The Care One Program

Douglas Binder, M.D., Medical DirectorThe Care One ProgramUniversity of New Mexico Hospital

March 7, 2008

What is Care One?

• An innovative program that targets high risk patients and actively manages their care

• Based on models tested and validated at other institutions

• Involves intensive outpatient case management • An exchange of case management hours for bed days

• Making an individualized care plan that can be carried out effectively

The Care One Patient

• At highest statistical risk of clinical deterioration within the near term

• Can be predicted• Interventions can be made• Can be potentially prevented

The Care One Patient

• One or more serious medical issues • Episodically attended to• Usually requires admission to sort out • Falls through cracks again following discharge

• Challenging social situation• Uninsured • Marginal housing

• Mental Health issues• Depression• Anxiety• Psychosis

• Substance abuse issues• Drugs• Alcohol

Stabilizing these patients makes sense for the Health Science

Center!

Care One patients represent 1% of the total UNMH population but consume about 20% of the resources

• Average cost to UNMH: > $100,000/year• Average bed days at UNMH: 27

What we are doing

• We provide services and oversight • These are our patients• It makes sense to manage these patients• It makes sense to have ongoing UNM HSC oversight

• We maintain an ongoing active partnership• With the patient• With community health resources

Care One today

• Started in Spring, 2004• Put on hold for variety of reasons

• Program resurrected and fully operational as of February, 2006

• 4 health care professionals• Medical assessments

– Douglas Binder

• Coordination of services– Duly Arenivar

• Case Management– Daniel Nagera

• Psychosocial assessments– Cynthia Goldblatt

What is Care One doing?

• Patient A

• Patient B

• Patient C

Patient A

• 69-year-old female

• DM, CHF, in wheelchair from stroke, on dialysis, recent gallbladder operation

• Housing situation• Came from Zapoteca with husband 8 years ago• Legal residents• 4 children here, some US citizens• Move from house to house, every few weeks or few

months

Patient A

• Gets dialysis at the DCI every other day

• Husband wheels her home afterwards

• No PCP

• No money

• No social services

• Episodic involvement with various social workers and various clinics over the years

Patient A

• Potential eligibility• Disabled and Elderly Waiver• Medicaid• Medicare• SSI• Food stamps• General Assistance• American Kidney Foundation funds• Transportation

• Needs PCP• Needs constant monitoring

Patient A

• PCP• Spanish speaker at Senior Health

• Connections with various social services, and follow through

• Home visits

• Her care is being managed so that she does not come to UNMH in crisis

Patient B

• 72-year-old male from Cuba• Living and working here since 1960s• Bad heart disease, with <20% EF

• Valve replacement• Pacemaker • On multiple medications

• Loosely affiliated with FP and Cardiology clinics

Patient B

• Living in a car

• No medicines

• No appointments at UNMH clinics

• No papers at all• Residency status unclear

Patient B

• Housing• Emergency temporary housing• Permanent housing

• Reliable transportation to and from UNMH• Medications• Clinic appointments• Citizenship• Medicare

Patient C

• 45-year-old gentleman with diabetes• Multiple admissions to UNMH

• Diabetes • Infections

• Admitted November, 2007• Diabetes out of control• Bone infection• Amputation and prolonged antibiotic treatment

• Discharged with excellent plan• Transportation arranged• Medications arranged• Good follow-up

Patient C

• Winds up on Care One list

• We schedule an appointment• Patient does not show

• We schedule an appointment• Patient does not show

• We schedule an appointment• Patient does not show

One definition of mental illness

Doing the same thing over and over again and expecting a different result

Patient C--the home visit

• Small trailer on the outskirts of town• Multiple family members

– Some with multiple amputations

• Past the bus lines• No car• Rely on friend in the East Mtns for transportation

• No medicines

• No social services

• Unaware of any follow-up appointments

The “plugging in” of Patient C

• Transportation

• Social services• Not just for patient, but for other household members

• Medications

• Follow-up appointments• Diabetes education• Diabetes clinic• Wound care• Primary Care

Patient C

• Despite our very best efforts…….

Change in UH charges

UNMH Charges for All Patients Activated Before 7/31/07Before and After Intervention by Month

R2 = 0.7113

(400,000.00)

(200,000.00)

0.00

200,000.00

400,000.00

600,000.00

800,000.00

1,000,000.00

1,200,000.00

1,400,000.00

1,600,000.00

1,800,000.00

UNMH Charges for All Patients Activated Before 1/31/07Before and After Intervention by Month

R2 = 0.5684

(200,000.00)

0.00

200,000.00

400,000.00

600,000.00

800,000.00

1,000,000.00

1,200,000.00

1,400,000.00

-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12

Change in UPA charges

UPA Charges for All Patients Activated Before 07/31/07Before and After Intervention by Month

R2 = 0.4599

0.00

50,000.00

100,000.00

150,000.00

200,000.00

250,000.00

300,000.00

350,000.00

400,000.00

450,000.00

-6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6

UPA Charges for All Patients Activated Before 1/31/07Before and After Intervention by Month

R2 = 0.4169

0.00

50,000.00

100,000.00

150,000.00

200,000.00

250,000.00

-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12

Change in Admissions

Number of Inpatient Admissions for All Patients Activated Before 07/31/07Before and After Intervention by Month

R2 = 0.6532

0

5

10

15

20

25

30

35

40

45

-6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6

Number of Inpatient Admissions for All Patients Activated Before 1/31/07Before and After Intervention by Month

R2 = 0.7216

-5

0

5

10

15

20

25

30

-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11

Change in ED Visits

Number of Emergency Room Visits for All Patients Activated Before 07/31/07Before and After Intervention by Month

R2 = 0.7285

0

5

10

15

20

25

30

35

40

45

-6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6

Number of Emergency Room Visits for All Patients Activated Before 1/31/07Before and After Intervention by Month

R2 = 0.5423

0

5

10

15

20

25

30

35

-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12

How UNMH benefits from Care One

• Prevention of unnecessary hospitalizations• Potential retro-billings of $3.6 million via

Medicaid and Medicare• Collections tend to be about 1/3 of billings• These are patients who are difficult to track down and

difficult to work with • Huge expenditure of energy• Need to work with business office more closely

The future of Care One

• Controlled expansion of the program• Expand patient population served by Care One• Expand our mental health services• Use community health workers for home visits• Pharmacy waivers• Transportation issues

#1 on our “wish list”

The Sunday NY Times ''Without Health Benefits, a Good Life Turns Fragile'’ (March 5, 2007)

To the Editor:

I am the medical director of a small program that focuses on uninsured and medically fragile patients. Most of my patients are impoverished. Those who are not are struggling. Some used to be what we refer to as middle-class.

When I ask, ''What is your most pressing problem?,'‘ I am invariably told that it is lack of money. The illnesses come second.

My patients cannot afford their medications or the co-payments for doctor visits and tests. They pick and choose among their options, and some do not choose wisely. I work with a social worker, an assistant case manager and a mental health counselor to try to repair the lives of these individuals and their families, and arrange things so that they do not have to make these choices.

I am fortunate to be working for an organization that is committed to this goal. I would like to think that we, as a society, are committed to this goal.

Douglas Binder, M.D. Albuquerque, March 5, 2007

The writer is medical director of Care One, University of New Mexico Hospital.

end presentation

Care One