Impacts of a High Touch Intervention on an Super Utilizing Disabled - - PowerPoint PPT Presentation

SLIDE 1

Utilization and Cost Data a) b) c)

Figure 1. Comparison of patient’s cost utilization (a,b) and healthcare encounter distribution (c) 18 months pre-intervention and 18 months post-intervention. Billing data taken from Cooper University Hospital and Virtua Hospital receipts via Camden Health Information

• Exchange. Health care encounters defined as any instance the patient visited a health care

setting on a unique date. All encounter data taken from Camden Health Information Exchange.

No Accommodation for Patient Disability

• No interpreters at

appointments

• Lead to

miscommunications

Fragmentation of Medical Records

• Inconsistent medical

records across institutions

• Unclear medical

history for providers

Lack of Necessary Resources

• No medical

transportation

• Unable to receive or

request medication refills.

.

Impacts of a High Touch Intervention on an Super Utilizing Disabled Patient Over 18 Months

Joshua Lee (BA) and Mary Kate Roccato (BS), Health Coaches Camden Coalition of Healthcare Providers; Camden, NJ

Debbie Hill is a 56 year old diabetic patient who is hard of hearing. Previously, Debbie’s disability and lack of family support prevented her from receiving the proper care. When we met Debbie, she was unable to afford her medications and she did not understand her diagnoses. After much progress, she has graduated from our Super Utilizer panel. Debbie is currently working with us on managing her diabetes.

Pre-Intervention

Driving diagnoses

• Hearing loss
• Osteoarthritis, Degenerative Joint

Disease, chronic pain

• Type II Diabetes Mellitus
• Asthma
• Morbid Obesity
• History of nephrectomy, chronic

renal failure

• Hyperlipidemia, hypertension,

hypothyroidism

Social history

• Lives in one story home with deaf partner
• Children work full time
• Unable to afford interpretation phone
• Literacy issues
• No access to reliable transportation
• Lack of motivation or clear goals for improving

health

• Underinsured, cannot afford medication
• Completed various diagnostic testing to aid in diagnosis

(including blood work, MRI, CT scan, X Rays, EMG)

• Coordinated and accompaniment to specialty

appointments (including orthopedics, rheumatology)

• Began outpatient physical therapy

Pain management

• Switched pharmacies to one that packs, organizes, and

delivers weekly medications to patient’s home

• Enrolled in Pharmaceutical Assistance to the Aged &

Disabled (PAAD)

Medication adherence

• Re-established relationship between patient and her

PCP through attending consistent appointments

• Applied for Sen Han transportation
• Taught appropriate usage of the ED

Decrease utilization and cost spending

• Requested sign language interpreting services at all

appointments

• Engaged patient in motivational interviewing to define

her goals

• Coached patient on what to say at an appointment

Promote self-advocacy and negotiation skills

• Met at patient’s home to prepare her for doctors

appointments

• Coordinated patient with diabetic nutritionist
• Taught the effects of high-risk medications
• Clarified patients medical records to providers

Chronic disease management education

Goals and Care Plan

The goals we set for the intervention (in blue) were a collaboration between the patient and the care team. The intervention was composed of specific steps to taken to complete these goals.

System Failures & Solutions

Care Team

Victoria DiFiglio, Amanda Santiago (RNs) Heidy Espada (LPN) Joshua Lee, Mary Kate Roccato (Health Coaches) Peter Cormier, Amanda Carter (Former Health Coaches)

10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 100,000

Pre-intervention Post-intervention Cost of Care ($) Hospital Admissions ER Visits Figure 2. Timeline of Debbie Hill’s milestones in health care settings in the span of three years from Jan of 2011 to Jan of 2014. Intervention began on July 3rd, 2012. Pain score records from primary care provider visits via Virtua NextGen EMR. All other milestone dates taken from Camden Health Information Exchange.

HOSPITAL ADMISSION ER VISIT ER VISIT ER VISIT HOSPITAL ADMISSION HOSPITAL ADMISSION

START OF INTERVENTION

ER VISIT HOSPITAL ADMISSION PAIN SCORE AT 10/10 HOSPITAL ADMISSION GRADUATED FROM SU PANEL PAAD APPROVED PHARMACY CHANGE COORDINATION HEMOGLOBIN A1C AT 7 ER VISIT ER VISIT ER VISIT PAIN SCORE AT 6/10 PAIN SCORE AT 0/10 PHYSICAL THERAPY REFERRED

1 Dec 1 Jan 1 Feb 1 Mar 1 Apr 1 May 1 Jun 1 Jul 1 Aug 1 Sep 1 Oct 1 Nov 1 Dec 1 Jan 1 Feb 1 Mar 1 Apr 1 May 1 Jun 1 Jul 1 Aug 1 Sep 1 Oct 1 Nov 1 Dec 1 Jan 1 Feb 1 Mar 1 Apr 1 May 1 Jun 1 Jul 1 Aug 1 Sep 1 Oct 1 Nov 1 Dec 1 Jan 1 Feb

