Implementing Brenner’s Collaborative Super-Utilizer Model

1. Implementing Brenner’s Collaborative Super-Utilizer Model Barry J. Jacobs, Psy.D., William Warning, MD, Steven Sluck, DO, Stephanie Maruca Watkins, DO Crozer-Keystone Family Medicine Residency Program—Springfield, PA Session #D4a October 6, 2012 Collaborative Family Healthcare Association 14th Annual Conference October 4-6, 2012 Austin, Texas U.S.A.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Objectives Describe the Brenner Collaborative Super-Utilizer Model using research data to demonstrate its efficacy for improving clinical outcomes and reduce healthcare costs Illustrate a successful implementation through presentations of two case studies Identify key operational and training components for effective collaborative super-utilizer teams

4. Learning Assessment A learning assessment is required for CE credit. Attention Presenters: Please incorporate audience interaction through a brief Question & Answer period during or at the conclusion of your presentation. This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy accreditation requirements.

5. Today’s Talk • The crucial issue of utilization in today’s healthcare • What is a “super-utilizer”? • What are the elements of an SU program using collaborative team interventions? • Case of SD, a hospital SU • Case of CB, an ER SU • SU Fellowship • Keys to SU operations and funding

6. High Utilization Driving Healthcare Costs • Premise: Our most medically and psychosocially complex patients use disproportionate amounts of healthcare resources • Drive up total healthcare costs

7. 1% 5% 10% 50% 22% 50% 65% 97% $90,061 $40,682 $26,767 $7,978 U.S. Population Health Expenditures Distribution of Health Care Expenditures for the U.S. Population, According to Magnitude of Expenditure, 2009 The sickest 10% of patients account for 65% of the health care expenses. Dollar amounts are annual mean expenditures per patient. Data from the 2009 Medical Expenditure Panel Survey, adapted from the Commonwealth Fund.

8. What is a “High-” or “Super-Utilizer”? • Well researched, well defined problem with a few successes. • 4 Major Studies were reviewed • 2010 Mount Sinai School of Medicine • 2009 Midwestern Urban Hospital • 2009 Camden Coalition of Healthcare Providers • 2006 IOM Report

9. Characteristics of High-Utilizers • Most are insured, 60% public insurance • Only 15% uninsured • Over 80% have identifiable PCPs • More utilization of health services in general • Diagnoses vary greatly • Ages 25-44 and over 65 • Addiction and mental health issues make it more difficult for patients to navigate system

10. Usage Patterns • High utilizers use the ED >3x per year • 5-8% of ED patients account for 21-28% of visits • Over 50% sought care at 2 or more EDs • 70% of frequent visits were on evening or night shift

11. Frustrated family MD Closed solo practice in Camden, NJ Began looking at data about city’s healthcare trends Who is Jeff Brenner, MD

12. Brenner (cont.) The Camden Study-An ED Alternative • 5 year study of 380,000 visits at 3 EDs • 1% of patients 40,000 visits, $46 million cost • Top 35 utilizers generated $1.2 million in charges each month

14. Brenner (cont.) • Formed Camden Coalition of Healthcare Providers in 2002 • Developed Camden Healthcare Database • Formed relationships with outpatient and inpatient providers, as well as social service agencies, throughout city and state • Promulgated “hot-spotting” or “super-utilizer” model of collaborative intervention

15. Components of SU Interventions • Data mining (sometimes across health systems and agencies) to create SU list • Creation of collaborative multi-disciplinary teams: physicians/nurses practitioners, case managers, social workers, mental health consultants, health educators • Assessment procedures and outcome measures • Relationship-building with other healthcare and social service providers to improve care transitions and marshal community resources

16. The Camden Study • 35 highest utilizers were put into Camden Coalition Project • Social Worker, CRNP, Case Managers, Health Educators, cost $300,000/yr • 35 patients received individualized case management services via the Coalition • Monthly charges reduced from $1.2 million to $531,000 • For every $1 spent $1.44 was saved in hospital costs

17. Who are we?

18. Crozer-Keystone Health System 5-hospital health system, with 6800 employees, in western suburb of Philadelphia Delaware County: pop. of 550,000; socioeconomically and culturally diverse; inner ring, decaying suburbs and more middle-class neighborhoods Residency: 9-9-9 program, founded in 1994; two family health centers; one an FQHC Two fellowship programs (SU and sports medicine) Clinical affiliation with Temple University School of Medicine

19. Timeline of Our SU Project Pilot initiated in summer of 2011 Joined FMEC SU Learning Community Feb. 2012: SU presentation to health system’s administrators by Jeff Brenner; SU team presented two cases Led to health system initiating High Utilizer Program At that presentation, announcement of SU Fellowship, co-sponsored by Crozer and Cooper Health System in New Jersey

20. Our SU Team (with Dr. Brenner)

21. SU Team Activities/Outcomes Graduated one of pilot cases; other has made gains but still underway Developed data mining and SU selection process Selected 5 more cases (at 3 outpatient centers) for this academic year Working on assessment procedures, team coordination processes and outcome measures

22. Case Report: Meet SD SD is a 64 yo male who has lived in the Delaware County community for years. He is a retired electrician and lives with his wife. Wife works part time 3 days a week. In 2010 -2011 - 13 Admissions for CHF.

