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Keeping Patients with Chronic Conditions Out of the Hospital:
Perspectives from a Hospital and a Public Health Agency
• Zosia Stanley, JD, MHA, Policy Analyst, WSHA• Eileen Branscome, RN, COO, Mason General Hospital, Shelton• Joan Brewster, MPA, Director, Grays Harbor County Public
Health and Social Services Department
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• Impact and cost of chronic disease• Zosia Stanley, JD, MHA, Policy Analyst, WSHA
• Hospital perspective• Eileen Branscome, RN, COO, Mason General Hospital, Shelton
• Public health perspective• Joan Brewster, MPA, Director, Grays Harbor County Public Health
and Social Services Department
Speakers
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• Chronic diseases – such as heart disease, stroke, cancer, and diabetes – are among the most prevalent, costly, and preventable of all health problems
• About half of all US adults—125 million people—have one or more chronic health conditions. One in four has two or more chronic health conditions.
• Seven of the top ten causes of death in 2010 were chronic diseases. • Two of these chronic diseases—heart disease and cancer—together accounted for nearly 48%
of all deaths.
• 84% of all health care spending in 2006 was for the 50% of the population who have one or more chronic medical conditions.
The impact and cost of chronic diseases
CDC, Chronic Disease Control and Prevention, May 2014; AHRQ, March 2014.
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Chronic diseases influence overall health
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Chronic disease at a county level
Washington Department of Health, Chronic Disease Profiles by County, 2014
• One in 8 adults have asthma.• One in 6 adults have diabetes.• One in 12 adults have heart disease
• One in 12 adults have asthma.• One in 11 adults have diabetes.• One in 11 adults have heart disease.
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Rising rates of chronic diseases
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Population Health PerspectivePreventionPartnershipsPreservation
Eileen T. Branscome, COO
Mason General Hospital and Family of Clinics
June 2014
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EQUITY
Prevention Management Promotion Medical Care
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Prevention & Promotion
SocialEconomic
Environment
LifestyleBehaviorsResilience
GeneticsPhysiological
Interventions
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Management & Medical Care
QualityHealth Status
Intermediate
Outcomes
Disease & Injury
Interventions
Health & Functionality
Well Being
Better Health
Progression & End of Life
Care Coordination
Care ManagementA Good Death
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Shared Responsibility
•Interventions & Outcomes▫Public health▫Health care delivery▫School systems▫Social services▫Employers▫Individual behaviors and choices
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Better Health
Better Care
Lower Cost
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Break the Vicious Cycle
Health deteriorates
Emergency Services
Acute Hospitalizati
onDischar
ge
Environment Social Economic
No Access
Provider Coverage Resources
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Prevention & Management Diabetes
Pre-Diabetes Clinic• Education
▫ Benefits of walking (30” five days/week)▫ How the body breaks down sugar▫ Reduces risk: T2DM,stroke, MI, stress▫ Lowers BP & HDL▫ Increases circulation, energy▫ Improves sleep
• Monitoring – A1C, health status, lifestyle, nutrition, activity
Diabetes Wellness Center• Living well with diabetes• Simple to complex care coordination• Education – Support – Monitoring – Interventions - Advocacy
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Employee
Wellness
Chronic
Disease
Managemen
t
Self care and
family health
Active
Lifestyl
e
Preventio
n/ Annual
check up
with PCP
Referred to
DWC
AIC (labs
) high
Child – N
ot Diabetic
Prevention
/ Annual
check up with
MVW
C
Information Sharing
Spouse - Diabetic
Patient’s Story
High Blood
Pressure
Diabetes Education Class
Hypertension Education
Stress Management
Pre-diabetic
Assessment
Active Lifestyle
Active Lifestyle
Nutrition/Diet
Changes
Nutrition/Diet
Changes
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Outcomes• Improved Health
▫A1C from 9 4▫BP 168/81 130/78
• Reduced Stress• Improved Well Being
• Small significant lifestyle changes• Move more, eat healthier
• Environmental change• Room to roam and play• A family affair
• Improved nutrition- weight loss [child & parent] Reduced rice and fast food intake Increased vegetable intake
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Complex Diabetic PatientMultiple Chronic Disease Processes