50% 30% 10% 10%

Pre-Intervention

ER Visit Hospital Admissions PCP Visits Specialist Visits Outpatient Diagnostic Testing

13% 7% 36% 27% 17%

Post-Intervention

• PCP Staff can

schedule interpreters

• Better awareness
• f patient

disability

• Implementation
• f Health

Information Exchange

• Consistent PCP

contact

• Advertise Sen

Han services at PCP office

• Pharmacist

coordinate between disabled patients and providers

Cost utilization Pre- intervention Post- intervention ER Visits $18,428 $1,815 Hospital Admissions $72,680 $22,846 Sum $91,108 $24,661 73% Reduction

Supporting Organizations

Virtua Family Health Center Farmacia San Antonios SCUCS (Senior Citizens United Community Services) Aging & Disability Resource Connections

SLIDE 2

“Erasing the Hotspot” Through Community Partnership

Segments Represent People

Final Steps: Community Partner Investment and Development for Program Sustainability

• Ms. Suarez* is a 57 year
• ld woman who lives

alone with assistance from a visiting home health aid. She goes to an adult day program every

• afternoon. Driving

diagnoses for her hospitalizations were COPD and stroke. She has difficulty speaking and residual left-sided weakness from her System challenges identified: Earlier efforts to improve the health of NGII residents and “erase the hotspot” had not engaged this patient Polypharmacy with duplication of therapeutic class from different providers Multiple barriers to medication adherence

1 2 3 4 5 6 Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Sep-12 Nov-12 Jan-13 Mar-13 May-13 Jul-13 Sep-13 Nov-13 Jan-14

Length of Stay (Days)

Hospital Utilization history for Ms. Suarez

Inpt Obs ER

Seeing that the initial interventions achieved limited engagement of the highest utilizing residents, we are now working to create a community-based care management model that comes alongside primary care to reach every hospitalized patient.

Current High Inpatient Utilizer Program goals:

Reduce preventable inpatient and emergency room utilization PCP follow-up within 7 days of hospital discharge Improve the health of NGII residents and the cultivation of a healthy community Enhance capacity for Fairshare Housing to promote a sustainable, healthy community Bend the cost curve & “eliminate the hotspot”

Next Steps: Designing workflows around each segment, starting with the highest utilizers

HIE daily report identifies any hospitalized resident Bedside visits in the hospital – twice if pos- sible 1st Home vis- it within 24- 48 hours of discharge with medication reconciliation Accompany patient to 1st PCP visit within 7 days

• f discharge

Follow up visit in 48 hours & hand-

• ff to NGII Social

Services Depart- ment

• 220 residents (66% of

Building)

• Preventative Health
• Education
• Activities (Yoga, Exercise)
• Coaching / Supporting
• 64 residents (19% of Build-

ing)

• Better linkage to primary

care (especially for chronic conditions)

• Improved transportation
• 29 residents (9% of build-

ing)

• Better linkage to primary

care (especially for chronic conditions)

• Care coordination
• Education on use of ED
• Transportation to primary

care (off-hours)

• Redi-Clinic
• 20 residents (6% of Build-

ing)

• Care Coordination
• Home visits post-

discharge

• Medical reconciliation
• Scheduling
• Post-discharge planning
• Health coaching

First Interventions Timeline

Finding the Hotspot – Why Northgate II?

Hospital Claims

The Camden Coalition of Healthcare Providers was able to pool the claims data from the 3 hospitals in the city of Camden, NJ. Analysis of hospital-based healthcare costs revealed two striking findings. First, it identified “superutilizers,” patients who consume a disproportionate amount of healthcare

• resources. In Camden, the top 1% of patients account for 30% of the hospital-based medical costs.

The second finding was that high-utilizing patients tend to be geographically clustered together in “hotspots” of medical cost. One of these hotspots was Northgate II, a 23-story high rise with 308 apartments for the elderly and disabled.

In-building PCP Patients Outside PCP Patients

# of Residents % of Building % of Receipts 220 66% 8.2% 64 19% 21.4% 29 9% 9.2% 20 6% 61.2%

% Receipts

Segmentation: “the Hotspot within the Hotspot”

While the in-building PCP practice served proportionally more of the highest utilizing residents, it engaged only about a third of the inpatient high utilizers.

7 2 14 29 13 27 49 191 52 280 13.5% 3.8% 26.9% 55.8% 68.2% 4.6% 9.6% 17.5%

SLIDE 3

Facilitating Community Connections For “Super-Utilizers” With Mental Health Diagnoses

Shakera Rainner, B.S., M.A. and Perry Patton B.A.

