maryland association of healthcare executives...

Maryland Association of Healthcare

Executives presents:

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PCP Networks-Hospitals-

Post-Acute Care

Population Health Across the Continuum

Session 3

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3

Panel Moderator: Michael Poku, MD, Resident,

Internal Medicine & Urban Health, Johns

Hopkins Hospital

David Stewart, MD, Chair of Family &

Community Medicine, University of Maryland

Jeanne C. Keruly, MS, CRNP, Director of Adult

Ryan White Services, Johns Hopkins

Catherine Hamel, MA, Vice President of

Continuing Care, Greater Baltimore Medical

Center

University of Maryland CareCoordination Center

David Stewart M.D., M.P.H.

Chairman Department of Family and

Community Medicine

University of Maryland School of Medicine

• Primary care perspective of care transition space

•Description of University of Maryland C‐3

•Preliminary data for year I

Goals

Reality: among “frequent utilizers” of

healthcare there exists the following

characteristics•Multiple chronic disease states

•Mental health conditions

• chronic, established diagnosis

• anxiety, depression, PTSD associated with violence

/ trauma

• unresolved grief

• learning disabilities / literacy

• family dysfunction

Characteristics associated with “high

utilizers” of healthcare

•Substance abuse

•Housing: instability ‐> homelessness

•Cultural variances: social ‐> legal

Population Health Models to Address

High Utilizers of Healthcare Must

Consider

•Quality

•Containing costs

•External forces: local ‐> regional ‐> national

•Uniqueness of healthcare organization

Population Health Models to Impact

Quality of Care & Contain Costs

•Health Insurance Plan Model

• telephonic

•Patient Centered Medical Home

• advanced primary care

• embedded care management

•Hospital Discharge Model

• transition from hospital ‐> home ‐> “primary care”

Population Health Models

•Emergency Department Based Model

• ED teams designed to provide care management

•Housing First Model

• emphasis on stability associated with housing

Population Health Models

•Community Based Model

• engages patient “wherever”

