integrating team-based coaching for patients & families with … · 2017-08-24 · objectives...
TRANSCRIPT
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MODERATOR: Erik Gulbrandsen, DO-Family Medicine, Intermountain Healthcare
PRESENTERS: Neal Davis, MD, Intermountain HealthcareSarah Petersen, MSN, ICM Director-Ambulatory & Comm., Intermountain Healthcare
Integrating Team-based Coaching for Patients & Families with Complex Medical & Social Needs
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Objectives
• Identify and integrate into practice strategies how to empower patients and families as leaders in achieving their health goals
• Develop and foster qualities needed for leaders to implement a continuum of integrated team-based care
• Integrate team coaching into current care models in order to improve outcomes for patients and families with high-risk needs
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IntroductionTeam-based Coaching for Complex Medical & Social Needs
Erik Gulbrandsen, DO-Family PracticeIntermountain Healthcare
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• Living Adults
• Not enrolled in a care management program
• Within defined regions defined by Care Management
• In Top 15% of hospital* & MG Cost in the previous year & in Top 15% in one of two prior years
Subset
• Hospital and MG Costs* in the previous year
• Charlson Comorbidity Index Score
Data • Likelihood of pre-screening patients being In top 15% of cost for 2 of 3 future years
• Ensemble model enables us to use as much data as possible for each individual
• Gradient Boosted Trees maximized proportion of correct positive predictions.
Predict
PreScreening 3.0 – Ensemble Learning
*Hospital costs exclude chemotherapy, dialysis, IV therapy, spinal fusion, knee & hip replacement
+ Additional Patient Demographics+ Additional Health Information+ Claims Cost History (when available)
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Back End Front End
Bringing Statistical Modeling into the Workflow
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Demographic & Health Information
Additional Comorbidities
Obstructive Sleep Apnea
Hyperlipidemia
Morbid Obesity
Coronary Artery Disease
Hypertension
Top 15% ~ Demographic Factors + Patient Utilization History + Health Complexity + ε
Behavioral Health Conditions
Schizophrenic Disorders
Depression
Bipolar
Affective Disorders
Organic Psychotic Conditions
Nonorganic Psychoses
Neurotic Disorders
Personality Disorders
Alcohol/Drug Dependence
Eating Disorders
Childhood/Adolesence Disorders
Intellect Disability
Charlson Comorbidities
Myocardial Infarction
Cancer
Connective Tissue Disease-Rheumatic Disease
Chronic Pulmonary Disease
Cerebrovascular Disease
Metastatic Carcinoma
Dementia
Moderate or Severe Liver Disease
Diabetes with complications
Diabetes without complications
Mild Liver Disease
Periphral Vascular Disease
AIDS/HIV
Peptic Ulcer Disease
Congestive Heart Failure
Renal Disease
Paraplegia and Hemiplegia
Patient Health HistoryCost DistributionConsistent Healthcare UseRising/Falling Use TrendsPhysician VisitsPharmaceutical UseExternal Healthcare Use
Demographic FactorsAgeGenderMarital Status
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Measure RankingPrescreen 1.0
LogisticPrescreen 2.0
EnsemblePrescreen 3.1
Likelihood of Pre-Screening Patients Remaining In Top 15% of Cost For 1 of 3 Future Years
63.0% 79.0% 94.9%
Likelihood of Pre-Screening Patients Remaining In Top 15% of Cost For 2 of 3 Future Years
31.0% 48.1% 84.0%
Identified Patients 1,400 1,800 8,400
Avg. Prior Year Cost $38,700 $44,000 $36,700
% with Area Deprivation Index > 115 (Top Quintile) 16.9% 18.0% 16.2%
Avg. Number of Charlson Comorbidities 3.6 5.0 3.3
Avg. Number of Behavioral Health Conditions 1.7 2.2 2.5
Avg. Number of Other Comorbidities 1.4 2.3 2.1
Diagnosed With Behavioral Health Condition 63.2% 82.8% 80.1%
Diagnosed With Obesity 27.8% 54.9% 52.8%
Number of Rising Risk Patients (Not in Top 15% but Predicted to Move to Top 15% 2 of 3 Future Years)
- - 700
Modeling Results
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Camden Coalition COACH Model
C: Connect Tasks with Vision and Priorities
O: Observe the Normal Routine
A: Assume a Coaching Style
C: Create a Backwards Plan
H: Highlight Progress with Data
camdenhealth.org/the-coach-model/
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Clinical PerspectivesTeam-based Coaching for Complex Medical & Social Needs
Neal Davis, MDIntermountain Healthcare
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Life Course Theory and Social Determinants
Prenatal Birth Childhood Adulthood
Optimal Trajectory
Sub-optimal Trajectory
Health
And
Wellness
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Medical Homes and Homes
• A medical home is only as effective as it’s ability to reach into the real home/life of a child and his or her family
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Trust and Team
PPC/MHI Team
Community Partner-Home
Visitation
Changed Life
Course
And decreased cost…Increased productivity…
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Matching Risk and Resource
High
Medium
Low
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Don’t Forget the Kids!!!
