the hot spotters - center for health journalism · 2012. 7. 31. · top 10 er diagnosis 2002-2007...
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The Hot Spotters: Lessons from the Front Lines of
America's Health Care Crisis
1Jeffrey Brenner, M.D.
Bending the Cost Curve and Improving Quality in One of America’s Poorest Cities
Jeffrey Brenner, MDExecutive Director/Medical Director
Long-term Federal Debt
More Specialty Care is Not Better Care
- 180 patients randomized to sham arthroscopy vs real arthroscopy with no difference in outcomes- 650,000 arthroscopies/year
Disruptive Change- Patient Centered Medical Home
Geisinger Demo- 18% reduction hospitalization, 36% reduction in 30 day readmissions
History of CCHP
Overview of the Coalition- 20 member board, incorporated non-profit- Foundation and hospital support- Structure of the Coalition:
- Operations- Health Information Exchange- Research/Data/Evaluation- Finance/Admin/Legal
- Programming- Citywide Care Management Project- Camden Chronic Disease/Primary Care Collaborative- Community-based Patient Engagement Strategies
Camden Health Data 2002 – 2011 with Lourdes, Cooper, Virtua data
500,000+ records with 98,000 patients 50 % population use ER/hospital in one year
Leading ED/hospital utilizers citywide 324 visits in 5 years 113 visits in 1 year
Total revenue to hospitals for Camden residents $100 million per year Most expensive patient $3.5 million 30% costs = 1% patients 80% costs = 13% patients
Top 10 ER Diagnosis 2002-2007 (317,791 visits)
465.9 ACUTE UPPER RESPIRATORY INFECTION (head cold)
12,549
382.9 OTITIS MEDIA NOS (ear infx) 7,638079.99 VIRAL INFECTION NOS 7,577462 ACUTE PHARYNGITIS (sore throat) 6,195493.92 ASTHMA NOS W/ EXACER 5,393558.9 NONINF GASTROENTERI (stomach virus) 5,037789.09 ABDOMINAL PAIN-SITE NEC 4,773780.6 FEVER 4,219786.59 CHEST PAIN NEC 3,711784.0 HEADACHE 3,248
11
12
ED visits, 2011
Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011
ED visits, 2011 0 1 2 3 to 4 5+
0 0 1,293 57 4 1
1 26,128 2,075 117 7 0
2 to 3 13,390 1,842 373 68 3
4 to 5 3,216 666 223 118 15
6 to 7 1,020 251 106 84 24
8 to 9 386 112 39 41 11
10 + 339 96 70 65 62
Utilization typology
ED visits, 2011
Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011
ED visits, 2011 0 1 2 3 to 4 5+
0
Normal Range of UtilizationNormal Range of Utilization
Potential High Utilizers
Inpatient High Utilizers
Inpatient High Utilizers
1 Normal Range of UtilizationNormal Range of Utilization
Potential High Utilizers
Inpatient High Utilizers
Inpatient High Utilizers
2 to 3
Normal Range of UtilizationNormal Range of Utilization
Potential High Utilizers
Inpatient High Utilizers
Inpatient High Utilizers4 to 5
Emergency Department
High UtilizersPotential High
Utilizers
Potential High Utilizers
Inpatient High Utilizers
Inpatient High Utilizers
6 to 7Emergency Department
High UtilizersPotential High
Utilizers
Potential High Utilizers
Inpatient High Utilizers
Inpatient High Utilizers
8 to 9
Emergency Department
High UtilizersPotential High
Utilizers
Potential High Utilizers
Inpatient High Utilizers
Inpatient High Utilizers
10 +
Emergency Department
High UtilizersPotential High
Utilizers
Potential High Utilizers
Inpatient High Utilizers
Inpatient High Utilizers
Utilization typology
ED visits, 2011
Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011Inpatient visits, 2011
ED visits, 2011 0 1 2 3 to 4 5+
044,728 (85%) patients5,210 Inpatient visits
63,489 ED visits
