Post on 30-Sep-2020
transcript
UR OARHS Office for Aging Research and
Health Services
Michael Hasselberg, PhD, NPP-BC
Assistant Professor of Psychiatry
Director of Project ECHO®
Director of Telepsychiatry
Extension for Community Healthcare Outcomes
in Geriatric Mental Health (ECHO® GEMH)
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Disclosures
I have no financial relationships with a
commercial entity producing health-
care related products and/or services
to the content I am presenting
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Acknowledgements
Supported by funding from
o The New York State Health Foundation
o The Health Foundation of Central and Western New York
o Greater Rochester Health Foundation
Infrastructure support from
o Project ECHO®, University of New Mexico (UNM)
(Slides adapted from those of Sanjeev Arora, MD, UNM Professor)
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Growing Need
Aging and disease impact in New York State
(NYS)
o Population age ≥ 65 years will rise from 2.5 to 4 million by
the year 2030
o Elderly with mental illness will rise from 495,000 to 772,000
by the year 2030
Costs of inadequate care in NYS
o In 2011, health care costs for elderly with dementia alone
was $690 million
• Value of unpaid care exceeded $13 billion
New York State Office of Mental Health, 2013; Alzheimer’s Association, 2012
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Alliance for Aging Research, 2002
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Geriatric Psychiatry Shortage
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• Only 1,596 physicians are currently certified in geriatric psychiatry
• One for every 11,372 older Americans
• By 2030 that total is predicted to rise to only 1,659, which would then be only one for every 20,195 older Americans (ADGAP, 2007b).
• Half of fellowship positions go unfilled nationwide
• General psychiatry is a partial solution
• 71% feel very prepared to dx and treat delirium
• 96% to dx and treat major depression
• 56% to diagnose and treat dementia.
Retooling for an Aging America: Building the Health Care Workforce http://www.nap.edu/catalog/12089.htm
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The mission of Project ECHO® is to expand the capacity to provide best practice care for common and complex diseases in rural and underserved areas and to monitor outcomes.
Goal is to touch the lives of 1 billion people by 2025
Supported by New Mexico Department of Health, Agency for Health Research and Quality, New Mexico Legislature, the Robert Wood Johnson Foundation and the GE Foundation.
One solution: Project ECHO®
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In 2004 less than 5% of patients with HCV in New Mexico had been treated o Estimated 28,000 people with HCV in New Mexico
o No Primary Care Physicians treating HCV in New Mexico
Good news … o Curable in 70% of cases
Bad news … o Severe side effects:
anemia (100%)
neutropenia >35%
depression >25%
Project ECHO® Hepatitis C (HCV)
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Methods of Project ECHO®
Use Technology (multipoint videoconferencing and Internet)
Disease Management Model focused on reducing variation in processes of care and sharing “best practices”
Case based learning: Co-management of patients
HIPAA compliant web-based database to monitor outcomes
Arora (2013); Supported by N.M. Dept. of Health, Agency for Health Research and Quality HIT Grant 1 UC1 HS015135-04, New Mexico Legislature, and the Robert Wood Johnson Foundation.
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Project ECHO® HCV Outcomes
Sustained Viral Response (SVR): no detectable
virus 6 months after completion of treatment
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Project ECHO® in New Mexico
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ECHO® Replication in United States
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• University of Washington (HCV, Chronic Pain, HIV, Multiple Sclerosis) – Seattle, WA • University of Chicago (Hypertension, Breast Cancer Survivorship/Women’s Health, Pediatric ADHD, Childhood
Obesity, HCV) – Chicago, IL • University of Nevada (Antibiotic Stewardship, Autism (closed group, by invitation only), Diabetes/General
Endocrinology, Gastroenterology, Rheumatology, Sports Medicine, Mental Health: Professional Development Groups (closed groups, by invitation only), Mental Health Clinic Director’s Group (closed groups, by invitation only), Marriage & Family Therapy Intern Supervision Clinic (closed groups, by invitation only) – Reno, NV
• University of Utah (HCV, Advanced Liver Care, Chronic Pain) – Salt Lake City, UT • Florida/Caribbean AIDS Education and Training Center, University of South Florida (General HIV,
Adolescents/Pediatrics HIV, HCV/HIV Co-Infection, Psychiatry & HIV, Spanish Language HIV) – Tampa, FL • Harvard/Beth Israel Deaconess Medical Center (HCV, Gerontology – ECHO AGE) – Boston, MA • St. Joseph’s Hospital & Medical Center (HCV) – Phoenix, AZ • Community Health Center, Inc. (HIV, HCV, Chronic Pain, Opioid Addiction – Buprenorphine, Coaches
International—supporting Quality Improvement and Specialists) – Middletown, CT • LA Net (AAPA Preventive Care, Nephrology, Adult Psychiatry) – Los Angeles, California • UNM: Center for Development and Disability (Autism) – Albuquerque, NM • UNM: Envision NM (Childhood Overweight Medical Management, Pediatric Nutrition, Psychiatry,
