redesigning the safety net
TRANSCRIPT
Presented ByPete Delgado, CEO, LAC+USC Medical Center &
Allen Miller, CEO, COPE Health Solutions June 2009
Redesigning the Safety Net Creative Restructuring of an Un-System into Regional
Integrated Delivery Networks
TopicsBackground – Use Case ScenarioOpportunities for ChangeIntegrated Delivery Network Components– Medical Home Assignment and Patient Flow Redesign
– Provider Practice Redesign– Care Management of Frequent Users
– Information Technology & Patient Information Sharing
– Financing of Care & Network Sustainability– Workforce Development
– Performance Management & Quality Improvement
A New Paradigm of Care – Use Case RevisitedValue
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Background – Use Case ScenarioPatient ProfileLisa D.Black femaleAge: 64Resides in South Los Angeles, works part-time at local grocery store, lives with husband
Health Care Access and Utilization History•No primary care provider or established medical home•Patient is overweight, smokes, and has a history of high blood pressure•Treated 5 years ago for repair of right heart valve•Visited emergency department (ED) 3 times in the past 6 months, complaining of shortness of breath and abdominal discomfort; admitted twice, with an average length of stay of four days-------•Was last taken to emergency department (ED) 3 months ago for extreme shortness of breath and edema•Diagnosed with right heart failure and undergoes treatment•Repeated admissions in the past for same condition suggests failure to adhere to medication regimen and diet restrictions
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Use Case Scenario – Lisa D.
Lisa visits an urgent care center. Complains of
shortness of breath and occasional abdominal
discomfort. Examined by Dr. T
Lisa informs Dr. T of her recent hospitalization; Dr.
T cannot access ED discharge report; continues w/exam
Dr. T diagnoses heart failure, but lacks
information to gauge severity and properly
manage Lisa
Determines that Lisa needs further work-up
and treatment. However, knowing the wait for a specialty appointment averages 6 months,
sends Lisa to ED
After 8 hour wait, Lisa is examined by ED doctor.
Lisa is admitted for further treatment and diagnostic
work-up
Lisa is discharged after 4 days and sent home with
orders to remain on a fluid and salt restricted diet, and is given a complex
medication regimen
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Use Case Scenario – Lisa D.
Lisa continues to have difficulty taking
her meds and adhering to her diet
2 months later, she experiences
recurring symptomsHer husband takes her back to the ED
Cycle Perpetuates
Opportunities for Change
Shift towards primary and preventive model of care
Maximize inpatient capacity
Align financial incentives and ensure parity in health care access and outcomes
Connect public and private sectors
Build and sustain a strong workforce
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Medical Home Assignment & Patient Flow RedesignObjective
Ensure patients have local and easily accessible primary careCoordinate and streamline care between hospital and clinic partners to enable continuity of care
ProcessAssign all patients to Medical HomeIntegrate Medical Home model into clinical operations
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Provider Practice Redesign
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ObjectiveExpand capacity of primary care providers to manage more complex patientsEnhance patients’ Medical HomeIncrease access to specialty care services
ProcessImplement Community Grand Rounds to build collegial relationships b/w Specialists and Primary Care ProvidersEstablish Consensus Care Guidelines and flow processesImplement Mini-Fellowships and phone and chart consultationsDecentralize diagnostics
Over 9,000 patient Medical Homes documented
865 Visits Managed at Community Clinic vs. Medical Center
Over 530 hours of specialty care time avoided
Guidelines completed: Rheumatoid arthritis, chest pain, congestive heart failure (CHF), colorectal cancer screening
630 mobile echocardiograms performed for CDSN clinics
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LAC+USC Camino de Salud Network – Provider Practice Redesign
Care Management of Frequent Users
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ObjectiveReduce disparities in care and drive effective use of resourcesDecrease avoidable, costly Emergency Department and Inpatient utilization
ProcessBilingual-bicultural bachelor-level care managers enroll patients into Care Management Program:– Medical Home Assignment– Systems navigation and advocacy– Patient-centered care plans– Patient empowerment and education
LAC+USC Camino de Salud Network Care Management
Care Management through the Camino de Salud Network– 42 actively managed patients– 56 transitioned/graduated– Program has demonstrated a $5.1 million cost avoidance– Model replicated at Kaiser, LBMMC and Kern County
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Emergency Service Outcomes57.54% Decrease in ED use after 1
year of care management
Inpatient Service Outcomes 54.05% Decrease in Inpatient Bed
Stay after 1 year of care management
ObjectiveEnable secure access to health care information at the point of care Reduce health care costsProvide IT health management tools
ProcessHealth information exchange portalClinic ConnectHealthATM KiosksNaviLinx Care Management Software
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Information Technology & Patient Information Exchange
Data Accessed by
Clinics
NaviLinx
Network HIE
Network HIE
Financial Sustainability