$28,000,000 (50%) IP payment$25,800,000 (59%) ED payment
44,728 (85%) patients5,210 Inpatient visits
63,489 ED visits
$28,000,000 (50%) IP payment$25,800,000 (59%) ED payment 985 (2%) patients
1,856 IP visits4,129 ED visits
$10,000,000 (17%) IP payment
$1,700,000 (4%) ED payments
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
1
44,728 (85%) patients5,210 Inpatient visits
63,489 ED visits
$28,000,000 (50%) IP payment$25,800,000 (59%) ED payment
44,728 (85%) patients5,210 Inpatient visits
63,489 ED visits
$28,000,000 (50%) IP payment$25,800,000 (59%) ED payment 985 (2%) patients
1,856 IP visits4,129 ED visits
$10,000,000 (17%) IP payment
$1,700,000 (4%) ED payments
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
2 to 3
44,728 (85%) patients5,210 Inpatient visits
63,489 ED visits
$28,000,000 (50%) IP payment$25,800,000 (59%) ED payment
44,728 (85%) patients5,210 Inpatient visits
63,489 ED visits
$28,000,000 (50%) IP payment$25,800,000 (59%) ED payment 985 (2%) patients
1,856 IP visits4,129 ED visits
$10,000,000 (17%) IP payment
$1,700,000 (4%) ED payments
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
4 to 5
4,961(9%) patients28,447 ED visits
$11,500,000 (27%) in ED payment
1,563 (3%) patients1,239 IP visits6,962 ED visits
$6,700,000 (18%) in IP payment
$2,800,000 (6%) in ED payment
985 (2%) patients1,856 IP visits4,129 ED visits
$10,000,000 (17%) IP payment
$1,700,000 (4%) ED payments
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
6 to 74,961(9%) patients28,447 ED visits
$11,500,000 (27%) in ED payment
1,563 (3%) patients1,239 IP visits6,962 ED visits
$6,700,000 (18%) in IP payment
$2,800,000 (6%) in ED payment
985 (2%) patients1,856 IP visits4,129 ED visits
$10,000,000 (17%) IP payment
$1,700,000 (4%) ED payments
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
8 to 9
4,961(9%) patients28,447 ED visits
$11,500,000 (27%) in ED payment
1,563 (3%) patients1,239 IP visits6,962 ED visits
$6,700,000 (18%) in IP payment
$2,800,000 (6%) in ED payment
985 (2%) patients1,856 IP visits4,129 ED visits
$10,000,000 (17%) IP payment
$1,700,000 (4%) ED payments
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
10 +
4,961(9%) patients28,447 ED visits
$11,500,000 (27%) in ED payment
1,563 (3%) patients1,239 IP visits6,962 ED visits
$6,700,000 (18%) in IP payment
$2,800,000 (6%) in ED payment
985 (2%) patients1,856 IP visits4,129 ED visits
$10,000,000 (17%) IP payment
$1,700,000 (4%) ED payments
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
503 (1%) patients2,026 Inpatient Visits
4,144 ED Visits
$10,900,000 (20%) in IP payment$1,700,000 (4%)in ED payment
Utilization matrix
0
4
7
11
14
1/3/111/4/111/6/111/23/111/27/111/31/112/8/112/9/112/9/112/16/112/19/112/20/112/21/112/22/112/23/113/6/113/6/113/13/113/19/113/27/113/30/113/30/114/2/114/3/114/4/114/18/114/19/114/20/114/21/114/22/114/24/114/25/114/26/115/5/115/6/115/8/115/13/115/16/115/17/115/19/115/21/115/23/115/26/115/28/115/29/115/30/116/3/116/6/116/8/116/9/116/12/116/15/116/16/116/17/116/19/116/20/116/23/116/24/116/25/116/26/116/27/116/28/117/5/117/6/117/8/117/10/117/11/117/12/117/18/117/19/117/21/117/25/117/31/118/6/118/7/118/8/118/10/118/14/118/15/118/20/118/21/118/30/119/15/119/16/119/22/119/28/1110/9/1110/12/1110/13/1110/19/1110/31/1111/10/1111/22/1111/24/1111/24/1112/3/1112/4/1112/4/1112/5/1112/6/1112/8/1112/22/1112/22/1112/23/1112/24/11
Leng
th o
f St
ay
EDIP
