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Maryland Association of Healthcare
Executives presents:
1
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PCP Networks-Hospitals-
Post-Acute Care
Population Health Across the Continuum
Session 3
2
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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
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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
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• Primary care perspective of care transition space
•Description of University of Maryland C‐3
•Preliminary data for year I
Goals
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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
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Characteristics associated with “high
utilizers” of healthcare
•Substance abuse
•Housing: instability ‐> homelessness
•Cultural variances: social ‐> legal
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Population Health Models to Address
High Utilizers of Healthcare Must
Consider
•Quality
•Containing costs
•External forces: local ‐> regional ‐> national
•Uniqueness of healthcare organization
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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”
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Population Health Models
•Emergency Department Based Model
• ED teams designed to provide care management
•Housing First Model
• emphasis on stability associated with housing
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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
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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
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C3 Team
•Physician medical director
•Nurse manager
•Nursing Coordinator
•Nurses
•Cardiology Nurse Practitioner
•Pharm PhD
•Social worker
•Community Health Worker
•Medical Assistant
•Trainees
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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
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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
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Intensive Ambulatory Care Referrals
July 1, 2016 until June 30, 2017
•Radiology 183
•Vascular surgery / lab 99 / 93
•Internal 87
•Nephrology 61
•Psychiatry 31
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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
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Intensive Ambulatory Care Year 1
Source of Payment
•Medicare 27 %
•Medical assistance MCO 27 %
•Medical assistance 5 %
•Medical assistance eligible 4 %
•Commercial 2 %
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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
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Patient Referrals to Heart Failure
Program at C3
Inpatient Units
Emergency room
Cardiology
Primary care
Internal C3
Self referral when established
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Heart Failure Year 1
•Scheduled patients 1087
•Arrived patients 623
•Canceled w/o reschedule 200
•Canceled with reschedule 173
•No show 87
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Heart Failure Year 1 Source of
Payment
•Medicare
•Medical assistance
•Commercial
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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
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Patient Referrals to Infusion
Component at C3
Heart Failure Program
Sickle Cell Program
Internal C3
Self referral when established
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C3 Infusions Year 1
Heart Failure 978
Sickle Cell 896
Total 1874
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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
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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.
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Population Specific Care
Jeanne C. Keruly, MS, CRNP,
Director of Adult Ryan White Services, Johns Hopkins
43
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44https://www.hiv.gov/federal-response/policies-issues/hiv-aids-care-continuum
accessed 10/10/2017
Care Continuum
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45https://www.hiv.gov/federal-response/policies-issues/hiv-aids-care-continuum
accessed 10/10/2017
HIV Care ContinuumWhere We Are
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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
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2016 Continuum of Care -
Maryland
47
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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54
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.(
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55https://www.hiv.gov/federal-response/policies-issues/hiv-aids-care-continuum
accessed 10/10/2017
Care Continuum
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56
Prescribe Antiretroviral Treatment (ART) to Achieve Viral Suppression
Demonstration Projects to Fast track initiation of ART
Pilcher, JAIDS, 2017
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57
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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58
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
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GBMCCatherine Hamel, MA
VP Continuing Care and President, Gilchrist
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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
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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
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General Strategies
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Delivering the Right Care to
Patients at GBMC Health Care
65
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
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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
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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
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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
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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)
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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
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Substance Use
15,849 screenings on primary care patients (NIDA tool)
269 visits performed with Substance Use Consultant
from Kolmac