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Enhanced Care Program: A Model for Complex Care Management Jodie Bryk, MD Medical Director UPMC General Internal Medicine Oakland (GIMO) 1
Enhanced Care Program: A Model for Complex Care Management
Jodie Bryk, MD Medical Director
UPMC General Internal Medicine Oakland (GIMO)
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Patient Narrative #1
• Sally is a 57 year old woman with cocaine-induced cardiomyopathy, morbid obesity, and bipolar disorder hospitalized 4 times in the cardiac ICU with congestive heart failure, requiring milrinone. Palliative and cardiology gave her a prognosis of 6 months. She lived alone, was estranged from her children, not taking her medications, and using actively.
• Our team met her during an admission, and asked her if she felt she wanted to change. She said yes, but was scared of being able to do this.
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Patient Narrative #2
• Jake is a 60 year old with cyclic vomiting syndrome, with over 40 trips to the ED.
• He’d undergone 18 abdominal CTs – all negative
• He has a systemic inflammatory response in reaction to the pain – with IV dilaudid the only way to manage this
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Objectives
• Background: – Current Model of Primary Care – Key Stakeholders – Complex Care Management
• Intervention: Enhanced Care Program – Aims – Program Description
• Evaluation: – Methods – QI vs. Research? – Successes/Barriers
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Objectives
• Background: – Current Model of Primary Care – Key Stakeholders – Complex Care Management
• Intervention: Enhanced Care Program – Aims – Program Description
• Evaluation: – Methods – QI vs. Research? – Successes/Barriers
5
Background: PCMHs
• GIMO is a Level 3 Patient-Centered Medical Home (PCMH)
• Limited effects on quality, utilization and costs of care
Friedberg, JAMA, 2013. Jackson, Ann Intern Med, 2013. Rosenthal, JAMA, 2013. 6
• Methods:
– 32 medical home and 29 comparison practices – June 2008 through May 2011
• Results: – 11 quality measures medical home improved on only 1 – Medical home participation increase in ambulatory care-
sensitive hospitalizations in year 2 – No other statistically significant measures of utilization or
costs of care
7 Friedberg, JAMA, 2013.
Background: The Problem
• 5% of population ~50% healthcare expenditures
• PCMHs not providing enhanced, coordinated services to these “hot spotters” or super-utilizers
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Cohen, Stat Brief, 2012. Gawande, New Yorker, 2011.
Background: “Hot spotters”
• ED utilization concentrated in small proportion of population
• Common co-morbidities: – Substance abuse – Mental illness – CHF – DM – COPD – HTN
• Other predictors: – Housing instability – Social isolation
9
Fuda, Annals of Emer Med, 2006. Raven, J Urban Health, 2009. Mautner, Pop Health, 2013.
Background: Key Stakeholders
• Patients with complex medical and psychosocial needs find it difficult to navigate healthcare system
• PCPs lack time and resources
• UPMC Health Plan burdened with unnecessary costs
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Background: Complex Care Management (CCM)
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•Review of models and practices of 18 successful CCM programs
Background: Key Components of CCM
• Identifying high-utilizing patients
• Comprehensive health assessment
• Care coordination
• Rapid access to care
12 Hong, Commonwealth Fund, 2014.
Background: Key Components of Effective CCM
• Tailor to context
• Identify patients at high risk and could benefit
• Tailor CCM team
• Patient needs caseload/# of interactions
• Build trust
• Coordinate care
• Use technology
13 Hong, Commonwealth Fund, 2014.
Background: Review Conclusions
• No meta-analysis
• Most programs improved quality and/or reduced acute care utilization
• Effects on net costs inconsistent thus far need more evidence
14
Hong, Commonwealth Fund, 2014. Hong, NEJM, 2014.