6/13 7/13 8/13 9/13 10/13 11/13 12/13 1/14

ED visit Inpatient Rehab Stay

Intervention Timeline*

Intervention begins Primary Diagnoses:

• Schizophrenia
• Hypertension

Background: Schizophrenia is a mental disorder that can profoundly impact all aspects of an individual‘s life. Symptoms include delusions and auditory

• hallucinations. It is frequently associated with social

withdrawal and increased risk of homelessness. Approximately half of those diagnosed with the disorder abuse recreational drugs within their lifetime.

Patient at New Visions day shelter

• Increased self-reported overall health and wellness.

Day 1: Fair Day 180: Excellent

• Dramatically decreased utilization of the ED
• 15 ED visits in three months before intervention
• 1 ED visits in three months after intervention
• Helped build self sufficiency in managing personal health.

and arranging medical care.

• Arranged longer term care for patient through day program.

Acknowledgements

• New Visions Day Shelter
• Project hope Health Center
• Unity Place Day Program
• Cooper University Hospital

Care Team

• Bill Nice: Intervention Specialist
• Hilda Mateo: LPN
• Shakera Rainner: Health Coach
• Perry Patton: Health Coach

New Visions Day Shelter Project H.O.P.E. Clinic

Community Connections

Cathedral Kitchen

*Admission data is from the Camden Health Information Exchange

System Failures

• No attempt by ED case

managers to connect patient to a primary care provider

• Previous hospital outreach

relied on contact by phone; number listed in patient’s file was out of date.

Solutions

• Referred patient to easily

accessible primary care provider

• Required intensive

community based outreach to engage patient in care plan. Problem: Patient did not have PCP Action: Connected patient to Project H.O.P.E. Outcome: Patient is proactive about seeking appropriate medical attention. Connected patient to a primary care provider (PCP) at Project H.O.P.E. Problem: Patient had no phone contact – difficult to get in touch with. Action: Became familiar with patient’s routine; met patient in community Outcome: Team was able to work with patient

• n medication

adherence. Problem: Patient was unable to navigate the Social Security system. Action: Accompanied patient to obtain Card and address benefits issues. Outcome: Patient has ID; is able to continue paying rent. Established regular contact with patient through community visits at the day shelter Problem: Patient needs long-term social and mental health support. Action: Enrolled patient in day program catering to mental and social needs. Outcome:

Pending

Enrolled patient in behavioral health day program

Summary of Intervention Steps

Helped patient obtain Social Security card and increase SSI benefits payment Patient History:

• 46 year old male
• Lives on his own in a boarding house
• Has a limited work history; only current source of income is

monthly SSI benefit of ~ $745

• Frequents a homeless day shelter for most meals

Primary Risk Factors:

• History of housing instability
• Lacks consistent social support.
• Intermittent drug use

Recent Utilization History (Refer to timeline below) 15 Emergency department (ED) visits in three months before intervention began. Presented frequently with:

• Chest pain
• Auditory hallucinations
• Minor cuts

Patient suffered stab wound one month before intervention

• Wound became infected, led to a series of inpatient stays for

antibiotic treatment.

• Patient completed treatment at a rehabilitation facility

System Based Learning Outcomes of Intervention

SLIDE 4

Guided by the Patient Voice: Learning from Stories

What can Jackie teach us, if we will only stop to listen?

*% *%

% *%

Medical College

Dawn Mautner is a faculty member at Thomas Jefferson University in the Department of Family and Community Medicine. The project described was supported in part by Grant Number D55HP10334 from HRSA / HHS. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the HRSA /

• HHS. Pilot work was done by Dr. Mautner during fellowship as a Robert Wood Johnson Foundation Clinical Scholar at the University of Pennsylvania.

Discussion / Conclusion

• ACEs are very common in this sample of

Super Utilizers.

• ACEs may be related to patterns of

healthcare utilization.

• A significant proportion of SUs report

positive impacts of ACEs, especially in the ‘physical abuse’ category.

• Results
• IMPOVERISHED

…you went to school

hungry, you came back that way, and you went to bed that way. So… it’s very hard to

learn when you are hungry.”

LOVING and RESILIENT

“…I swore if I had kids, they was never gonna live like that... Because they always say that abuse rolls over. NO. Not if you strong, and you love your kid, ain’t nothing rollin’ over.”

DISCRIMINATED AGAINST “At age 11 I had my first asthma attack. [Then, the hospital] had 3 floors called PF floors, which mean poor

• families. And they didn’t give

us the good medicine that people got who had insurance.” KIND and MATRIARCHAL “My grandkids have to have a safe place to lay they heads…”

• TOUGH

“I carried a switch blade when I walked the street. Nobody bothered me.” RESOURCEFUL, CREATIVE AND ACTIVATED “Last month collecting my cans brought $45. That was

enough to buy my medicines and my test strips!”

