Preventing Tipping Points in High Comorbidity Patients: A Lifeline - - PowerPoint PPT Presentation

Preventing “Tipping Points” in High Comorbidity Patients: A Lifeline from Health Coaches

Co-PI: Mary Charlson, MD (Weill Cornell Medicine) PI: Jonathan N. Tobin, PhD (CDN/The Rockefeller University)

Funding: PCORI Award #IHS-2017C3-8923 With support from: AHRQ Grant #P30-HS-021667 NYC-CDRN (INSIGHT) PCRF Award #20171205 CAPriCORN PCRF Award #20171205

Conflicts

Mary Charlson MD: Cornell University has filed a patent for the use of the enhanced comorbidity index to predict future costs.

Team in Attendance

• Mary Charlson
• Guillerma M. Martinez
• Andrea Cassells
• Shelly Sital

Partners

Clinical Directors Network Weill-Cornell Medicine AllianceChicago PCORnet New York City Clinical Data Research Network (NYC- CDRN/INSIGHT) Chicago Area Patient-Centered Outcomes Research Network (CAPriCORN)

Federally Qualified HC Partners

Chicago

• Erie Family Health Centers (Red)
• Friend Family Health Center (Yellow)

New York

• Family Health Centers of NYU Langone

(Purple)

• Community Healthcare Network (Blue)

Backg kground Patients with Multiple Chronic Diseases:

• Increased mortality and morbidity
• High risk for destabilization, including hospitalization, ER visits and

increased disability

• Excluded from clinical trials because they have worse outcomes,

confounding results

• Almost no guidelines for the care of such patients
• Experience social and psychosocial challenges – “Tipping Points” –

that may lead to destabilization

Charlson C Comorbidity Index: x: A Adults

Condition Points Myocardial infarction 1 Congestive heart failure 1 Peripheral vascular disease or bypass 1 Stroke 1 Hemiplegia 2 Chronic pulmonary disease/ asthma 1 Diabetes 1 Diabetes with end organ damage 2 Renal disease 2 Mild liver disease 2 Severe liver disease 3 Gastric or peptic ulcer 1 Cancer (lymphoma; leukemia; solid tumor) 2 Rheumatic or connective tissue disease 1 Hypertension 1 Skin ulcers/ cellulitis 2 Condition Points Depression 1 Warfarin 1 Inflammatory bowel disease 1 Excluded: Dementia or Alzheimer’s 1 Metastatic solid tumor 6 HIV or AIDS 6 Any transplant: renal; heart; liver; bone marrow; lung 6 Schizophrenia or bipolar 3 Bipolar disease 3 Taking antipsychotics or medications for bipolar disorder 3 Drug or alcohol addiction 3

Backgroun und d

Design

• Cluster randomized clinical trial
• Predominantly low-income, black and Latino/a adult patients with multiple

chronic diseases (defined by Charlson Comorbidity Index of >4)

• Conduct recruitment, assessment and intervention at 4 FQHC networks

through designated, trained Health Coaches

• Engage 4 FQHC sites in each Health System with at least 500 patients who

have high comorbidity at each Health System (total=16 FQHC sites)

Charl rlson Comorb rbidity Index x by Network rk

FQHC Network/Health System Total # of Adult Patients* Total # of Patients with CCI ≥4 % of Patients with CCI ≥4 Health System 1 35,141 1,949 5.6% Health System 2 23,819 1,888 7.9% Health System 3 12,839 2,984 23.2% Health System 4 11,521 2,199 19.1% Total 83,320 9,020 10.8%

*This total is for only the 4 recruitment sites at each health system (n=16 sites)

Interve vention

PCMH: Patients will receive their usual care at their health center per Patient-Centered Medical Home (PCMH) guidelines (Control) PCMH+coaching: Patients will receive their usual care at their health center per Patient-Centered Medical Home (PCMH) guidelines plus health coaching (Experimental)

Site Recruitment & Randomization Design: 4 FQHC Networks, 16 FQHC sites, N = 1920 Patients

Tippi ping ng P Points - Inter erven ention

• n

Experimental Arm Includes:

