Hotspotting in Aurora Angela Green, PsyD Heather Logan, MSW
Director of Behavioral Health Director of Accountable Care & Bridges to Care
Erin Loskutoff, MPH, MSN, AGNP-C B2C Nurse Practitioner
MCPNEvery touch, every time.
MCPNEvery touch, every time.
MEDICAL REPORT
THE HOTSPOTTERS
Can we lower medical costs by giving the neediest patients better care?by Atul Gawande JANUARY 24, 2011
The Round Table:Aligning the Partnerships
What are we trying to accomplish here?
• Identify WHY patients over-utilize the hospital: Build a model around the WHY
• Stabilize, Coordinate, Improve Care, Reduce Cost
• Reduce ER visits and Inpatient stays through a community intervention
Helping people one at a time to empower themselves with tools, knowledge, and confidence to take responsibility for their own physical and psychological health.
The Bridges to Care Vision
Bridges to Care Model• Hybrid of the Hospital Discharge, ED, Home,
and Community Based Models• Intervention begins at bedside• 60 day model: Patient graduates from the
program• 8 visits minimum• Collect information at each step to
evaluate/improve program• Inclusion/Exclusion Criteria• MCPN’s model includes 2 unique
components
Medical Providers
Behavioral Health Providers
CriteriaINCLUSION
• Live in Aurora• 3 Hospital Visits (ER & IP) in
last 6 months• Adults• Non-violent offenders,
homeless, BH are all ok
EXCLUSION
• Acute visits (?)• Pregnancy• HIV (?)• Malignancies• Primary dx of personality disorder• Post-surgical• Primary diagnoses of substance
abuse• Diminished capacity• Pediatrics • Violent offenders/sex offenders• Care giver as primary decision
maker or Power of Attorney
Updated8/5/13 SA
Pre-enrollment #1 #2 #3 #4 #5 #6 #7 #8
333333#
Pre-Graduation Visit –HC
Review graduation checklist - Teach-back Opportunities
Any combination of NP/BHP/CCC/PNP/HC
Enrollment 24-72hrs post d/c CHW/CCC
Present giveaways and B2C contact info
Complete Enrollment forms
Medical Visit w/ NP
(w/in a week of hospital d/c- if possible)
Any combination of NP/BHP/CCC/PNP/HC
30 days Assessment HC
Complete 30 day assessment and Outcome forms
B2C Home Visit Timeline
Any combination of NP/BHP/CCC/PNP/HC
Graduation Celebration –CCC
Present giveaways and home clinic contact information Complete -60 day assessment and Outcome forms
60 day model (Minimum of 8 visits) More home visits may be needed to graduate the patient from the program
NOT ALL PATIENTS WILL FOLLOW THIS TIMELINE EXACTLY.
Complete pre-enrollment forms (Track Via) - CHW Schedule: 1st Home Visit (Enrollment w/CCC) 2nd Home Visit - NP visit
Behavioral Health:An Essential Component
• SDAC data revealed nearly 80% of Medicaid patients in this data set had a behavioral health component to condition
AIM-C Approach
• Assess – SBIRT, PHQ, initial visit, CPCQ, risk stratification, enrollment evaluation, CCC assessment• Intervene – brief counseling, meds,
referrals, coaching • EMpower – educate, activate,
validate, participate, motivate• Connect – relationship, resources,
referrals
Outcomes/Deliverables• 1. Enroll our 689 patients• 2. Demonstrate cost savings• - Reduce re-hospitalizations • - Decrease Illness Burden• 3. Transition patients from home visits to clinic
visits• 4. Establish health homes for patients• 5. Demonstrate sustainability/develop a
sustainability plan
Demographics
Demographics
Demographics
Doubling Up7%
Homeless Shelter
1%
None13%
Not Homeless54%
Other21%
Street2%
Transitional1% Unknown
1%
B2C Homeless Status
Encounters By Type & Team Member
CHW26%
Med16%
CCC28%
Health Coach15%
BH4%
Psych NP5%
MA 6%
Encounters by Type & Provider
Physically Unhealthy Days
After 30 days After 60 Days After 180 days0
20
40
60
80
100
120
38
23
14
30
1612
65
94
107
Increase Unchanged DecreaseN = 133
29%
23%
49%
17%
71%
12% 11% 12%
80%
Chronic DiagnosesB2C Status More than 1 Chronic DX Frequency PercentageActive 36 38 95%Graduated 239 244 98%Lost to Follow 83 106 78%Total 358 388 92%
ICD9 Description Freq1 401.9 Unspecified essential hypertension 1832 305.1 Nondependent tobacco use disorder 1413 311 Depressive disorder, not elsewhere classified 1034 300.00 Anxiety state, unspecified 955 250.00 Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled 906 272.4 Other and unspecified hyperlipidemia 887 493.90 Asthma, unspecified, unspecified 798 300.4 Dysthymic disorder 609 530.81 Esophageal reflux 58
10 278.00 Obesity, unspecified 56
11 309.81 Posttraumatic stress disorder C 50
12 250.02 Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled 42
13 496 Chronic airway obstruction, not elsewhere classified 40
14 300.01 Panic disorder without agoraphobia 38
15 296.80 Bipolar disorder, unspecified 37
16 244.9 Unspecified hypothyroidism 36
17 428.0 Congestive heart failure, unspecified 33
18 305.00 Nondependent alcohol abuse, unspecified drunkenness 31
19 296.32 Major depressive disorder, recurrent episode, moderate 28
20 346.90 Unspecified migraine without mention of intractable migraine 27
Top 20 Chronic Diagnoses (All statuses)
• An overwhelming proportion of B2C patients suffer from chronic illnesses (92%)
B2C Patients with BH Diagnoses
78% of Active patients
86 % of Graduates
81% of All B2C Patients
69% of Lost to Follow
Mentally Unhealthy Days
After 30 days After 60 Days After 180 days0
10
20
30
40
50
60
70
80
90
33 33
15
37
30
39
63
70
79
Increase Unchanged DecreaseN = 133
25%28%
47%
25%23%
53%
11%
29%
59%
Current B2C – Utilization Trend Data
Current B2C – Utilization Trend Data
What We Already Know About Cost Savings
“Health centers save $1,263 perperson per year, lowering costs across the delivery system‒from ambulatory
care settings to the emergency department to hospital stays”
Source: NACHC analysis based on Ku L et al. Using Primary Care to Bend the Curve: Estimating the Impact of a Health Center Expansion on Health Care Costs.GWU Department of Health Policy. Policy Research Brief No. 14. September 2009.
Lessons Learned
• You need good people to do hard work!• Systems are not designed for innovative work!• Chances are no one has gotten this far before!• Sometimes being a gardner is all you can do!• Be realistic about what change means!• Buy in is crucial, it just may not always come
from the top or look the way you envisioned!
Constantly Evolving: Don’t use pen!
Achieving the Triple Aim“The integrator’s role includes at least five components:
1. Partnership with individuals and families,
2. Redesign of primary care,
3. Population health management,
4. Financial management, and
5. Macro system integration. “
Health Aff May 2008 vol. 27 no. 3 759-769
Thank you.