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Care Manager ViewpointTeam-based Coaching for Complex Medical & Social Needs
Sarah Petersen, MSNICM Director-Ambulatory & Comm.Intermountain Healthcare
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Integrated Care Management Efforts and CCM
• Great efforts are underway to integrate care management across the system and across settings including: Ambulatory, Acute, Specialty and Community.
• Efforts to educate what care management really is – it is not just disease management – we miss great opportunities when we think of care management in terms of disease management
o For example – managing diabetes – story of CCM patient
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What are we doing?
• Changing reporting structures of CMRC’s (Care Management Regional Consultants) to myself to allow for “one Intermountain” and improved efficiency, effectiveness, education, standardization, and to ensure we meet goals related to Population health, ACO, as well as meet the patient’s needs.
• Working on metrics to show how care management can help people live the healthiest lives possible.
• Introducing the idea of social determinants and how they affect health, as well as what to do as a care giver to address these.
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Insights into the Camden Coalition COACH ModelTeam-based Coaching for Complex Medical & Social Needs
Erik Gulbrandsen, DO-Family PracticeIntermountain Healthcare
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Camden Coalition COACH Model
TECHNIQUES
O: Observe the Normal Routine
C: Connect Tasks with Vision and Priorities
A: Assume a Coaching Style
camdenhealth.org/the-coach-model/
TOOLS
C: Create a Backwards Plan
H: Highlight Progress with Data
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Camden Coalition COACH Model
TECHNIQUES
O: Observe the Normal Routine
C: Connect Tasks with Vision and Priorities
A: Assume a Coaching Style
camdenhealth.org/the-coach-model/
TOOLS
C: Create a Backwards Plan
H: Highlight Progress with Data
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Connect Tasks with Vision and Priorities
Patient Goals
Fly my airplane
Go fishing
Go to the cabin
Get married
Get a job
Find a house
Care Provider Goals
Control Diabetes
Control High Blood Pressure
Come to appointments
Reduce narcotic use
Quit smoking
Take Medications
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Connect Tasks with Vision and Priorities-Tug of War
• Diabetes and Food for Kids
• Opioids and housing
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Camden Coalition COACH Model
TECHNIQUES
O: Observe the Normal Routine
C: Connect Tasks with Vision and Priorities
A: Assume a Coaching Style
camdenhealth.org/the-coach-model/
TOOLS
C: Create a Backwards Plan
H: Highlight Progress with Data
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Camden Coalition COACH Model
TECHNIQUES
O: Observe the Normal Routine
C: Connect Tasks with Vision and Priorities
A: Assume a Coaching Style
camdenhealth.org/the-coach-model/
TOOLS
C: Create a Backwards Plan
H: Highlight Progress with Data
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Discussion Questions
o How should Intermountain Healthcare best integrate and align to perform chronic care management?
o How do concepts of clinic team-based care (TBC) help allow clinicians to practice together, at the top of their license, and meet complex patient needs?
o How can health care clinics (service sites) begin to implement concepts shared in this presentation? Where should they start?