cabin creek
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Craig Robinson, MPH
Amber Crist, MS Cabin Creek Health Systems
Creating a Senior Medical Home
Becoming as Complex as our Patients
Cabin Creek Health Systems
Craig Robinson, MPH
Amber Crist, MS
Cabin Creek Health Systems An FQHC with 4 Centers in
central West Virginia.
14,000 annual users
2,259 Patients 65 and older
65 – 74 = 1,298
75 – 84 = 711
85 years and older = 250
Implemented Electronic Health
Record in 2008
Affiliated with the Central
Counties Area Health Education
Center
Implemented Senior Medical
Home in 2009
Cabin Creek Health Center -- Dawes, WV
An organization is a conversation before it is anything else: it begins with people talking together about something they would like to do that is beyond
their capacity to do as individuals. Anthony Suchman
Leading Change in Healthcare
Let’s Start-- With Some Conversations
CMS, under Don Berwick, is promoting the Triple Aim: improve the individual patient experience, improve the health of populations, and lower cost.
What are the issues in your community or organization that are barriers to meeting the triple aim for the elderly?
Group Issues
Why focus on elders?
We had…
A problem (high hospital use by seniors).
Some money (Claude Worthington Benedum Foundation, AHEC).
Some interest (medical staff struggling alone with complex elderly patients, PACE project failed)
Some expertise (consulting geriatrician, consultant researchers, AHEC leader)
Some maps. (the Medical Home model, COPC, SoC)
The Problem: Dartmouth Health Atlas
Hospital discharges per 1,000 Medicare enrollees (overall 2005)
http://www.dartmouthatlas.org/
Charleston, WV
HRR = 117.0
http://www.dartmouthatlas.org/
Medicare Discharges for ACSC per 1,000 - CY2005
What’s Behind the Numbers? Complexity
Our Patients are Complex
Elderly Patients are Complex
Multiple chronic conditions
Functional and cognitive variation
Many, many medicines – opportunities for harm/waste.
Multiple medical providers – minimal coordination.
Fat complicated medical records – error prone.
PCP not told important stuff – i.e. hospital stays, ED visit...
Behavioral health conditions not discovered, not treated.
Gaps in patient/family health knowledge
Big variation in home/family support
Ambiguity over end of life care – family disagreements
And – Primary Care Health Organizations are Complex
There is a continuous flurry of diverse demands facing the staff
AND
There is a Culture – “How we do things around here.” Culture develops through staff interactions and relationships. It is Emergent.
A common aspect of primary care culture – “We are already overloaded and you want to add what?”
BUT - Our Care Model was Simple
Problems Can be Simple, Complicated or Complex AND
“Disasters can occur when complex issues are managed or measured as if they are merely complicated or simple.” *
*Brenda Zimmerman, Getting to Maybe. 2006
Mann Gulch, on the Missouri River
(138 miles east of Missoula, MT)
History of Learning from
Mann Gulch
August 1949 – Mann Gulch Forest Fire
and Disaster
September 1993 – N. Maclean’s book,
Young Men and Fire
December 1994 – Karl Weick’s article,
The Collapse of Sensemaking at Mann
Gulch
December 1999 – Dr. Berwick’s IHI talk,
The Escape Fire.
(and now Don Berwick takes the
lessons from Mann Gulch to CMS)
Some of Weick’s Lessons from Mann Gulch --
Four Sources of Resilience for Organizations ALSO: Required for Medical Homes
1. Improvisation and Bricolage (creating with what you have).
2. Virtual Role Systems (carrying the team’s roles in your head).
3. The attitude of Wisdom - (understand we don’t fully understand what’s happening.)
4. Respectful Interaction – (showing trust, honesty and self-respect.)
Characteristics of Useful Conversations
Listening and Talking
Structure that invites input
Diversity in the group
Learning from stories
Take note of ideas and of action steps
Sources of
Resilience/
Effectiveness
Actions Promoting
Transformation to
Medical Homes at CCHS
Improvisation /
Bricolage
o Staff involved in continuous design of the set of services, the tools, the reporting
and the training.
o Diverse staff members participate in program assessment and planning meetings.