•Care Coordination▫Internal and external providers and teams▫Community resources▫Advocacy- needs not covered by health plan ▫MGHFC intervention-equipment & supplies
starting June 16, 2014
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2013 Admissions
Emergency OnlyER to ObsER to Obs to Inpt.ER to Inpt.Planned Admits
2014 Admissions through June 4, 2014
Emergency OnlyER to ObsER to Obs to Inpt.ER to Inpt.Planned Admit Obs
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Stroke Prevention – TIA Clinic• Access to services in our local community• Telemedicine & early interventions• Collaboration with tertiary stroke center• Care Coordination: Primary care and specialists• Personal connection & education
• Preliminary Outcomes▫Small lifestyle changes – diet, activity, smoking▫Positive personal experience-caring & concern▫Health Status – No progression to stroke in 12 of
13 individuals
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Chronic DiseasesCare Coordination & Care Transitions• Risk assessment • Coordination
▫ Follow up medical care and plan• Coaching
▫ Treatment plan, health status, medication management, support
• Care Transitions▫ Warm hand over
• Communication▫ Electronic health record
• Community resources • Coverage by health plan• After-hours access to clinics
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Oct Nov Dec Jan Feb0
2
4
6
8
10
12
14
16
18
Readmission Comparison
201220132014
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ED Care Coordination Project• ED, clinics, coordinators, providers, community• EDIE – emergency department information
exchange▫Care guidelines, pain management contracts▫ Intervention, narcotic and visit history▫Behavioral health connection▫Connection, communication, primary care follow up▫Education, information sharing▫Coordination with health plan and MGH
coordinators▫Re-direct to clinic after triage▫Community resource connections
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Mental Health• Tele-psychiatry pilot – non-urgent patients
▫Familiar private setting – primary provider team ▫Timely access▫ Integrated treatment plan ▫Combine with other resources [chemical
dependency, BHR (limited services), others]• Results so far
▫30 patients ▫4.1 overall satisfied (five point scale)▫Medication management▫Spread to other primary care locations
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MGHFC Approach• Align vision and priorities with Community Needs Assessment
▫ Access to Primary Care and coverage [Apple Health, QHP, Health Plans]▫ Communication [Electronic Health Record]▫ Connectivity [personal connection-caring, concern, compassion]▫ Relationships
• Patients First-Always▫ Caring for our community in our community
Coordination Specialist referrals Telemedicine Expanded hours and services
• Community Partners ▫ Mason Matters▫ Health Department▫ School System ▫ Sub-Acute settings▫ Local employers
Outcome: Community Health Ranking improved from 39th in 2005 to 35th in 2013
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Contact Information and References
Contact Information:Eileen T Branscome, COO
References:• Population Health in the Affordable Care Act Era, Michael A. Soto,
Ph.D., AcademyHealth, February 2013• IHI Innovations Series 2012• IHI Triple Aim, 2013• Center for Medicare and Medicaid Innovation• County Health Rankings• Beating Diabetes with Exercise, Catherine McHugh, ARNP
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Chronic Disease Self-Management
Strategies for Building a Community-wide Program
Joan Brewster, MPADirector, Grays Harbor County Public
Health and Social Services [email protected]
360-500-4062
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What is “CDSM”?
• Evidenced-based Course– Stanford Patient Education Research Center.
Kate Lorig, et. al.
• 6 weekly classes, 2.5 hours• Standard Curriculum
– “Lay Leaders”, Licensed
• General, Diabetes, or Pain
“The class was the best one I have been to…”
“Helps you to learn how to help yourself do better”
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Value For Hospitals
• Discharge planning• Care coordination• Reduce readmissions• Community Benefit• Reduce extra ER visits• Patient engagement • Provider support
Self- managing for
Better Health
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• A coalition of five community agencies
• A commitment to: – Coordinate Efforts – Share the Load – Sustain Over Time
• Mutual effort to seek a revenue source and sustain the program
Agency on Aging Health Department
Hospital Community Action Program
Community Health Clinic
About Our Program
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Our Motivation
If we bring this program to scale, can we change this picture?
