Improving Care & Reducing Costs with Hotspotting & - - PowerPoint PPT Presentation

▶
improving care reducing costs with hotspotting community
SMART_READER_LITE
LIVE PREVIEW

Improving Care & Reducing Costs with Hotspotting & - - PowerPoint PPT Presentation

Nov 13, 2023 181 likes •709 views

Aaron Truchil & Kelly Craig January 13, 2015 Improving Care & Reducing Costs with Hotspotting & Community-Based Care Management morning session Agenda 1 About the Camden Coalition 2 What is hotspotting? .1 Using Data .2

slide-1
SLIDE 1

Improving Care 
 & Reducing Costs 
 with Hotspotting & Community-Based Care Management

Aaron Truchil & Kelly Craig January 13, 2015 ¡

slide-2
SLIDE 2

Agenda

1 About the Camden Coalition 2 What is hotspotting? .1 Using Data .2 Camden findings .3 Segmentation

.3 Hotspotting in Action

morning session

slide-3
SLIDE 3

§1 About
 the Camden Coalition


  • f Healthcare

Providers

slide-4
SLIDE 4
slide-5
SLIDE 5

Mission:

to improve the health of Camden residents by enhancing the quality, capacity, coordination, efficiency, and accessibility of the city’s healthcare delivery system.

Vision:

to be the first city in the country to bend the healthcare cost curve while improving quality.

Theory of Change:

CCHP believes that three basic elements are needed to revitalize primary care and improve the healthcare system: data, engagement, and redesign.

slide-6
SLIDE 6

Our Board:

  • Incorporated non-profit
  • Membership organization
  • 20 member board

Hospitals PCPs Residents Social Services

slide-7
SLIDE 7

About the Organization:

  • 65 staff
  • $5 million annual budget
  • Mix of foundation, federal grant funding, and

hospital support

Care Management Initiatives Clinical Redesign Legal & External Affairs Data, Research & Evaluation

Cross-Site Learning & Workforce Development

Finance & Administration

slide-8
SLIDE 8

Switzerland

Providers Social Services Government Residents / Community

slide-9
SLIDE 9

§2 Hotspotting:
 the Camden Coalition’s
 data strategy

slide-10
SLIDE 10

1960

65 70 75 80 85 90 95 2000 05 10 2012

6% 5%


 is 60 times what it was
 in 1960, consuming one fifth


  • f personal income and 17% of

GDP

20% 17%

21%

National Health Spending Per Capita ¡

slide-11
SLIDE 11

34% ($882 billion) 29% 20% 10%

Insurance

Rx Professional Services Hospitals

7%

Other (e.g. Home health, Nursing, D.M.E.)

$2.63 Trillion National Health Expenditures (CMS Estimates)

slide-12
SLIDE 12

The mission of CCHP is to improve the health

  • f all Camden residents

by increasing the capacity, quality, and accessibility

  • f the city’s healthcare delivery system.

A core value of CCHP is to be data-driven Where’s the data in the mission?

slide-13
SLIDE 13

a data driven process for the timely identification

  • f extreme patterns in a defined region 

  • f the healthcare system

used to guide targeted intervention and follow up to better address patient needs, reshape ineffective utilization, and reduce cost.

:

slide-14
SLIDE 14
slide-15
SLIDE 15

Health Data Integrated Data Warehouse

the observed world

Claims Claims

slide-16
SLIDE 16

Health Data

Claims

Other Data

? Health Plan

Integrated Data Warehouse

EMR

Social Service Data

Housing School Justice Child Services

Public Data

Property Census the observed world

slide-17
SLIDE 17

§2.1 Camden findings

slide-18
SLIDE 18

total hospital revenue: $108,000,000 total patients with a hospital visit: 43,710 patients visiting multiple hospitals: 41%

Camden Hospital Utilization


2011 Snapshot

slide-19
SLIDE 19

the Camden Cost Curve

10% of patients accounted for 74% of receipts

1% ¡of ¡pa(ents ¡= ¡30% ¡

  • f ¡receipts ¡

10% ¡of ¡pa(ents ¡= ¡74% ¡

  • f ¡receipts ¡
slide-20
SLIDE 20

Spatial Analysis

  • f Camden

Hospital Costs

slide-21
SLIDE 21

Spatial Analysis

  • f Camden

Hospital Costs

Several buildings (e.g.) annually generate $1-$3 million in hospital costs. 6% of city blocks account for 18% of patients and 37% of receipts.

