Umpqua Health AllianceUmpqua Community Health Center

Extended Care Clinic

Integrated clinic for patients with complex health and addiction issues

Physical Health Mental Health Addictions TX

• Assessment• Diagnosis• Treatment Plan (EBP)

• Pre-set rate per service

• Monitor / Update

OHP Client

• Assessment• Diagnosis• Treatment Plan (EBP)

• Pre-set rate per service

• Monitor / Update

• Assessment• Diagnosis• Treatment Plan (EBP)

• Pre-set rate per service

• Monitor / Update

Oral Health

• Assessment• Diagnosis• Treatment Plan (EBP)

• Pre-set rate per service

• Monitor / Update

Why This Why Now?

CCO created a culture which allowed providers to bring these local activities into the next generation of integration

Current Conditions

Douglas County is ranked thirty-one (31) out of thirty-three (33) counties for poor health outcomes in a National study

Intergenerational issues of at risk behaviors which impact health:• Smoking• Substance abuse• Poor diet• High poverty rates

High rate of chronic diseases – Poor personal health care (disease management)

People with chronic health conditions and mental illnesses on average die 25 years younger than counterparts

Limited access to health care

Overuse of ER due, in part, to waiting until health issues escalate, limited access to care, poor personal health care, etc

Fragmented health care systems limits implementation of evidence based practices and increases health risks

Above conditions drive health care cost

Leading Causes of Death (Crude Death Rates per 100,000: 2005-2009)Douglas County Rural OR Roseburg Sutherlin

Myrtle Creek Winston

Drain/Yoncalla Glide Canyonville

Cancer 269.2 232.7 191.4 231.7 322.3 265.5 261.9 335.2 198.4 352.5Heart Disease 248.5 210.1 169.4 219.5 263 207 250.6 301.2 198.4 504.5Cerebrovascular Disease (Stroke) 59.9 60.4 51.2 53.4 86.7 49 40.6 63.6 41 82.9Chronic Lower Rispiratory 77.4 63.8 48.8 63.9 89.6 64.8 106.1 89.1 41 82.9Unintended Injuries 57.2 50 41 42.4 60.7 75.8 51.9 84.9 88.9 76Alzheimer's 39.8 35.9 32 46.4 33.2 30 36.1 46.7 13.7 48.4Diabetes 39.4 33.7 28.4 32.2 43.4 55.3 36.1 12.7 41 69.1Flu & Peumonia 17.8 15.8 13.5 20.4 17.3 20.5 9 0 13.7 20.7Suicide 21.4 18 15.3 18.3 20.2 30 22.6 12.7 34.2 13.8Alcohol Induced 17.8 16.7 13.8 17.9 14.5 19 2.3 29.7 13.7 13.8

Prevalence Rate (per 1,000 Eligible - 2011 – OHP)

One Two Three Four Five Six

One 339 107 48 18 5 2 519

Two 103 45 14 16 6 1 185

Three 18 11 3 3 1 0 36

Four 6 1 1 0 0 0 8

Five 1 0 1 0 0 0 2

Six 1 0 0 0 0 0 1

468 164 67 37 12 3 751

Number of Physical Health Conditions

Total

Number of Mental Health Conditions

Total

All OHP Clients At High Risk -

Chronic DiseaseChronic Disease

Coordinated case management – Reduce high end costs

Coordinated case management – Reduce likelihood become chronic

Early Assessment & Identification of High Risk For Chronic Disease

Improve Health System, Improve Health Outcomes, Lower Costs

All OHP Clients At High Risk -

Chronic DiseaseChronic Disease

Coordinated case management – Reduce high end costs

Coordinated case management – reduce likelihood become chronic

Early Assessment & Identification of High Risk For Chronic Disease

All OHP Clients At High Risk -

Chronic DiseaseChronic Disease

Coordinated case management – Reduce high end costs

Coordinated case management – reduce likelihood become chronic

Early Assessment & Identification of High Risk For Chronic Disease

All OHP Clients At High Risk -

Chronic DiseaseChronic Disease

Coordinated case management – Reduce high end costs

Coordinated case management – reduce likelihood become chronic

Early Assessment & Identification of High Risk For Chronic Disease

Savings = reinvestment into system – incentive, etc.