• Worst health status statewide
• Hospitalization and death rates are high
• Huge and costly burden of chronic disease
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Our Aims
Create and sustain a community condition in which:1. CDSM Programs are
commonplace 2. Access is easy; no cost to
the participant3. Health providers routinely
refer participants
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Strategy 1: Get Organized
Creating a Coalition made this work more powerful than separate, disconnected efforts.
– Joint marketing, brochure, media, newsletters– One registration phone line – Coordinated training for Lay Leaders, Master Trainers and
special topic courses (diabetes, pain, Tomando.)
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Strategy 2: Year-Long Calendar • Advance commitment
means people can count on us.
• Primarily for providers, but worked great for all others.
• Each brochure has a long shelf life.
Posters and tear off cards also used. (Not prescription pads or stamps.)
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Strategy 3: Provider OutreachWe have used all of the following. CDC materials were very helpful, saved time.
– Blast fax– Brochures delivered in person– Request posters be placed in exam,
waiting rooms– Letter from Health Officer– Cards in MD boxes at hospital
Limited success: Necessary, but not sufficient
Best results: – Stand up meetings with MDs before
practice opens– Accompanying drug reps, taking lunch– Repeat, repeat, repeat…
Grays Harbor Community Hospital Staff are Leaders and Master Trainers
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Strategy 4: Participants as ‘Marketeers’
Direct Marketing to Providers – with a twist:• Participants inform their
providers, take materials, write and deliver letters
• Providers listen well to patients, peers
• Personal stories carry the most weight
“My personal physician…suggested I join the
workshop and I will be forever indebted to her for
doing so…”
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Strategy 5: Involve Health Plans
Invited Medicaid Health Plans to attend a Coalition Meeting
All 4 Plans gave a short summary of their services: Individual support. Disease management and case management, using telephone contact. No group contact. No local contact.
Health plan staff were unaware of the availability and efficacy of community based classes.
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Strategy 5 - Plans: It’s working…• Agreed with Plans that we could
maximize impact by:– Learning how to coordinate
individual case management with community offerings
– Having Plans influence providers through marketing, reporting requirements, data point feedback
• Future? Direct marketing to enrollees by Plans
• Funding from Plans? Reduces enrollee health care costs
“…to submit a written proposal along with an
invoice, to Coordinated Care for
sponsorship…”
May 14, 2014 email:
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Additional Strategies
• Purchased news ads• Free “Senior” columns• Radio shows • Senior meal sites• Civic group talks• Five agency leaders and
staff talking about CDSMP-- always have brochures in hand.
• Next: Faith communities, behavioral health centers
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Results Year Workshops Participants: 280
2011 5 75
2012 10 69
2013 8 95
2014 12 (41 by May)
Facilitators Trained :
41 (2011- present)
Year MD Referrals
# MDs
2012 5 3
2013 8 3
2014 14 5
Workshop Types:
Regular, Diabetes, Pain Management
Special classes for Behavioral Health clients
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Results – Typical Post Class Surveys
In general, how effective have you found this program in helping you manageyour chronic condition? Excellent 100%
I found the approach used to present “Living Well With Chronic Conditions” extremely effective and interesting.Strongly Agree 100%
I would recommend this program to others:YES 100%
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Typical Post Class Comments “I lost weight, have more energy”
“Helped me to manage & learn about my Diabetes”
“Very informative” “Excellent information”
“It is very beneficial and I learned a lot”
“Because it tells true feelings of what Diabetes is”
“Active, laugh, positive thinking, slow down, ways to be optimistic”
“Get more walking and completing more of my projects”
“Action plans and goal setting; weight loss”
“Better eating, better confidence, worthiness”
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Questions?
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Thank you!