Coordinating Chronic Care Delivery

through Technology and Innovation

Nick Macchione, FACHE Director, Health & Human Services Agency

County of San Diego, California

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Our Purpose…

Vision

Safe, Healthy, and

Thriving Communities

Mission

Make people’s lives safer, healthier and self sufficient by managing essential services.

What the HEALTH is

going on in San Diego?

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Lif

e E

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Years

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Year of Birth

San Diego County Life Expectancy 1990 - 2009

Prepared by Public Health Services, Epidemiology & Immunization Services Branch, June 17, 2011

Today, in San Diego County we have…

Grim Outcome…

What is the economic impact?

“Change the way you see

before you can change the way you look.”

- Nick Yphantides, MD, MPH

Call to Action on Discovery!

“Discovery consists in seeing

what

everyone else has seen, and

thinking what no one else has

thought.”

-Albert Szent-Gyorgi

We See the Symptoms Everyday

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Physicians’ Perspective

Courtesy of the VIP Program, Rush University Medical Center, Chicago, Illinois.

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San Diego Physicians’ Report: Barriers in Caring for the Chronically Ill

– Multiple chronic problems – Drug-drug interactions – Physical disability – Functional Impairment – Environmental / Cultural Diversity – Economic Stressors – Patient and Provider Navigation Challenges – And of course, dwindling gov’t reimbursement.

17 March 19, 2008 Team San Diego GMU Module 1 Draft 17

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Patient’s Perspective

Courtesy of the VIP Program, Rush University Medical Center, Chicago, Illinois.

Patient’s Experience

• Aging Population

– San Diego County to increase significantly

• Elderly: 14% in 2008 25-33% by 2030

• From 1990 to 2010, 75 YO’s increased by 81%

• 85+/minority elderly: fastest growing segments

– 60% of those 65+ will require long term care services at some point.

– Those who need service can’t find it.

– Care is fragmented!

– Providers now asked to do more with less.

At the dawn of the 21st Century Coping with Long-term Conditions is the Norm

• 1 in 4 Americans have a chronic illness

• 54 million Americans have some level of disability

• 50% of Adults > 65 years old report limitations of activity • Adults > 80 years old... - 25% in chronic care facilities - 40% need assistance with ADLs

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Number of Chronic Conditions per Medicare Beneficiary

Number of

Conditions

Percent of

Beneficiaries

Percent of

Expenditures

0 18 1

1 19 4

2 21 11

3 18 18

4 12 21

5 7 18

6 3 13

7+ 2 14

63% 95%

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Challenges in Our Local Health Systems

• The health care system is increasingly complicated and difficult for patients, providers, payers and policy makers;

• Primary care physicians are under increasing pressures;

• Increased cultural and social diversity coupled with the complexity of health and human services in the community, challenges traditional medical practice effectiveness;

• The emergence of chronic illness as the major reason for medical

encounters rather than acute care;

• The demographic shift is complicating all of the above.

• Public budgets can not sustain current model of care.

So, ready for true “health” reform or just merely more of the same “sick care”

janitorial services?

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Live Well, San Diego! Blueprint for Building Better Health

Changing Culture From Within

Healthy Choices

Better Service System Policy/Environment Change

Accountable Care Community

Informed, Activated Individual

Productive Interactions

Integrated, Proactive Health

Environment

Delivery System

Re-Design

Decision Support

Interoperability Self-Management Support

Health System Primary Prevention

Community Health Plans, ACOs, etc

Bottom Line is Better Health! Healthier Communities Healthier People…Healthier Workers Healthier Business…

Healthier and Thriving Economy! 25

Employers Work Safe, Stay Healthy

Schools No Child Left Behind…in Academics and Health!

Accountable Care Communities

What the Future Holds…

“The biggest scale that you can get

requires the simplest idea. And you

achieve this by connecting with

people.”

- Bono, U2

Improve quality of life… and reduce economic waste.