Virtual Roles o New roles are defined by planning groups for MAs/nurses, pharmacist, behavioral
health, care coordinator, patients.
o Medical providers/leaders respect new (expanded) roles.
Attitude of
Wisdom
o Staff determine their gaps in knowledge and skills and help to decide content of
training.
o Regular staff meetings at the clinics to review progress (data) and problems.
o Outside experts invited to give different perspectives.
Respectful
Interaction
o Enlarged the team boundary and created processes for sharing patient care
information among team members.
o Referrals and requests flow back and forth among all team members.
o Leaders model norms of effective communication and cooperation.
o Rules for meetings: Listen and talk; agendas and minutes, everybody invited to
talk/share.
Rather than planning a long series of steps in advance and getting anxious when things start to go off course, we can just plan one step at a time and pause after each
one to notice what’s happened and only then plan the next step. The plan emerges as we go.
Anthony Suchman
Leading Change in Healthcare
When we got going, the conversations
focused on: PORT3 AL
Population (who are we working with)
Objectives (what are our aims)
Relationships (With patients/staff/resources)
Tasks (how do we do it)
Training (how do we do it)
Tools (how do we do it)
Administrative (what support is needed)
Logic (why will it work?)
Developed by C. Robinson, Cabin Creek Health Systems
Senior Medical Home – 2 Populations - Frail Elders = 100
- Risk of Falls and Meet 3 of the 5 criteria
- Low physical activity
- Exhaustion
- Unintentional Weight Loss
- Failed Time Walk Test
- Failed grip strength
- Multiple Chronic Conditions = 540
- Patients with diabetes and at least one other chronic condition
Senior Medical Home - Objectives
Describe the population in terms of health issues and health status.
Patients and caregivers are highly satisfied with their care.
Minimize re-hospitalizations.
Improve adherence to clinical standards for chronic conditions and preventive measures.
Minimize adverse drug events.
Improve the experience for the medical staff.
Who’s on the Team - Relationships Medical Provider
Medical Assistant Administers screenings, tests, and preventive care review
Behavioral Health Consultant Address behavior change issues related to health risks to serious
mental illness, arrange for the next level of care if needed
Care Coordinator Patients main point of contact
Pharmacist Conducts drug utilization reviews for patients at risk for adverse
drug events
Tools Teams create, apply, and redesign the tools. This is
achieved by experience and conversation
The GCT reviews and endorses tools.
The Clinical teams actually apply the tools and give feedback about their usefulness and feasibility
POV and Assessment forms
Electronic Surveys
Patient Registry and templates in the EMR
Computer Notification of Hospitalization –“real time”
Training
Topics covered included:
Common geriatric medical conditions and preventive measures.
Communicating
Medication Review/Falls Prevention
In home risk assessments
Connecting with community resources
Partnered with a local Community College to design a 15
week college credit course
References – Logic Journal Articles
Anderson, R. & McDaniel, R. Managing health care organizations: where professionalism meets
complexity science. Health Care Management Review. 2000; 25(1): 83 – 92.
Boult, C., Counsell, S., Leipzig, R., & Berenson, R. The urgency of preparing primary care physicians
to care for older people with chronic illnesses. Health Affairs. 2010; 29(5): 811 – 818.
Fried, L., Tangen, C., Walston, J., Newman, A., Hirsch, C., Gottdiener, J., Seeman, T., Tracy, R., Kop,
W., Burke, G., & McBurnie, M.A. Frailty in older adults: evidence for a phenotype. Journal of
Gerontology. 2001; 56A(3): M146 – M156.
Jordan, M., Lanham, H., Crabtree, B., Nutting, P., Miller, W., Stange, K. & McDaniel, R. The role of
conversation in health care interventions: enabling sensemaking and learning. Implementation
Science. 2009; 4 (15): 25 – 38.