January 2002 – June 2008

slide-22
SLIDE 22

top ¡diagnoses

Respiratory ¡Abnormality Chest ¡Pain Abdominal ¡Pain Sep6cemia Acute ¡Renal ¡Failure Urinary ¡Tract ¡Infec6on Pneumonia Chronic ¡Systolic ¡Heart ¡Failure

≈1% of population >5 chronic conditions averages: 57 years old
 4.5 ED visits 5.3 inpatient 
 hospitalized 54 days____ $673,000 charges $73,143 receipts

Who uses Camden’s hospitals most?

slide-23
SLIDE 23
slide-24
SLIDE 24

§ ¨ ¦

495

§ ¨ ¦

95

§ ¨ ¦

495

§ ¨ ¦

95

£ ¤

202

£ ¤

1

£ ¤

2

£ ¤

201

£ ¤

1

£ ¤

201

£ ¤

201

£ ¤

201

£ ¤

201

£ ¤

202

£ ¤ £ ¤

201 China Augusta Sidney Belgrade Clinton Albion Rome Winslow Litchfjeld Pittston Dixmont Vassalboro Windsor Winthrop Fayette Benton Wayne Monmouth Vienna Etna Oakland Readfjeld Mount Vernon Plymouth Chelsea Unity Gardiner West Gardiner Farmingdale Manchester Waterville Hallowell Randolph Newburgh New Gloucester

Waldo Knox Franklin Lincoln Somerset Oxford Androscoggin Sagadahoc

¤ £ ¤ £ ¤ £

Lincoln

MaineCare Hot Spot Analysis: Kennebec County 7/1/2008 - 6/30/2010

A hot spot is any geography where a large number of high utilizers reside. High Utilizers are defjned as any individual with 3 or more hospital admissions or 6 or more ER visits within 2 years. Hot spots range from blue (no hot spot) to red (intense hot spot) What is a hot spot?

Low

High utilizer density

High
slide-25
SLIDE 25

§2.3 Segmentation

slide-26
SLIDE 26
slide-27
SLIDE 27
slide-28
SLIDE 28

Healthcare Does Segment

slide-29
SLIDE 29

Longevity, by preventing accidents, illness, and progression of early stages of disease Healthy babies, low maternal risk Return to healthy state with minimal suffering and disruption Longevity-limiting disease progression, accommodating environment Support for caregivers, maintaining function, skin integrity, mobility, advance planning

healthy maternal / infant acutely ill (likely
 recovery) chronic conditions long decline

Physicians' offices, health clinics, occupational health Prenatal services, delivery, and perinatal care Emergency services, hospitals, physicians'

  • ffices, medications,

short-term rehab services Self-management, physicians' offices, hospitalizations and ER visits Home-based services, mobility and care devices, family caregiver training and support

slide-30
SLIDE 30

healthy babies, low maternal risk longevity- limiting disease progression, accommodating environment

maternal / infant chronic conditions

prenatal services, delivery, and perinatal care self- management, physicians'

  • ffices,

hospitalization & ER visits

maternal w/ chronic conditions

slide-31
SLIDE 31
slide-32
SLIDE 32

Intervention Paradigms

Traditional Medical

Diabetes Heart Failure COPD ESRD

Hotspotting

slide-33
SLIDE 33

1 2-3 4 + 0 .

2,900 6.6%
 $132m 14.8%
 $16m 14.7% 355 .8%
 $165m 18.6%
 $20m 18.6%

1-2 .

26,819 61.0%
 $87m 9.9%
 $11m 10.6% 2,332 5.3%
 $115m 13.0%
 $14m 12.9%

3-5 .

9,010 20.6%
 $298m 33.6% 
 $37m 33.8%

6+ .

2,293 5.2%
 $90m 10.2%
 $10m 9.4%

Patient “Typology”, 2011

inpatient visits emergency visits

X patients $ charges
 $ receipts

slide-34
SLIDE 34

High Cost High Utilization

Four-cluster solution with per patient averages

1 ED 0 INP <$10k 0 Chronic 40 y.o. 4 ED 0 INP $33k 1 Chronic 40 y.o. 4 ED 3 INP $400k 3 Chronic 55 y.o. 13 ED 1 INP $58k 1 Chronic 40 y.o.

slide-35
SLIDE 35

Use/Cost ¡Cluster ¡ pa(ent ¡share ¡ Top ¡primary ¡diagnoses ¡

One-­‑Time ¡ED/Low ¡ Average ¡Cost ¡Popula(on ¡ 68% ¡ Abdominal ¡pain ¡ Back ¡problem ¡ Upper ¡respiratory ¡infec6on ¡ Arthri6s/other ¡non-­‑trauma6c ¡joint ¡disorder ¡ Sprain/Strain ¡ Low ¡Inpa(ent/Medium ¡ ED ¡U(lizing/Medium ¡ Cost ¡Popula(on ¡ ¡ 27% ¡ Abdominal ¡pain ¡ Back ¡problem ¡ Upper ¡respiratory ¡infec6on ¡ Staph/other ¡skin ¡or ¡6ssue ¡infec6on ¡ Arthri6s/other ¡non-­‑trauma6c ¡joint ¡disorder ¡ High ¡ED ¡U(lizing/High ¡ Cost ¡Popula(on ¡ 3% ¡ Asthma ¡ Abdominal ¡pain ¡ Back ¡problem ¡ Arthri6s/other ¡non-­‑trauma6c ¡joint ¡disorder ¡ Upper ¡respiratory ¡infec6on ¡ High ¡Inpa(ent ¡ U(liza(on/High ¡Cost ¡ Popula(on ¡ ¡ 2% ¡ COPD ¡ Conges6ve ¡heart ¡failure ¡ Diabetes ¡ Abdominal ¡pain ¡ Asthma ¡