REALLY?

Cost Impact Sample – Using Diabetes for Douglas County:

Number of Persons:

Number of Deaths:

Costs:

9,300

531

$42.6M

If you can prevent 4.67% of people from getting Diabetes:

Number Prevented: 437

Lives Saved: 32

Financial Cost Savings: $2 M

If you can prevent 20% of people from getting Diabetes:

1,860

121

$8.52 M

Cost Impact Sample – Using Diabetes for Douglas County:

If you can prevent 4.67% of people from getting Diabetes:

Number Prevented: 437

Lives Saved: 32

Financial Cost Savings: $2 M

If you can prevent 20% of people from getting Diabetes:

1,860

121

$8.52 M

$8.52 Million Question:What is the likelihood of preventing 5%, 10%, 20% of population from getting

Diabetes?

The risk of Type 2 Diabetes can be reduced by

50-70% by control of obesityAnd by

30-50% by increasing physical activity

• Personal impact cannot be quantified• Can apply model to other chronic diseases – Each has risk

factors which increase the likelihood of illness:

Heart Disease and Stroke Prevention:•No tobacco•Physically active•Healthy weight•Healthy food choices•Preventing / controlling high blood pressure•12 – 13 point reduction in average systolic blood pressure over 4 years reduces heart disease risk by 21%, stroke risk by 37%

Cancer Prevention:•No tobacco•Limiting alcohol•Limited exposure to ultraviolet rays•Diet rich in fruits and vegetables•Maintaining a health weight•Being physically active•Seeking regular medical care

PCP

Oral HealthMental HealthAddictions

Health Integration System

Behavioral Health

Mental Health

Dental Health

Patients

Physical Health

Neighborhood Health

Family

Spiritual Community Providers

Peers

“How would a patient with chronic health conditions, mental health issues and substance abuse problems receive effective treatment through an integrated system of care in Douglas County?”

What do you think about health integration?

Purpose Statement - The team (health, mental health and substance abuse treatment) provides prevention and integrated health care (physical, mental health and substance abuse treatment) for OHP members with or at risk of chronic conditions in order to improve health outcomes and reduce costs.

Low Risk OHP Members(Provide episodic treatment (members only

needing short-term or one time treatment and screening / assessment to identify high risk

members)

High Risk – Early Identification and Intervention (Prevention)

Chronic Disease – Coordinated Intervention

Target Population Focus

• What model?• Best serve

complicated patients?• One from around

Oregon• Nationally recognized

• What will be built ---

Patient AdvocateMedical Case Manager (Nurse)

NurseClinic Manager

MH Case ManagerPsychiatric Nurse Practitioner

Behavioral SpecialistReceptionist

Medical AssistantDoctor

RX Coordinator

What do you want for these patients – “survey responses”:

• I am involved in – help direct my health care (engaged)• I have easier access to care• One stop care – each team member is understanding and helpful• I am part of the team & feel empowered to help myself• I am heard – listened to – my input matters• I receive better health care through each team member• I am better able to manage my health • I learned to take charge of “my health”• I feel better• I would refer family / friends to the clinic• I took skills learned about managing my health needs and applied

them to other parts of my life…

Who does what….

Day 1 – Develop the model…

• Start with the “empty chair” –• How might they feel that day• How to get to the “want” list? – who will do what

• Engagement – goal setting• Referral• Meeting them• Screening• Clinic education• Meeting the team• Information sharing• Scheduling• Daily huddle• Weekly review meetings

What are we doing right?•Build relationships - bring people to the table•Focus on processes•Start with something that can be fixed•Keep momentum and don’t get stuck•Bring it back to the patient and quality of care•Optimize productiveness of meetings – set goals, use a facilitator, have food….•Always find the Win Win•Respect the expertise of the team•Allow for a paradigm shift

Changes in Oregon Health PlanFederal Accountable Act

Healthcare Coordination & Integration

Coordinated Care Organizations

Dual E

ligibi

lity

Global Budgets For All

Primary Care Health Homes

Metrics /

Perform

ance M

easures

Community Advisory Councils