Lanham, H., McDaniel, R., Crabtree, B., Miller, W., Stange, K., Tallia, A., Nutting, P. How improving
practice relationships among clinicians and non-clinicians can improve quality in primary care. The
Joint Commission Journal on Quality and Patient Safety. 2009; 35(9): 457 – 466.
Nelson, K., Pitaro, M., Tzellas, A., & Lum, A. Transforming the role of medical assistants in chronic
disease management. Health Affairs. 2010; 29(5): 963 – 965.
Nutting, P., Miller, W., Crabtree, B., Jaen, C., Stewart, E., & Stange, K. Initial lessons from the first
national demonstration project on practice transformation to a patient –centered medical home.
Annals of Family Medicine. 2009; 7(3): 254 – 260.
Pham, C. & Dickman, R. Minimizing adverse drug events in older patients. American Academy of
Family Physicians. 2007; 76: 1837 – 1844.
Tallia, A., Lanham, H., McDaniel, R., & Crabtree, B. Seven characteristics of successful work
relationships. Family Practice Management. 2006: 47 – 50.
Parkerson, G., Broadhead, W., & Tse, C. The duke health profile: a 17 – item measure of health and dysfunction. Med Care . 1990; 28(11): 1056 – 1072.
References – Logic Websites The Plexus Institute – http://www.plexusinstitute.org
An organization that is dedicated to fostering the health of individuals, families, communities,
organizations, and our natural environment by helping people use concepts emerging from the new
science of complexity.
The Dartmouth Atlas of Health Care - http://www.dartmouthatlas.org/
The project uses Medicare data to provide information and analysis about national, regional, and local
markets, as well as hospitals and their affiliated physicians.
Books Weick, K. + Sutcliffe,K. (2001). Managing the unexpected: assuring high performance in an age of
complexity. San Francisco, CA: John Wiley & Sons.
ROI for the Health Center
Job enhancement for Medical Assistants. Opportunity for more learning and independence.
Increase job satisfaction for primary care provider.
Builds community support for the health center.
Team members learn a systems approach to understanding problems and solutions – carries over to other problems.
Preparation for Health Reform - Medical Homes and Accountable Care Organizations
The Money is Coming…… Affordable Care Act Initiatives that Provide Resources
for Care Coordination
Accountable Care Organizations
Medicaid Health Home Initiative with enhanced federal match
FQHC Advance Primary Care Demonstration Project
CMS Healthcare Innovation Challenge Programs
Community Care Transition Programs
Closing Conversation
What resources do you have in
place that could be used to improve
the care of your elderly patients?
What can you build upon?
QUESTIONS
Senior Medical Home – Numbers
Currently 640 patients enrolled
Avg age 82, 74% female 87% Diabetic 90% Hypertension 68% Heart Disease 42% Chronic Pain 56% Psychiatric Diagnosis
Drug Utilization Reviews Completed Avg # meds in the
beginning = 10.3 Avg # of meds today = 8.1
263 home visits 3,120 care coordinator
contacts 10 ramps built 84 grab bars installed 30 trips to visit patients in
the hospital Linking patients with
outside resources Educating all about health
care reform
Limiting Our Focus – Frailty Patients identified as frail have a significantly higher
health service and hospital use compared to those adults the same age who are not considered frail.
Presence of three or more of the following components Weight loss
Weakness
Poor endurance and energy
Slowness
Low physical activity
Fried, L., et al. Frailty in older adults: evidence for a phenotype. Journal of
Gerontology. 2001; 56A(3): M146 – M156.
Our Team’s Definition of Frailty Risk of falls – determined by the provider
AND
Patient meets 3 of the 5 following criteria:
Low physical activity
Exhaustion
Unintentional weight loss (≥ 10 pounds in last years)
Failed timed walk test (≥ 7 seconds to walk 15 feet)
Failed grip strength (based on BMI)
Enrolled first frail patient April 2009
Two kinds of Teams—First Team
Geriatric Project Development Team (reps from the 4 clinics):
Providers
Medical Assistants
Pharmacist
AHEC facilitator
Consulting Geriatrician
Care Coordinator
Behavioral Health Consultant
Two kinds of Teams – Second Team Care teams at each of 4 clinic sites.