• community health worker

•Ambulatory Intensive Care Unit

• high utilizing complex patients receive all primary

care from a high‐risk interdisciplinary team focused

on a defined panel of patients

Care Coordination Center / CCC / C3

Conceptualization

•Transitional Care

•Intensive Ambulatory Care

•Subspecialty: CHF & Sickle Cell

•Potential Fluidity / Cushion

• mental health, substance abuse, further primary &

subspecialty care relationships, define community

health worker role

C3 Team

•Physician medical director

•Nurse manager

•Nursing Coordinator

•Nurses

•Cardiology Nurse Practitioner

•Pharm PhD

•Social worker

•Community Health Worker

•Medical Assistant

•Trainees

Patient Referrals to Intensive

Ambulatory Care Component of C3

•Transitional Care Team located in ER and on Inpatient

Floors

•Hospital Transitional Care Team Program

•Outlying hospital discharges

•Campus Urgent Care

•Primary & subspecialty care outpatient offices

•System hospitals

Intensive Ambulatory Care July 1, 2016

until June 30, 2017

•Scheduled patients 2,350

•Arrived patients 1,292

•Canceled w/o reschedule 389

•Canceled with reschedule 285

•No shows 384

Intensive Ambulatory Care Referrals

July 1, 2016 until June 30, 2017

•Radiology 183

•Vascular surgery / lab 99 / 93

•Internal 87

•Nephrology 61

•Psychiatry 31

Intensive Ambulatory Care Outside

Labs July 1, 2016 until June 30 2017

•Comprehensive chemistry 76

•CBC 57

•Drug screen 55

Total of all labs ordered 420

Intensive Ambulatory Care Year 1

Source of Payment

•Medicare 27 %

•Medical assistance MCO 27 %

•Medical assistance 5 %

•Medical assistance eligible 4 %

•Commercial 2 %

Volumes Pre / Post IAC Visit

0

100

200

300

400

500

600

700

800

900

Pre-IAC ED Post-IAC ED Pre-IAC INP Post-IAC INP Pre-IAC OBS Post-IAC OBS

IAC Volume Pre- & Post-Visit

Patient Referrals to Heart Failure

Program at C3

Inpatient Units

Emergency room

Cardiology

Primary care

Internal C3

Self referral when established

Heart Failure Year 1

•Scheduled patients 1087

•Arrived patients 623

•Canceled w/o reschedule 200

•Canceled with reschedule 173

•No show 87

Heart Failure Year 1 Source of

Payment

•Medicare

•Medical assistance

•Commercial

Volumes Pre / Post Heart Failure

Program

0

50

100

150

200

250

300

350

Pre-IAC ED Post-IAC ED Pre-IAC INP Post-IAC INP Pre-IAC OBS Post-IAC OBS

Volume Pre- & Post-Visit Heart Failure Program

Patient Referrals to Infusion

Component at C3

Heart Failure Program

Sickle Cell Program

Internal C3

Self referral when established

C3 Infusions Year 1

Heart Failure 978

Sickle Cell 896

Total 1874

0

100

200

300

400

500

600

Pre-IAC ED Post-IAC ED Pre-IAC INP Post-IAC INP Pre-IAC OBS Post-IAC OBS

Volumes Pre- & Post-Infusion

Volumes Pre / Post Infusion

Conclusions

•Population health models such as those utilized by the

University of Maryland C3 are valid methods to impact

quality, cost containment, and patients’ experience with

care. Institutions should design and implement such

models depending upon specific population and

organizational needs.

Population Specific Care

Jeanne C. Keruly, MS, CRNP,

Director of Adult Ryan White Services, Johns Hopkins

43

44https://www.hiv.gov/federal-response/policies-issues/hiv-aids-care-continuum

accessed 10/10/2017

Care Continuum

45https://www.hiv.gov/federal-response/policies-issues/hiv-aids-care-continuum

accessed 10/10/2017

HIV Care ContinuumWhere We Are

46https://www.hiv.gov/federal-response/policies-issues/hiv-aids-care-continuum accessed 10/10/2017

HIV Care ContinuumWhy is it Important?

HIV testing and diagnosis

Access care to stay healthy

Stop the spread of the disease

Getting and staying in medical care

Access treatment

Prevention counseling

Lifelong process (no cure)

Antiretroviral therapy

Controls the virus

Reduces sexual transmission of the virus (Treatment as

prevention)

Achieving viral load suppression

Live longer, healthier

Reduce the chance of passing HIV to others

2016 Continuum of Care -

Maryland

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Using data as reported through 6/30/2017

Slide courtesy of Colin Flynn, Maryland State Department of Health

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Testing and Linkage to Care

JHH ED & HIV Clinical Services

• Intake with RN/Social Worker within 48 hours of diagnosis

• Navigators available to counseling/support

• In 2013, 87% successfully linked to care with this intervention

• In 2016, patients diagnosed within the year, 95% linked to care within 90

days, average: 31 days (JHU RSR data, 2016)

Graphs courtesy of Kisten Nolan, RN, MPH

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Engaged and Retained in CareAdherence Monitoring & Navigators

• Engagement in Care is associated with better clinical outcomes

• Missed visits increased mortality1, 2

• Missed visits Lack of viral suppression3

• HRSA and CDC have funded demonstration projects to better

understand what types of programs best support adherence

• Multidisciplinary

• Use of navigators (peers)

• Motivational interviewing techniques4

• JHU HIV program has made use of an adherence strategy since

1997 which includes: nurses, case managers and navigators

1 Giodarno et al. Retention in Care: A Challenge to Survival with HIV Infection; CID, 2007.2 Mugavero et al. Beyond Core Indicators of Retention in HIV Care: Missed Clinic Visits Are

Independently Associated With All-Cause Mortality. Clin Infect Dis. 20143 Mugavero et al. Early retention in HIV care and viral load suppression: implications for a test

and treat approach to HIV prevention. Acquir Immune Defic Syndr. 2012.4 Gardner et al. Efficacy of a brief case management intervention to link recently diagnosed HIV-

infected persons to care. AIDS 2005

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Engaged and Retained in CareAdherence Monitoring

Clinical Pharmacists (2) & Registered Nurses (10)

InstructionMedication Readiness AssessmentMedication Teaching & SimplificationSide effect management

Instructions in the use of Adherence Tools Pill box, cell phones, diary, medication calendar

HIV 101 education

Adherence monitoring Self reportPill box refill demonstrationContinuous pill box refillPharmacy pick up review

Slide Courtesy of Shivaun Celano, Pharm D

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Engaged and Retained in CareAdherence and Navigation Services

Patient Navigator (5): works directly with patient and the clinical care team. HIV navigation is a process of service delivery to help a person obtain timely, essential and appropriate HIV-related medical and social services to optimize his or her health and prevent HIV transmission and acquisition. 1