Objectives
• Background: – Current Model of Primary Care – Key Stakeholders/“Hot Spotters” – Complex Care Management
• Intervention: Enhanced Care Program – Aims – Program Description
• Evaluation: – Methods – QI vs. Research? – Successes/Barriers
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Intervention: Aims
• Our QI project is implementing an Enhanced Care Program (ECP) to meet the needs of our complex patients.
• The aims of this project are: – Aim 1: To reduce healthcare resource
utilization for complex patients – Aim 2: To improve continuity and quality of
care for complex patients – Aim 3: To improve patient
experience/satisfaction with care for complex patients participating
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Intervention: Funding
• Funded by the UPMC Health Plan.
• Collaboration between UPMC Health Plan and the University of Pittsburgh Physicians (UPP).
• “Shared savings" program i.e. savings are being used to fund the ECP with hopes that more savings can be created to be shared with the HP and GIM
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ECP: Participant Inclusion
• PCPs and ECP team identify appropriate patients: 1) > 6 ED visits OR > 2 inpatient hospitalization in the last year 2) 18 years of age or older; 3) UPMC Health Plan member; 4) Receive primary care at GIMO; and 5) Agreed to participate.
• Contacted by phone by PCP or ECP team • Aim to enroll and follow 300 patients over 3 years
• 888/11,626 or ~8% of all GIMO patients meet eligibility criteria to
be in the ECP
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ECP: Participant Exclusion
• Patients beyond the scope of ECP:
– reside in a skilled nursing facility,
– reside in an area outside the network of UPMC Home Nursing,
– have non-ambulatory sensitive medical conditions,
– are hospice patients, or
– PCP feels program would be disruptive current plan of care
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ECP: The Team
• Funded by the UPMC Health Plan • Comprised of
– 1 FTE physician, – two full-time nurse care managers, – a full-time medical secretary, – a part-time community case manager Also assistance from: – a pharmacist, – a psychologist, – a psychiatrist
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ECP: Collaborations
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ECP: Program Description
• Extensive chart review – all problems listed
• Initial comprehensive care appointment with ECP team individualized care plans
• Collaborate with family, existing medical and mental health teams
• Connect with HP case manager to connect to community resources
• Connect to mental health
• Delivered, pre-packaged medications
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ECP: Program Description
• 24/7 direct access to ECP team via direct cellphone
• Urgent care walk-in clinic
• Home visits
• ED collaboration
• Hospital collaboration
• Discharge planning
• Daily huddle meetings
• ECP database
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ECP: Graduation
• Once patients have met care plan goals and able to self-manage in the standard care system
• Discharge summary provided to PCP and nurses, as well as practice-based care manager
• Patient has ECP number and low-threshold for readmission
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Patient Narrative #1 Follow-up
• We did an initial 1.5 hour appointment, determined barriers in her care.
• We connected her with transportation, home telehealth, delivered pre-packaged medications, a home behavioral health nurse, and weekly visits
• We created an ED diversion plan as she frequently went to the ED with anxiety-induced tachycardia
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Patient Narrative #1 Follow-up
• With taking her medications routinely, we were able to wean off milrinone drip
• She has remained clean for 7 months
• She feels empowered
• Her next goal is losing weight and is taking classes in medical assisting
• She is reconnecting with her family who is proud of her progress and just enjoyed an Easter egg hunt with them
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Patient Narrative #2 Follow-up
• At his initial appointment, we reviewed the triggers leading to episodes in detail – mainly stress.
• We made a ED diversion plan to take ativan at onset of symptoms and come to the clinic for guidance in deep breathing/relaxation methods
• We invited his wife to come to a follow-up appointment who gave the collateral information, he showered up to 20 times per day during episodes
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Patient Narrative #2 Follow-up
• Although the patient initially downplayed his marijuana use, with his wife in the room, he admitted to using chronically “for years.”
