/hospital in one year
1 2
Camden Coalition of Healthcare Providers
Camden Health Data Leading ED/hospital utilizers citywide
• 324 visits in 5 years
• 113 visits in 1 year
113 VISITS 1 YEAR
324 VISITS 5 YEARS
Camden Coalition of Healthcare Providers
Cost Breakdown in Camden
Total revenue to hospitals for Camden residents $108 million per year
• Most expensive patient $3.5 million
• 30% hospital receipts = 1% patients
• 80% hospital receipts = 13% patients
• 90% hospital receipts = 20% patients
Camden Coalition of Healthcare Providers
Primary ED Diagnosis, 2011 PATIENTS VISITS % OF VISITS RECEIPTS
Upper respiratory infections (head colds) 4,092 4,858 16.3% $1,456,464
Sprains and strains 2,980 3,295 11.1% $1,159,452
Contusions 2,561 2,786 9.4% $837,132
Abdominal pain 1,986 2,318 7.8% $926,239
Skin and subcutaneous tissue infections 1,717 2,213 7.4% $673,115
Urinary tract infection 1,892 2,182 7.3% $720,050
Back pain 1,484 1,735 5.8% $517,997
Asthma 1,058 1,580 5.3% $675,230
TOTALS 65,992 ~$29 million
Camden Hospital Utilization
2011 Snapshot
Potentially Avoidable Hospitalizations
• Addiction
• Advocacy & Activism
• Benefits & Entitlements
• Education and
Employment Connection
• Family, Personal, Peer
Support
• Food and Nutrition
Support
• Health Maintenance,
Management, and
Promotion
• Housing &
Environment
• ID Support
• Legal Assistance
• Medication and
Medical Supplies
• Mental Health
Support
• Provider Relationship
Building
• Transportation
Support
• Patient-Specific
Wildcard
PATIENT
Hospital
#1
Sub-Acute
Rehab
Hospital
#2
Home
Nursing
Home
PT/OT
Durable
Goods
Meals
Dialysis
Nephrology
Transplant
PCP
Urology Oncology
Surgery
GI
Cardiology
Optho
Pain
Mgt
Transport
Camden Coalition of Healthcare Providers
Dash-boarding & Score-carding
Standard of Care
Key Outcomes: reduced re-hospitalizations and ED visits in 12 month period following discharge
CCHP’s Care Management RCT
current n = 250 / 800
Clinical Redesign Activities Seven Day Pledge
CATC
34
Clinical Redesign Activities Seven Day Pledge
CATC
35
Clinical Redesign Activities Seven Day Pledge
36
37
Clinical Redesign Activities ACO Incentive Plan
• Practice incentive • $150 payment for each 30 minute post-hospital follow-
up PCP visit within 7 days of discharge
• $100 payment for each 30 minute post-hospital follow-
up PCP visit within 14 days of discharge
• Patient incentive • Cab voucher to and from post-hospital follow-up PCP
visits for patients (given at hospital bedside)
• $20 Visa gift card for patients upon completion of post-
hospital follow-up PCP visit (if within 14 days)
• Other incentives • Patient satisfaction surveys $500
• 2 practice work sessions $1,000
• 4 quality improvement dinners (provider/staff
incentivized)
• Approved QI plan $2,500
Why is saving
money so hard in
healthcare?
Effective vs Efficient
Fountain of Youth Discovered
in Doylestown, PA
Effect of a Community-Based Nursing Intervention onMortality in Chronically Ill Older Adults: A RandomizedControlled Trial
Kenneth D. Coburn*, Sherry Marcantonio, Robert Lazansky, Maryellen Keller , Nancy Davis
Health Quality Partners, Doylestown, Pennsylvania, United States of America
Abst ract
Background: Improving the health of chronically ill older adults is a major challenge facing modern health care systems. Acommunity-based nursing intervention developed by Health Quality Partners (HQP) was one of 15 different models of carecoordination tested in randomized controlled trials within the Medicare Coordinated Care Demonstration (MCCD), anational US study. Evaluation of the HQP program began in 2002. The study reported here was designed to evaluate thesurvival impact of the HQP program versus usual care up to five years post-enrollment.
Methods and Findings: HQPenrolled 1,736 adults aged 65 and over, with one or more eligible chronic conditions (coronaryartery disease, heart failure, diabetes, asthma, hypertension, or hyperlipidemia) during the first six years of the study. Theintervention group (n = 873) was offered a comprehensive, integrated, and tightly managed system of care coordination,disease management, and preventive services provided by community-based nurse care managers working collaborativelywith primary care providers. The control group (n = 863) received usual care. Overall, a 25% lower relative risk of death(hazard ratio [HR] 0.75 [95% CI 0.57–1.00], p = 0.047) was observed among intervention participants with 86 (9.9%) deaths inthe intervention group and 111 (12.9%) deaths in the control group during a mean follow-up of 4.2 years. When covariatesfor sex, age group, primary diagnosis, perceived health, number of medications taken, hospital stays in the past 6 months,and tobacco use were included, the adjusted HR was 0.73 (95% CI 0.55–0.98, p = 0.033). Subgroup analyses did notdemonstrate statistically significant interaction effects for any subgroup. No suspected program-related adverse eventswere identified.
Conclusions: The HQP model of community-based nurse care management appeared to reduce all-cause mortality inchronically ill older adults. Limitations of the study are that few low-income and non-white individuals were enrolled andimplementation was in a single geographic region of the US. Additional research to confirm these findings and determinethe model’s scalability and generalizability is warranted.
Trial Registration: ClinicalTrials.gov NCT01071967
Please see later in the article for the Editors’ Summary.
Citat ion: Coburn KD, Marcantonio S, Lazansky R, Keller M, Davis N (2012) Effect of a Community-Based Nursing Intervention on Mortality in Chronically Ill OlderAdults: A Randomized Controlled Trial. PLoS Med 9(7): e1001265. doi:10.1371/journal.pmed.1001265
Academic Editor: Carol Brayne, University of Cambridge, United Kingdom
Received March 9, 2011; Accepted May 29, 2012; Published July 17, 2012
Copyright : ß 2012 Coburn et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This study was funded by Health Quality Partners, provided by the U.S. Centers for Medicare and Medicare Services (CMS) through a cooperativeagreement with HQP to provide care coordination services as part of the conduct of the Medicare Coordinated Care Demonstration (MCCD). CMS and itscontracted evaluator, Mathematica Policy Research, Inc. (MPR) had a significant role in the overall conduct and evaluation of the MCCD, but neither had any rolein the data collection, analysis, decision to publish, or preparation associated with this manuscript.
Compet ing Interests: All authors are paid employees of Health Quality Partners, a nonprofit health care quality research and development organization.
Abbreviat ions: CMS, Centers for Medicare and Medicaid Services; HQP, Health Quality Partners; HR, hazard ratio; MCCD, Medicare Coordinated CareDemonstration; MPR, Mathematica Policy Research, Inc.
* E-mail: coburn@hqp.org
PLoS Medicine | www.plosmedicine.org 1 July 2012 | Volume 9 | Issue 7 | e1001265
• 1,700 adults over 65 over 10 years
• Randomized study run by Mathematica begun in 2002
• Part of a Medicare Coordinated Care Demonstration Project
• 25% lower relative risk of death (9.9% vs 12.9%)
• Highest risk patients 48% reduction in death rates
• 33% reduction in hospitalization
• 22% reduction in total cost to Medicare
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