Navigators in our HIV practice

Meet and greet new patients

Support newly diagnosed (ER and Inpatient units)

Serve as group facilitators

Escort patients to outside visits or procedures

Long-term support to selected patients

Outreach in the community

Document activities in the EMR (member of the team)

Patrice Henry, a patient advocate/community program coordinator for the Moore Clinic at Johns Hopkins Hospital, also was diagnosed with HIV in 1995. She's pictured outside the Carnegie Building at Johns Hopkins Hospital, which houses the clinic. (Algerina Perna, Baltimore Sun) http://www.baltimoresun.com/health/bs-hs-aids-women-20120308-story.html

1

https://effectiveinterventions.cdc.gov/en/HighImpactPrevention/BiomedicalInterventions/HIVNavigationServices.as

px

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Engaged and Retained in Care

Practice Enhancements

Care Teams Medical provider (MD, PA-C, CRNP) teamed with a nurse and case manager

to support care coordination

Co-located Services within the main ambulatory practice 5 Subspecialty services Substance Abuse treatment- buprenorphine Medical case managers, nurses and navigators Group counseling

On site Pharmacy

Ability to purchase medications/support payment of copays

Care programs within the larger care program ACE – dedicated multidisciplinary group for young adults Latino – multidisciplinary group for Latino population Surrounding County Program – providers, nurses and case manager travel

to health departments and health centers (9) to deliver HIV specialty care

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Engaged and Retained in CarePractice Enhancements

Care Coordination post Acute Care

HIV Clinical program has had a dedicated inpatient since 1985

Managed by ID faculty; Dedicated RN care coordinator; Social

Worker

HIV provider notified of admission and discharge (EMR

notification & notification from the and Care Coordinator

Discharge Planning

Appointment with the primary HIV provider within 7 days of

discharge

All medications filled at the time of discharge (pill box) and

appointments to specialty providers are made.

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Engaged and Retained in CarePractice Enhancements

Care Coordination post Acute Care Stay

•HIV Clinical program has had a dedicated inpatient since 1985

• Managed by ID faculty; Dedicated RN care coordinator; Social

Worker

• HIV provider notified of admission and discharge (EMR

notification & notification from the and Care Coordinator

• Discharge Planning

• Appointment with the primary HIV provider within 7 days of

discharge

• All medications filled at the time of discharge (pill box) and

appointments to specialty providers are made. Outpatients

Social work and Navigators engaged if warranted.(

55https://www.hiv.gov/federal-response/policies-issues/hiv-aids-care-continuum

accessed 10/10/2017

Care Continuum

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Prescribe Antiretroviral Treatment (ART) to Achieve Viral Suppression

Demonstration Projects to Fast track initiation of ART

Pilcher, JAIDS, 2017

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Prescribe Antiretroviral Treatment (ART) to Achieve Viral Suppression

Why Rapid HIV Treatment initiation (RHTI)?

Early ART start with sustained viral suppression decreases morbidity and mortality with risk of transmission negligible to non-existent (START Study, HPTN 052, PARTNER study)

INSIGHT START Study Group, NEJM, 2015

Cohen, NEJM, 2011

Rodger, JAMA, 2016

Slide courtesy of Joyce Jones, MD

Successful Rapid HIV Treatment

RapIT South AfricaRAPID San Francisco Port-au-Prince, Haiti same-day ART initiationIMPROVED ART INITIATION, VIRAL SUPRESSION, RETENTION (S. Africa, Haiti)

Rosen, PLOS Med, 2016

Pilcher, JAIDS, 2017

Koenig, PLOS Med, 2017

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Prescribe Antiretroviral Treatment (ART) to Achieve Viral Suppression

Project RHAE: Rapid HIV treatment initiation access and engagement in care (funding: CFAR)

Recruitment: Johns Hopkins ED, BCHD STD clinics, John G. Bartlett Specialty Practice

Criteria: Newly diagnosed and previously diagnosed patients (no ART and no care >6 months)

Treatment: Patients receive 14 days of HIV medication + expedited access to clinical services

Outcomes Number of patients started on ART

Time to ART initiation Number of patients who achieve an undetectable HIV viral load Retention in care

Slide courtesy of Joyce Jones, MD

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HIV Care ContinuumJHU HIV Services

Large HIV Clinical Practice Urban, regional and rural HIV Specialty Care

Significant external support for “Practice Enhancement’ 3 million dollars annually in clinical care and supportive

service funding

Able to achieve good clinical outcomes > 95% prescribed ART 89 % viral load suppression