Our Challenge:

Care Transitions Intervention (CTI)

Evidence-based Coleman Model “to coach, not do,”

• Establish and maintain PHR • Establish and maintain Medication List • Prompt follow-up with specialists • Recognition of “Red Flags”

CTI applies technology in multiple ways to support chronic-disease

self-management.

Focus is the transition from hospital to home. Help discharged patients better understand their treatment plan and what they can do to help

themselves succeed at home.

“Patient

Experience”

• Donald Ryan is a 85 Y.O. • Has multiple chronic

conditions: • Diabetes • High Cholesterol • Heart Problems • And more..

• Donald is mentally sharp and knows he has to loose weight.

• His goal, Not to sleep in any more hospital beds but his own.

•Team San Diego involves PCPs and PHNs, like Melissa Thun, County PHN, who is a Transitions Coach. •She meets with Donald before and after his hospital discharge to review his “personalized health goals” •Follows up with series of phone calls with Donald and his caregiver. •Emphasis is helping Donald recognize the “red flags” of his condition so he’s better able to see when trouble might be around the corner. and act to avoid it.

“Provider

Process”

• Donald also agreed to participate in our Tech4Impact .

• Thai Sukrachan, County Tech analyst, visits Donald in his home to train him on the use of the web and his PHR.

• Help Donald set up and learn how to maintain his own free confidential PHR on the NOC.

• Donald uses the County’s AIS Network of Care (NOC) which allows him to keep track of all his medical instructions.

• Donald also gives permission to his daughter, Jane, to access his information and communicate with Melissa, his PCP and all of his clinical specialists .

“Personalized

Technology”

• Donald reports that he’s finally “feeling normal” again.

• He takes walks with his sons and has started a Weight Watchers program wit his daughter.

• Regards to his PHR - “It helps me communicate the kind of information that my family needs.”

• “I’m hopeful for the next year. I want to see what I’m like when I’m 86. And when I hit 100, I want a big b-day party.”

“Personal

Benefit”

Donald Ryan

“Payoff”

• Comparison groups: 88 patients who completed CTI and were at least 90 days post discharge and Sharp Memorial Hospital patients admitted during the 2009 calendar year with the same dx as the CTI patients .

• A readmission was defined as an inpatient readmission for the same diagnosis to the same hospital .

• 7 out of the 88 CTI patients were readmitted; for a total of 9 readmissions .

• Based on past experience, expected number of readmissions would have been 21.

• Pilot cost $157,557. • Average charge per readmission for the

Sharp group was $59,540; estimated “net benefit” for the CTI program totaled $556,928 or an estimated per patient savings of $6,329.

CTI has had a measurable impact:

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Within 30 Days Within 60 Days Within 90 Days

2.3%

5.7%

8.0%

12.6%

17.0%

24.3%

CTI Readmission Rate SMH Readmission Rate for 2009

Wellness Focused Care needs a Team Approach

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Healthy Bottom Line!

Public-Private System

Developing internal capabilities to better optimize existing programs & services

Focus is InterOPTIMALability

Innovating practical solutions across all industry sectors

Expanding public-private partnerships in furthering our Accountable Care Community

The Road

Ahead

Building Better Health through

Partnerships

• Our mission – The Noblest Motive is the Public Good.

• Trusted local conveners in furthering social entrepreneurism that drives innovation and sustainable transformations that helps improve the QOL thru ROI.

• Horrendous fiscal environment without relief in near sight…however, with crisis comes opportunities.

• Wise investment in technology tied to effective policies and operational reengineering will bolster our strategic capability to serve constituents more efficiently with increased value while reducing economic waste.

• Discover operational efficiencies in existing core services while building new, innovative programs and still earn the public’s trust.

Nick Macchione, FACHE Director & Deputy Chief Administrative Officer

Health & Human Services Agency

County of San Diego, CA

Executive Assistant: Ms. Aurora K. Nudd: Aurora.Kiviat@sdcounty.ca.gov

(619) 515-6525

Live Well, San Diego! Building Better Health, Safer Living and Economic Vitality