• Setting life goals and self-management goals with Health Coaches to

engage patients

• Coaching toward self-management goals shared with patient’s primary

care clinician and Health Coach to work with patient to develop an action plan for when they should contact their clinician

• Emotional and tangible support for life stresses Patients in the PCMH+

coaching intervention will be able to contact the Health Coach if they need help because of new life events, psychosocial challenges, new diagnoses or deterioration in their current social or clinical status. The Health Coach can help to mobilize family and friends to provide support

PCM CMH v ver ersu sus s PC PCMH with Health Coaching Intervention

Needs Identified by Patients PCMH Intervention alone (Control) PCMH plus Health Coach (Experimental) Domains of Health Education Impact Questionnaire Engagement in self-management Patient-centered care that supports patients in learning to manage their

• wn care

Same as PCMH Positive and active engagement in life Effectively communications with physicians Comprehensive accessible care that meets each patient’s needs Same as PCMH Skills and technique acquisition Navigating the health care system Coordinated care across all elements of the health care system Same as PCMH Health services navigation Providing emotional support Empathic listening Emotional well-being Assistance with handling life stresses Mobilizing social support and connecting with relevant community support services Constructive attitude/approaches; Social integration and support

Tippi ping ng P Points - Key D Demographics

NY/Chicago FQHC Prevalence Rate (%) Subgroup Sample Size Total 1920 Race/ethnicity White

20.8%

344 Black

48.5%

1006 Hispanic

42.2%

659 Insurance Medicaid

62.3%

1169 Medicare

5.1%

115 Other Private

13.3%

259 Uninsured

19.3%

376 SES <100% FPL

80.8%

1649 <200% FPL

94.5%

1837 Health Literacy Language other than English

23.6%

394

Ti Tipping P Points s - Outcome mes

Primary Outcomes

• Decreased unplanned hospitalization
• Decreased disability (WHODAS)

Secondary Outcomes

• Decreased emergency department visits
• Improved Patient-reported Outcomes:
• Increased patient activation (PAM-13)
• Increased self-management (HEI-Q)
• Increased patient satisfaction (CAHPS)

Assessments

• Baseline; 6-months post baseline; 12-months post baseline; 24-months post-

baseline

ClinvestiGator D r Database System

• Web based complete data entry, reporting and statistical and graphical analysis

system.

• APACHE, PHP, MySQL
• High levels of security HIPPA compliant; site specific and role specific access;

full audit trail

• Baseline and follow up data entered extracted directly from FQHC/Health

Systems EHR data into ClinvestiGator and reviewed by Health Coaches

• Real time and dynamic reports to track recruiting, follow-up and missing data
• Integration of outcome data (hospitalizations and emergency dept visits) from

PCORnet networks, Regional Health Information Organizations (RHIOs), and FQHC data alert partners.

• Most interventions have been focused on improving outcomes in

patients with chronic disease using guidelines, protocols and process measures

• BUT most interventions have not reduced hospitalization
• Because patients with one chronic disease do not drive hospitalization rates
• Patients with multiple chronic disease or “high comorbidity” do drive

hospitalization

• There are no guidelines for patients with high comorbidity
• We need to give patients tools and support and the reason to believe

that they can achieve their OWN life goals by learning to better manage their own multiple chronic diseases, and support them through multiple psychosocial crises they face

Tippi ping ng P Points - Concl clusions

Tippi ping ng P Points – Resea esearch Tea eam

Clinical Directors Network (CDN): Jonathan N. Tobin, PhD Principal Investigator JNTobin@CDNetwork.org Andrea Cassells, MPH Shelly Sital, MPH Dena Moftah, BS TJ Lin, MPH Weill-Cornell Medicine: Mary E. Charlson, MD Co-Principal Investigator mecharl@med.cornell.edu Erica Phillips, MD James P. Hollenberg, MD Rosio Ramos, BA, CRCC Martin Wells, PhD Lewis L. Perin, MS AllianceChicago: Fred Rachman, MD Nivedita Mohanty, MD Roxane Padilla, MPH