Patient Diagnosis Profiles

slide-36
SLIDE 36

Present: ¡known ¡but ¡misunderstood. ¡Future: ¡changing. ¡ ¡ Wrong ¡6me ¡horizon ¡for ¡savings ¡& ¡quality ¡improvement ¡ ¡ Exis6ng ¡models ¡don’t ¡work ¡well ¡ ¡ More ¡resources ¡to ¡reach ¡fewer ¡pa6ents ¡

¡

Why ¡We ¡Don’t ¡Predict: ¡(now, ¡or ¡maybe ¡ever) ¡

slide-37
SLIDE 37

§ 3 Hotspotting
 in Action

slide-38
SLIDE 38

Camden Coalition of Healthcare Providers

The Problem

slide-39
SLIDE 39

Camden Coalition of Healthcare Providers

Variation of Patient Complexity

Social Complexity Medical Complexity

HIGHER

  • 23 Y.O. Male
  • Hx of Type 1 Diabetes
  • Lives with Grandmother
  • Works as Day Laborer
  • Learning Disability

¡

  • 52 Y.O. Male
  • Hep C, CHF, HTN
  • Homeless
  • Uninsured
  • Active substance use
  • No income
  • No Social Support
  • 67 Y.O. Female
  • Hx CHF, HTN, COPD
  • Depression, Anxiety
  • 17 Meds Daily
  • Work History
  • D/C To LTAC
  • Daughter Is Primary Caregiver

LOWER

L O W E R H I G H E R

slide-40
SLIDE 40

Uncoordinated Patient Care

slide-41
SLIDE 41

Camden Coalition of Healthcare Providers

Clinical Interventions


upstream ¡workflows ¡ for ¡hospital-­‑based ¡ enrollment ¡and ¡ini6al ¡ care ¡planning ¡

PUSH ¡

centralized ¡ community-­‑based, ¡ pa6ent-­‑centric ¡ ac6vi6es ¡

CARRY ¡

refocused ¡efforts ¡to ¡ redesign ¡primary ¡care ¡ around ¡PCP-­‑based ¡ ACO ¡ac6va6on ¡

CATCH ¡

slide-42
SLIDE 42

Camden Coalition of Healthcare Providers

Daily Data Feeds

slide-43
SLIDE 43

Camden Coalition of Healthcare Providers

Triage

slide-44
SLIDE 44

Camden Coalition of Healthcare Providers

Bedside Engagement

slide-45
SLIDE 45

Camden Coalition of Healthcare Providers

Initial Bedside Care Planning

slide-46
SLIDE 46

Camden Coalition of Healthcare Providers

Home Visits

slide-47
SLIDE 47

Camden Coalition of Healthcare Providers

Home-based Medication Reconciliation

  • Before and After

BEFORE AFTER

slide-48
SLIDE 48

Camden Coalition of Healthcare Providers

Accompaniment

slide-49
SLIDE 49

Camden Coalition of Healthcare Providers

Graduation

slide-50
SLIDE 50

Camden Coalition of Healthcare Providers

It Takes a Team

Social ¡Worker ¡ Behavioral ¡Health ¡Consultant ¡ Interven6on ¡Specialist ¡

¡ RN ¡Clinical ¡Manager ¡ Program ¡Manager ¡ Licensed ¡Prac6cal ¡Nurse ¡ Licensed ¡Prac6cal ¡Nurse ¡ Community ¡Health ¡Worker ¡ Community ¡Health ¡Worker ¡ Health ¡Coach ¡ Health ¡Coach ¡

¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡Program ¡Director ¡ ¡ ¡ ¡ ¡ ¡Associate ¡Clinical ¡Director ¡

Team ¡Supreme ¡

RN ¡Clinical ¡Manager ¡ Program ¡Manager ¡ Licensed ¡Prac6cal ¡Nurse ¡ Licensed ¡Prac6cal ¡Nurse ¡ Community ¡Health ¡Worker ¡ Community ¡Health ¡Worker ¡ Health ¡Coach ¡ Health ¡Coach ¡

Team ¡Awesome ¡

slide-51
SLIDE 51

Breakout I