Composed of those doing the work at each site.
Medical Provider
Medical Assistant (trained in geriatric care)
Care Coordinator (shared)
Pharmacist (shared)
Medical Assistants Tasks
Administer screenings, tests, and preventive care review – at routine PCP visits.
Conducted quarterly home visits – ck risk for falls, med reviews, education
Regular phone call check-ins with enrolled patients.
Made referrals to Care Coord.
Completed notes in the Electronic Health Record
Geriatric Care Coordinator Tasks Develop working relationships with outside
resources.
Telephone resource for care givers – for benefits, legal issues, medications, access to medical care.
Link patients with health center services
Contact hospitalized patients - in person or by phone and arranges follow-up PCP visit.
Enter notes and data in the EMR.
Pharmacist Tasks Review patient medication list against standard criteria:
1. Reviewed accuracy of medication list
2. Beers Criteria: i.e. to identify drugs with potential for adverse outcomes in older patients.
3. Hamdy Review: Still indicated?
Duplication?
Prescribed for adverse reactions?
Is Dosage subtherapeutic or toxic due to age or renal status?
Possible Drug-Drug interactions?
4. Lower Cost options available?
Assessing for Frailty Patient assessed during
regular primary care visit
Duke Health Profile
Vulnerable Elders Survey
Timed walk test
Grip strength assessed with a dynameter
Duke Health Profile Clinically valid instrument Reference values for
primary care patients 66 – 92
User friendly, self administered
Questions relate to events of the past week – easy to remember
Responsive to real change in health related quality of life
Items are generic, not disease specific
Duke Health Profile – Data
Variables Baseline 8 Months CCHS Norm
National Norm
*Physical Health
19.7 26.8 42.5 49.9
**Anxiety-Depression
51.5 61.3 33.8 26.3
*Higher the score the better
**Lower the score the better
73 patients enrolled over 8 months
Average Age = 79.7
80% Female
Average number of medications = 9.1
63% need assistance with ambulation
60% hospitalized or visited the ER in the previous year
17% have had a fall in the previous year
70% depression/anxiety
52% chronic pain
45% diabetes
20% dementia
85% hypertension
Avg # prescriptions = 9.5
TT
Senior Medical Home
Cost Projection
Total project participants= 200
Personnel Costs
Cost
PMPM
Cost
PMPY
Annual
Cost
SMH Care Coordinator $24.00 $288.00 $57,600
Med Assist (service/training) $17.07 $204.78 $40,960
Pharmacist $7.11 $85.33 $17,070
Medical Director - (physician) $3.56 $42.67 $ 8,533
Total Personnel Costs $51.73 $620.78
Other Expenses
Travel $3.33 $40.00 $8,000
Home safety equipment $4.17 $50.00 $10,000
Administrative overhead
20% $10.35 $124.16 $24,831
Total Other Expenses $17.85 $214.16 $42,831
Total All Expenses $69.58 $834.94 $166,988
PMPM PMPY Project
Annual
Utilization Data Primary Care Visits = 4.6 per patient per year
Medical Home Visits = 2.5 per patient per year
Care Coordinator Contacts = 4.7 per patient per year
Hospital Admission Rate = 719 per 1,000 per year
(Compared to 433.5, Medicare rate for our HRR)
NO patients were re-hospitalized within 30 days of discharge
Emergency Room Visit Rate = 68 per 100 per year
Avg # prescription meds = 9.5 at start, 8.5 after 8 months
ROI – Lessons for Change
Step by step. Build on what we did and what we learned.
Stay with it. Keep talking and listening.
Models are helpful but must customize.
Be mindful of everything else going on in the primary care setting.
“Bricolage” – taking advantage of what we had.