• He stopped marijuana and his episodes have improved
• At the start of episodes, he comes to the clinic for IV zofran and relaxation coaching
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Objectives
• Background: – Current Model of Primary Care – Key Stakeholders/“Hot Spotters” – Complex Care Management
• Intervention: Enhanced Care Program – Aims – Program Description
• Evaluation: – Methods – QI vs. Research? – Successes/Barriers
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ECP: Evaluation
• Comparison of
– complex patients in ECP for 1 year vs.
– comparison group of propensity-matched controls
• Pre/post evaluation
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ECP Evaluation: Outcome Measures
• Primary outcome:
Utilization: # of hospitalizations, # of ED visits, specialist visits, PCP visits
• Secondary outcomes:
– Continuity: % of PCP visits, # of unique providers
– Quality of care: HgbA1C, blood pressure, preventive care
– Pt satisfaction: surveys
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ECP Evaluation: Data Sources & Analysis Plan
• Data sources: claims data, EMR, ECP database
• Appropriate statistical testing will be performed
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ECP: Successes
• Coordinating care
• Reducing ED visits and hospitalizations
• Improving clinical outcomes and updating health maintenance
• Establishing meaningful relationships with patients and building trust
• Easier access to mental health
• Engage patients in self-management
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ECP: Barriers
• Developing the team
• Workload: quality versus quantity
• Discharging patients
• Resistance to change
• Financial barrier: “…unrealistic expectations for a return on investment in less than 3 years.” -Dr. Clemens Hong
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Hong, NEJM, 2014.
Take Home Points
• PCMHs limited effects on healthcare quality and utilization, while complex care management programs show promise
• Super-utilizers/hot spotters tend to have chronic illnesses, particularly substance abuse and mental illness, and lack social supports
• ECP = multi-disciplinary, coordinated, 24/7 accessible care
• QI the GOAL is improvement, not evaluation • Seeing day-to-day successes so far
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Acknowledgements
• UPMC Health Plan • Wishwa Kapoor, MD • Marian Essey, RN • Pamela Peele, PhD • James Schuster, MD • John Reilly, MD • Gary Fischer, MD • Joanne Riley, RN • Thui Bui, MD • Jackie Cunnard, RN • Bob Arnold, MD • Patty Daub, RN
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References
1. Cohen S. The concentration and persistence in the level of health expenditures over time: estimated the U.S.
population, 2009-2010. Stat Br no 392 Rockville, MD Agency Healthc Res Qual 2012;(November):2009–10. 2. Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association between participation in a
multipayer medical home intervention and changes in quality, utilization, and costs of care. Jama 2014;311(8):815–25.
3. Fuda KK, Immekus R. Frequent users of Massachusetts emergency departments: a statewide analysis. Ann Emerg Med 2006;48(1):9–16.
4. Gawande A. The Hot Spotters. New Yorker 2011. 5. Hong CS, Siegel AL, Ferris TG. Caring for high-need, high-cost patients: what makes for a successful care
management program? Issue Br (Commonw Fund) 2014;19:1–19. 6. Hong CS, Abrams MK, Ferris TG, Press MJ. Toward increased adoption of complex care management. N Engl J
Med 2014;371(6):491–3. 7. Jackson GL, Powers BJ, Chatterjee R, et al. Improving patient care. The patient centered medical home. A
Systematic Review. Ann Intern Med 2013;158(3):169–78. 8. Mautner DB, Pang H, Brenner JC, et al. Generating hypotheses about care needs of high utilizers: lessons from
patient interviews. Popul Heal Manag 2013;16 Suppl 1:S26–33. 9. Raven MC, Billings JC, Goldfrank LR, Manheimer ED, Gourevitch MN. Medicaid patients at high risk for frequent
hospital admission: real-time identification and remediable risks. J Urban Health 2009;86(2):230–41. 10. Rosenthal MB, Friedberg MW, Singer SJ, Eastman D, Li Z, Schneider EC. Effect of a multipayer patient-centered
medical home on health care utilization and quality: the Rhode Island chronic care sustainability initiative pilot program. JAMA Intern Med 2013;173(20):1907–13.
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