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ObjectiveAppropriately incentivize primary careEnsure providers comply with Network guidelines and meet performance standards as related to processes of patient care
ProcessAdapt the Disproportionate Hospital (DSH) funding scheme and apply it to primary care, reserving DSH funds for primary care providers and facilities w/in IDNsReward and reimburse providers for extra time committed to Provider Practice Redesign model
Workforce Development
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ObjectiveBuild and sustain a strong health workforce pipeline that is culturally and linguistically competent
ProcessFunnel career transition professionals hit by the economic downturn into the health care field where there is job growthExpand education and training capacityPromote interest and commitment to primary care with incentive programs, e.g. practice-based research networks, scholarship and loan repayment Adapt Graduate Medical Education Health Professions reimbursement model
Workforce Development Outcomes
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Nursing Pipeline Implemented since 2000 at 3-Hospital System in Los Angeles
Over 300 active interns contributing 32 FTE each year– Estimated to amount to $520,000 - $640,000 per year
40% reduction in the RN vacancy rate – Estimated cost savings of $4,101,760 on registry alone
Decrease in the new graduate RN attrition rate from 32% to 3% after the third year
Performance Management & Quality Improvement
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ObjectiveEnhance measurement, management and evaluation of strategic objectives, improvement efforts, achievement, outcomes and patient experiencesIncrease transparency
ProcessImplement Balanced Scorecard to:– Transform strategic planning into integral and daily
component of operations– Continuously evaluate internal processes, adherence to
Network guidelines and outcomes– Improve performance
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A New Paradigm in Care Delivery – The Case of Lisa D. Revisited
Patient ProfileLisa D.Black femaleAge: 64Resides in South Los Angeles, works part-time at local grocery store, lives with husband
Health Care Access and Utilization History•No primary care provider or established medical home•Patient is overweight, smokes, and has a history of high blood pressure•Treated 5 years ago for repair of right heart valve•Visited emergency department (ED) 3 times in the past 6 months, complaining of shortness of breath and abdominal discomfort; admitted twice, with an average length of stay of four days-------•Was last taken to emergency department (ED) 3 months ago for extreme shortness of breath and edema•Diagnosed with right heart failure and undergoes treatment•Repeated admissions in the past for same condition suggests failure to adhere to medication regimen and diet restrictions
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Lisa D. Revisited
Lisa flagged as a Frequent User after her latest ED admission and assigned to a Network Care Manager (CM)
Lisa agrees to enroll in Care Management.
Before discharge, CM helps Lisa identify Clinic Y, near her home, as a
Medical Home
Lisa discharged and instructed to follow
medication and strict diet regimen; Outpatient echo
is ordered for follow up
CM helps Lisa get a follow-up appointment at Clinic Y with Cardiology Champion (CC) 10 days
after discharge
CM establishes Care Plan for Lisa, meets with
her weekly—assisting with medication and diet
management
CM goes with Lisa to her first appointment.
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Lisa D. Revisited
As they wait, Care Manager teaches Lisa how to use HealthATM
Kiosk to access her health records and Care
Plan
Nurse Practitioner (NP) looks up Lisa’s medical record through Network
Health Information Exchange Portal
CC follows Consensus Care Guidelines to assist with management of Lisa
CC notes multiple ED visits for recurring heart failure symptoms; Also notes that the ordered
outpatient echo had not been performed
Per guidelines, CC orders echocardiogram through Network Mobile Echo
service
Lisa receives her echo and results are sent to CC
within 2 weeks
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Lisa D. Revisited
Lisa’s echo results are abnormal. CC obtains telephone consultation from hospital specialist
With help of consult, CC establishes a
management plan for Lisa
Lisa receives continued Care Management support and obtains regular care at her
Medical Home
Lisa learns to better manage her heart
condition and transitions out of Care Management
after 6 months
ValueIntegration & StandardizationAlignment of financial incentives to encourage participation in Integrated Delivery NetworkAssurance of equitable access and quality of care
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Table 1: Program Impact on PMPM Medi-Cal Costs
Contacts
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Pete Delgado, CEO, LAC+USC Healthcare [email protected]
Allen Miller, CEO, COPE Health Solutionsamiller@copehealthsolutions.orgwww.copehealthsolutions.org
www.COPEHealthSolutions.org; www.lacusc.org 24
This document is proprietary and confidential to COPE Health Solutions and is protected under the copyright laws of the United States and other
countries as an unpublished work.
Any other reliance or disclosure in whole or in part of this information without the express written permission of COPE Health Solutions is
prohibited, and COPE Health Solutions does not accept any responsibility to any other party to whom it may be shown or into whose
hands it may come.
5/11/2009