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

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


ED visits, 2011 0 1 2 3 to 4 5+

0

Normal Range of UtilizationNormal Range of Utilization

Potential High Utilizers

Inpatient High Utilizers


1 Normal Range of UtilizationNormal Range of Utilization




2 to 3

Normal Range of UtilizationNormal Range of Utilization



Inpatient High Utilizers4 to 5

Emergency Department

High UtilizersPotential High

Utilizers




6 to 7Emergency Department


Utilizers




8 to 9



Utilizers




10 +



Utilizers




Utilization typology

ED 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


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


4,144 ED Visits


1


63,489 ED visits



63,489 ED visits



$10,000,000 (17%) IP payment

$1,700,000 (4%) ED payments


4,144 ED Visits



4,144 ED Visits


2 to 3


63,489 ED visits



63,489 ED visits



$10,000,000 (17%) IP payment

$1,700,000 (4%) ED payments


4,144 ED Visits



4,144 ED Visits


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


4,144 ED Visits



4,144 ED Visits


6 to 74,961(9%) patients28,447 ED visits

$11,500,000 (27%) in ED payment


$6,700,000 (18%) in IP payment

$2,800,000 (6%) in ED payment


$10,000,000 (17%) IP payment

$1,700,000 (4%) ED payments


4,144 ED Visits



4,144 ED Visits


8 to 9


$11,500,000 (27%) in ED payment


$6,700,000 (18%) in IP payment

$2,800,000 (6%) in ED payment


$10,000,000 (17%) IP payment

$1,700,000 (4%) ED payments


4,144 ED Visits



4,144 ED Visits


10 +


$11,500,000 (27%) in ED payment


$6,700,000 (18%) in IP payment

$2,800,000 (6%) in ED payment


$10,000,000 (17%) IP payment

$1,700,000 (4%) ED payments


4,144 ED Visits



4,144 ED Visits


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


Patient Centered Care Coordination


Patient

Hospital #1

Sub-Acute Rehab

Hospital #2

Home Nursing

HomePT/OT

Durable Goods

MealsTransport

Dialysis

Nephrology

Transplant

PCPUrology

OncologySurgery

GICardiology

Optho

Pain Mgt


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



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!


Clinical Model


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

the hot spotters - center for health journalism · 2012. 7. 31. · top 10 er diagnosis 2002-2007...

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