GBMCCatherine Hamel, MA

VP Continuing Care and President, Gilchrist

Reducing Avoidable

Admissions

General Strategies

Building a Continuing Care Network

Integrating Behavioral Health

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GBMC HealthCare System

6

2

ALLEGANY

ANNE

ARUNDEL

BALTIMORE

CALVERT

CAROLINE

CARROLL CECIL

CHARLES

DORCHESTER

FREDERICK

GARRETT

HARFORD

HOWARDKENT

MONTGOMERY

PRINCE

GEORGE'S

QUEEN

ANNE'S

ST.

MARY'S

SOMERSET

TALBOT

WASHINGTON

WICOMICO

WORCESTER

BALTIMORE COUNTY

BALTIMORE CITY

CARROLL COUNTY HARFORD

COUNTY

HOWARD COUNTY

Resources for this work ED Care Managers

Community Health Worker, Mosaic

Care Managers

Inpatient Care Managers

Hospitalists

Advanced Care Management (Palliative Care)

Continuing Care Network

Skilled Nursing Facility Network

Elder Medical Care at Home

Elder Medical Care in residential care facilities

Hospice, Inpatient, home and residential care

Primary Care Providers

Medical Assistants

Patient Service Assistants

Care Manager

Care Coordinator

Behavioral Health Specialists

Psychiatrist

LCSW-C

Substance Abuse Specialists

General Strategies

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Delivering the Right Care to

Patients at GBMC Health Care

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Primary Care Providers

Medical Assistants

Patient Service Assistants

Care Manager

Care Coordinator

Dying

Advanced

Illness

Chronic Disease

~15 – 30% of Patients

Healthy Individuals

Individuals with Asymptomatic

Conditions

~ 60 – 80% of Patients

5% of

Patients

GBMC Services

Complex Illness

Advanced Primary Care

Patient-Centered

Medical Home (PCMH)

Medical Neighborhood

PCMH

Specialists

Medical and Surgical

Hospital Care

Gilchrist Hospice Care

Elder Medical Care

Home and Residential Care

Advanced Care

Management/Palliative Care

Specific Initiatives

Risk Screening

“Mandatory” Wrap-around services

PCP Appointments

“Loyalist” Care Plans and Care Alerts

ED, Inpatient, PCMH’s, Payers

Serious Illness/End of Life Care

“Mandatory” triggers for PC consults

Dartmouth Atlas Data 2014Understanding the Efficiency and Effectiveness of Health Care

*Hospital with significant hospice affiliations/ownerships

**Region High

***Region Low

HOSPITAL % admitted to hospice Hospice Days

GBMC 66.6%* ** 20.5

Carroll Hospital Center 61.6% 15.1

UM St. Joseph 60.2% 17.3

Howard County GH 59.4% 20.9

Medstar Franklin Square 58.8% 17.7

Northwest Hospital 58.2% 16.4

UM Upper Chesapeake 57.2% 21.1

Johns Hopkins Hospital 54.1% 21.4 **

Medstar Harbor Hospital 54.1% 19.3

Harford Memorial 51.8% 19.8

Region Low 29.0% 8.3

Maryland Average 49.3% 19.0

Building a Continuing

Care Network

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Continuing Care Network

RFP’s, HH, LTC, Adult Day Care, Ambulance

Liaisons, Rounds

Quarterly meetings-Metrics/Goals

Collaboratives

Readmissions Committee/Data

ED Messaging from LTC

Case Studies reviewed

New Programs Elder Medical Care

Advanced Care Management, LTC

Integrating Behavioral

Health

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The PCMH Care Team Restructured

Physician Lead and Practice Manager

Primary Care Providers

Medical Assistants

Patient Service Assistants

Care Manager

Care Coordinator

Behavioral Health Consultant (Sheppard Pratt)

Substance Use Consultant (Kolmac Clinic)

Psychiatrist/Specialist (Sheppard Pratt/Mosaic)

Community Health Workers (Mosaic)

ED Interventions

Mosaic Community Health Worker

Joined the team in June 2017

Key responsibilities

Placement assistance

Continuity for existing Mosaic patients

Reconnect to existing services

160 cases placements

60 “reconnections”

Data collection on placement gaps

Substance Use

15,849 screenings on primary care patients (NIDA tool)

269 visits performed with Substance Use Consultant

from Kolmac