Asthma/Pulmonary) – Albuquerque, NM • CHI St. Luke’s Health (HCV, HBV, Infectious Disease) – Houston, TX • University of California Davis (Pain Management) – Davis, CA • University of Wyoming, Wyoming Institute for Disabilities (Assistive Technologies) – Laramie, Wyoming • Ochsner Health System (Liver Care) – New Orleans, LA • University of Texas MD Anderson Cancer Center (Cervical Cancer Prevention) – Houston, TX • Oregon Health and Science University/Health Share of Oregon (Psychiatric Medication Management) –
Portland, OR • University of Rochester Medical Center (Geriatric Mental Health) – Rochester, New York • Visiting Nurses Association Health Group (Care Transition) – Red Bank, New Jersey • Missouri Telehealth Network/University of Missouri (Autism) – Columbia, MS • University of Colorado School of Public Health (Children and Youth with Epilepsy) – Denver, CO
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ECHO® Replication Worldwide
National AIDS Control Organization and Maulana Azad (HIV) – New Delhi, India Institute of Liver and Biliary Sciences (HCV) – New Delhi, India Universidad de la República (Liver Disease) – Montevideo, Uruguay West/North West Hospitals Group (Diabetes) – Galway, Ireland ECHO Ontario (Chronic Pain) – Queens University & University of Toronto Ontario, Canada Northern Ireland Hospice (Hospice Care) – Belfast, NI National Institute for Mental Health Services (NIMHANS) (Mental Health and Drug Addiction) – Bangalore, India B.J. Medical College (HIV) – Ahmedabad, India Vietnam National Lung Hospital (TB) – Hanoi, Vietnam Hospital Italiano (HCV) – Buenos Aires, Argentina PUCRS Brazil-( Depression and Dementia)
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Geriatric Mental Health
&
Memory Care
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Project ECHO® GEMH Goal
To support the delivery
by primary care practices (PCPs) in
underserved and rural areas of New
York State (NYS)
of expert care
to older adults with dementia or
mental disorders.
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Project ECHO® GEMH
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PC Practice
PC Practice
PC Practice
PC Practice
PC Practice
URMC Hub Site
• Geriatric psychiatry • Geriatric medicine • Geriatric psychology • Social work • Pharmacy
PC Practice
PC Practice
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Current Participants
Primary Care Practices
o Hospital system affiliated
o Accountable care affiliated
o Provider owned group
Federally Qualified Health Centers
Health Service Corporations
County Department of Aging Centers
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Workforce Development
UR School of Medicine
o Medical School Program
o Family Medicine Residency Program
o Psychiatry Residency Program
o Geriatric Psychiatry Fellowship
o Interdisciplinary Geriatric
Medicine Fellowship
o Clinical Psychology Fellowship
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UR School of Nursing
o Undergraduate Nursing Program
o Family Nurse Practitioner Program
o Adult Nurse Practitioner Program
o Psychiatric Nurse Practitioner Program
o Graduate Nurse Leadership Program
St. John Fisher Collage of Pharmacy
Niagara Falls Medical Center Family Practice
Residency Program
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UR Medicine Project ECHO® Hub Site
Health System Affiliated Primary Care Site
Primary Care Practice Group Site
Federally Qualified Health Center Site
Health Care Service Corporation Site
County Department of Aging Site
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Program Evaluation
First TeleECHO™ clinic was held on
September 18, 2014
To Date:
24 TeleECHO™ clinics
546 participants
181 Continuing Medical Education (CME) credits
49 patient case presentations
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Preliminary Outcomes
Overall Rating/Content Poor Fair Good Very Good Excellent
How well were objectives met 0% 0% 2% 19% 79%
Objective/evidence-based content 0% 0% 2% 17% 81%
Opportunities to ask questions 0% 1% 7% 17% 75%
Appropriate pace 0% 0% 4% 29% 67%
Organization of presentation 0% 0% 1% 16% 83%
Presenter clearly communicated 0% 0% 1% 13% 86%
Relevance of presentation 0% 1% 0% 13% 86%
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n = 181
CME Survey Results:
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Preliminary Outcomes
Participant Qualitative Interviews:
Most feel clinics are useful, some do not
Of those who could implement suggestions, they often saw results
Most feel that they will use learnings in future work
Clinics are considered particularly useful for complex cases, poly pharmacy, reducing reliance on antipsychotics
Clinics can be perceived as validating for participants in that cases are complex and it’s normal to struggle with them
Major value – access to specialists otherwise unavailable
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Sustainability
External cost evaluation being conducted by the
New York Academy of Medicine
Collaboration with Excellus BCBS o Practice level claims data
Fee-for-service versus
Accountable Care
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Accountable Care
An accountable care organization or network is a healthcare organization characterized by a payment and care delivery model that ties provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. A group of coordinated health care providers forms an ACO, which then provides care to a group of patients.