• HURT and DISTRUSTFUL

“It makes so you don’t trust no one. If you don’t trust the doctor,you will tell them just enough to get some medicine, but not enough to get the right medicine” DILIGENT “I did everything my doctor told me – she checked me every month, and I took the medicine exactly like she told me.” ADVERSE CHILDHOOD EXPERIENCES (ACES) “My mother made the …mistake of marryin’ an alcoholic. And, as a result when I grew up, I learned to fight real good. ‘Cause…when he got drunk, he did strange things. So I made sure that I slept with a knife, and I made sure that when I closed my bedroom door I put stuff up against it.” LIVING WITH PAIN…and FUNNY

• “[At a pain clinic] when I couldn’t

remember all the medicines I ever got he started yelling at me. I told him, ‘You can’t even remember what color drawers you wore last month. How you expect me to remember all those medicines? They’re right there in your computer! Everybody that’s poor is not a junkie or a crack head… My pain is so bad I vomit every day…”

Many Super Utilizers have ACEs, and often report a positive impact of specific ACEs

ACE Category N (%) Impact Type Of Impact Negative Divorce 5 (22.7) (not assessed) Mental Illness in home 5 (22.7) Substance Abuse in Home 13 (59.1) Unsafe Neighborhood or Home 5 (22.7) Witnessing Parental Violence 9 (40.9) 6 None 3 A lot 3 Very/Mostly Negative 1 50/50* 1 Very/Mostly Positive* Physical Abuse 12 (54.5) 4 none 1 very little 2 some 5 a lot 2 Very/Mostly Negative 2 50/50 (both from ‘none’ category) 5 Very/Mostly Positive Sexual Abuse 3 (13.6) 1 missing 2 none 1 a lot 2 Very/Mostly Negative 1 Very/Mostly Positive Psychological/ Emotional Abuse 7 (31.8) 3 none 1 very little 3 a lot 1 Very/Mostly Negative 1 50/50 3 Very/Mostly Positive Abandonment/ Neglect 13 (59.1) 3 none 2 very little 1 some 7 a lot 2 Very/Mostly Negative 5 50/50 4 Very/Mostly Positive

Dawn Mautner, MD, MS1; Jeffrey Brenner, MD2,3; Brent Troy4,5; Marianna LaNoue, PhD1,4

• Background
• Primary drivers of costly patterns of care utilization

in complex, vulnerable patients known as Super Utilizers are not well understood.

• Adverse Childhood Events (ACEs) may predict

high levels of healthcare utilization. (Chartier, 2010;

Mautner 2013)

Using Qualitative methods, what can we learn about Super Utilizers from their stories?

Excerpts from interviews with Jackie, a CCHP Care Management Team graduate

Using Quantitative methods, what can we learn more generally about Super Utilizers?

Methods

• 22 adult former patients of the Care Management

Team, selected for chronic illness, vulnerability, and repeat visits to Camden’s hospitals.

• Assessed for Adverse Childhood Events and

perceived impact of these experiences on their adult lives Super Utilizers have high rates

• f ACEs

1 Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, PA; 2 Camden Coalition of Healthcare Providers, Camden, NJ; 3 Cooper Medical School of Rowan University, Camden, NJ; 4 Albany Medical School, Albany, NY; 5 School of Population Health, Thomas Jefferson University, Philadelphia, PA

• Black

68% White 14% Other 9% Multi- racial 9%

Race Race

8 10 2 2 2 4 6 8 10 12 Grade 6-12 GED/HS Diploma Some College College Grad

Education n

Unable but not disabled Unemployed <1yr Mentally Disabled Physically Disabled Retired Employed for Wages 10 20 30 40 50 60 70

Emplo loyme yment nt S Status

Demographics

JACKIE

Any y ACEs 1 19 No A ACEs 3 3

ACEs r reported?

SLIDE 5

Employment Status* N (%) Unable to work but not disabled 1 (4.5) Out of work for less than 1 year 1 (4.5) Mentally/ emotionally disabled and unable to work 6 (27.3) Physically disabled and unable to work 14 (63.6) Retired 4 (18.2) Employed For Wages 2 (9.1)

Abstract: Characterizations of these patients have been mainly retrospective and secondary. These patients likely have insights into their own health care use along with ways to improve their health. Pilot work suggests important roles for childhood instability and relationships with providers in their patterns of high-cost healthcare utilization.

• This study describes Super Utilizer patient stories and

Perspectives using interviews, surveys, chart reviews, and program outcome data. Psychometric assessment of resilience, grit and adverse childhood experiences (among

• ther measures) will inform outreach programming and

health system design.