Estimated 2011 PaymentED: $38,000 to $76,000 (93 visits) IP: $65,000 to $130,000 (12 visits)Total: $103,000 to $206,000
Saving Estimates30% reduction in utilization :
Patient A
Patient Case Presentation #1 55-yo Male At time of enrollment, admitted for GI bleed and SOB (November 2011) Dual coverage Lives alone in high-rise apartment Complex chronic conditions
ESRD Renal Carcinoma Hepatitis B Hypertension Hyperlipidemia Peripheral vascular disease Asthma Glaucoma (blind in one eye) Sleep Apnea Severe Back Pain
12 Medications daily
www.camdenhealth.org
Patient Case Presentation #1
6-Month hospital utilization 9 ED visits 6 Inpatient stays Average time b/t hospitalization - 45 days
Contributors to hospital readmission Family resistance to sub-acute rehab
November 2011 - CCHP Identified through HIE daily hospitalization report Visited by CT team during hospitalization
RN, LPN, MA
www.camdenhealth.org
Patient Centered Care Coordination
www.camdenhealth.org
Patient
Hospital #1
Sub-Acute Rehab
Hospital #2
Home Nursing
HomePT/OT
Durable Goods
MealsTransport
Dialysis
Nephrology
Transplant
PCPUrology
OncologySurgery
GICardiology
Optho
Pain Mgt
www.camdenhealth.org
www.camdenhealth.org
Patient Case Presentation #2
52 y/o female Spanish-speaking with COPD/Trach/Vent dependent, admitted for resp. distress.
8 readmits last 12months. Avg. admit every 29 days prior to intervention.
No referral, directly outreached by team @ hospital
www.camdenhealth.org
Patient Case Presentation #2
Transitioned at LTACH in Philly, while family trained on vent and vent was placed at home.
Transitioned home and f/u to PCP & Specialist appointments
Currently at home and medically stable – “graduated” May 2012
120 days without hosp. utilization, scooter delivered to home!
www.camdenhealth.org
www.camdenhealth.org
www.camdenhealth.org
Clinical Model
www.camdenhealth.org
Data• Lourdes• Cooper• Virtual
Triage• Assessment• Assignment
High Risk• Medically complex• Socially complex• 6-12
Medical Home• Quality Improvement• Patient Engagement
••Medically complex
••30-90 day Engagement
Interm.Risk
Patients Flagged:• 2+ hospital admissions
< 6 months
Selection Criteria:• History of chronic
disease related admits• Rule out criteria• Assigned to pathway
“Care Transitions”
Daily Admissions Feed
Train local residents to participate in decision-
making over health care resources
Promote collaboration among providers and
between providers and the community
Emergency Department High Utilizers Top 1% 2007CamdenPatients 386Visits 5169Visits/Patient 13.4% visiting more than one hospital 80.6%
TrentonPatients 504Visits 7616Visits/Patient 15.1% visiting more than one hospital 78.2%
NewarkPatients 928Visits 14367Visits/Patient 15.5% visiting more than one hospital 71.1%
Comparing Emergency Room High Utilizers in Camden, Trenton, and Newark
The Plan: Competing ACOs
Cooper ACO
Lourdes ACO
Virtua ACO
A Different ACO Model for Camden
Camden cost savings strategies1. Nurse practitioner led clinics in high cost
buildings2. More high utilizer outreach teams3. Medical home-based nurse care
coordination4. More same day appointments (open
access scheduling)
Lessons from Camden
Strategic ability to filter, focus, and segment Comfort with ambiguity and willingness to
tinker Adaptive challenge not a technical challenge Passion for moving towards standardization
and efficiency when the time is right Meaningful solutions are local, gradual, and
require chunking
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