UR Medicine– Accountable Health Partners (AHP)
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Private MDs &
Community Hospital
Employed MDs
UR Medical Faculty Group
Community Hospitals
Highland, Thompson,
Jones Memorial, Noyes, Arnot Ogden
Strong Memorial Hospital
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NYS Delivery System Reform Incentive
Payment (DSRIP) Program
o Restructure the health care delivery system
• To create an accountable, coordinated network of care that improves
access, quality and efficiency of care for patient populations
o Reinvesting in the Medicaid program
• Up to $8 billion dollars are allocated to this program
o Primary goal of reducing avoidable hospital use
* DSRIP Project Toolkit (page 39) “Modeling of Project
ECHO is encouraged where appropriate.”
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How do we integrate Project ECHO®
into Accountable Care
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Finger Lakes Performing Provider System (FLPPS)
Rochester Regional Health System
(RRHS) and UR Medicine
o Lead implementation of DSRIP
o In partnership with over 600 organizations
30 http://flpps.org/
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FLPPS DSRIP Project 3.a.v
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Behavioral Interventions Paradigm in Skilled Nursing Facilities (SNF)
Vision:
1. Build an education, consultation & training
infrastructure for SNF clinical and non-clinical staff
2. Improve access to psychiatric expertise and
behavioral health sub-acute care
3. Modify facilities to assure that adequate recreation
and holistic interventions can be carried out
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SNF Needs Assessment NYS Statistics
Approximately 30% of new
nursing home admissions are
among persons with mental illness
Older adults with dementia have
a three-fold increased risk of
hospitalization
1 in 5 residents will be given an
antipsychotic medication, though
only 1% will ever be diagnosed
with a psychotic condition
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FLPPS Region Statistics
Hospital readmissions following
discharge to a SNF account for
about 16% of all Medicaid
readmissions
o Behavioral symptoms are within the Top 11
reasons for readmission
Greatest and most consistent
increase (58%) in citations for
inappropriate antipsychotic use
from 2011 to 2012 across NYS
Grabowski, et. al., 2009.; Becker, et. al., 2009; The Long Term Care Community Coalition, 2014; NYSDOH, 2012
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SNF Needs Assessment
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ALLEGANY
CHEMUNG
ORLEANS
SCHUYLER
SENECA
STEUBEN
WYOMING
YATES
CAYUGA
GENESEE
LIVINGSTON
ONTARIO
WAYNE
MONROE
Entirety as lacking mental health services
In need of additional mental health services
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Harvard ECHO® AGE in SNFs
Geriatric mental health and dementia ECHO® to New
England SNFs associated with the Beth Israel Deaconess
Medical Center
o 34% discontinuation or reduction of antipsychotics
o Behavioral interventions recommended in 72.3% of patient cases
o 74% patients had clinical improvement when recommendations
were followed
- Significantly lower mortality (p < 0.03)
o 60% reduction in hospitalizations when recommendations were
followed Catic, et. al. 2014
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ECHO® GEMH in DSRIP Project 3.a.v
Implementation underway
Participants to include all staff with patient care
responsibilities
Rollout to begin November 2015?
o Year 1: 30 SNFs participate in biweekly clinics
o Year 2: Additional 30+ SNFs to participate on alternating weeks
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Potential Benefits to the Participant
access to consultation re: effective management of
gero-psychiatric disorders and dementia.
burden on family caregivers (with resulting health
benefits).
quality (didactics and care target quality metrics).
cost across the system, with unnecessary care.
provider satisfaction – engagement in community of
practice.
CME credits (1 hr/hour of participation).
NO COST
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Potential Benefits of Project ECHO®
to the Health System
• Quality and Safety
• Rapid Learning and best-practice dissemination
• Reduce variations in care
• Access for Rural and Underserved Patients, reduced disparities
• Workforce Training and Force Multiplier
• De-monopolize Knowledge • Improving Professional Satisfaction/Retention
• Cost Effective Care- Avoid Excessive Testing and Travel
• Prevent Cost of Untreated Disease
• Integration of Public Health into treatment paradigm
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ECHO® PSYCH (General Psychiatry)
o Funding from New York State Health Foundation
o Expected launch in November 2015
ECHO® GEMH in Long Term Care
o Funding from Greater Rochester Health Foundation
o Expected launch in November 2015
ECHO® Pal (Palliative Care)
o Funding from Greater Rochester Health Foundation
o Expected launch in June 2016
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ECHO® Expansion in NYS
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ECHO® model is a robust method to safely and effectively treat common and complex diseases in underserved areas and to monitor outcomes
UR Medicine - expansion to other disorders may soon follow
Sustainability
Conclusions