24. Past Medical History BPH CAD CHF (7-2010 EF = 30-35 % ) CKDIII CVA Depression/Anxiety/Insomnia Diabetes Mellitus II Gout Hypercholesterolemia HTN Hypothyroidism

25. Past Surgical History CABG 1998 ICD placement x2 (11/2008 & dual chamber 3/2010) L4-L5 Laminectomy Mastoidectomy

27. 1 year Charges = $520,000; Receipts: $90,000; Inpatient Admissions: 12; ED visits: 7 Length of Stay • ED Visit • IP Admit

28. Comprehensive Medication Management Opportunity Within the Patient-Centered Medical Home (PCMH)

29. Medication Management6-2011 Aggrenox one po daily Aspirin 81 mg po daily Lopid 600 mg po bid Lipitor 80 mg po hs Zetia 10 mg po daily Lantus sc daily Lasix 40 mg po bid KCl 20 mEq po daily Norvasc 10 mg po daily Enalapril 20 mg po daily Sotalol 80 mg take ½ po bid Coreg 25 mg po bid Toprol XL 100 mg po daily Colchicine po prn gout attacks Vit D 50000 units po q other month Flomax 0.4 mg po daily Levothyroxine 50 mcg po daily Celexa 20 mg po daily Ativan 0.5 mg po hs Melatonin 3 mg po hs Diphenhydramine 25 mg caps Omeprazole 40 mg po daily

30. Identify, Resolve and Prevent Drug Therapy Problems Indication Adherence 4 Areas Safety Effectiveness Cipolle, R., Strand, L., Morley, P-Pharmaceutical Care Practice-The Clinicians Guide-2004-2nd edition-McGaw Hill

31. Adherence Retrospective Medical Record Chart Review Jan 2012

32. Retrospective medical record review 2-2012

33. SD’s Medication Management Resolve Drug Therapy Problems Discontinue Sotalol and Toprol XL Continue Coreg 25 mg twice daily Communicate with cardiologist Communicate with pharmacy Wife educated about medications Assumes responsibility to assure medications set up and taken correctly by patient.

34. 1 year pre-enrollment Charges= $520,000; Receipts= $90,000; Inpatient:12; ED visits:7 Post-enrollment Charges = $11,686 ; Receipts= $0. Inpatient: 0; ED visits:3 Length of Stay • IP Admit • ED Visit

35. Family Perspective SD is not aware of the difference. Wife is both proud of her accomplishment as a caretaker and grateful that he is not in the hospital and ER so much.

36. Hospital EncountersReadmissions within 30 days1/2010 – 1/2011

37. Now and Future Prepared Office Visits Team approach SD and his wife Physician seeing SD RN reviews diabetes Pharmacist med review

38. CB seemed to be in office waiting room every week—well dressed, friendly, no apparent distress We reviewed the chart—multiple ER visits and brain CTs over past 2 years Who is she? Case of CB: “Why is she here so much?”

39. Meet CB

40. Meet CB • 60yo AAF • Youngest of 5 children; identical twin • Grew up in Philadelphia home with marital discord, high levels of family conflict • Physically abusive first marriage; strong second marriage for past 24 years • Has 3 adult children, many grandchildren • On Social Security disability for chronic pain • Works part-time as a hospital chaplain • Currently working on second MA in theology

41. Family History Mother - died at 53 y/o from DM complications Father - died at 62 y/o from CAD, h/o stomach cancer with mets Twin sister – BRCA gene positive 2 brothers - one died from suicide, other brother died from drug and etoh abuse

42. PMH • Anxiety/depression • Fibromyalgia • HTN • CVA-1995 • TIA • Nephrolithiasis- 2009 • PUD, GERD • Diverticulosis • MVA -2011

43. PSH • Hysterectomy, oopherectomy ('89) • Bilateral Mastectomy with breast reconstruction ('00) - precancerous lesion in nodes and twin sister with BRCA • Cholecystectomy

44. CB as a Super-Utilizer • 5/5/2009: patient first presents to CFH for primary care • Patient with multiple ER visits prior to presentation to CFH for care for various complaints • Patient first identified as a super-utilizer on 8/22/11 • Around this time patient was in ER/admitted multiple times for syncope/gait imbalance and was complaining of memory issues, often forgetting her CFH appointments

45. CB as a Super-Utilizer • Methods: Electronic medical records from 1996-present reviewed • Date of ER visit, Diagnosis, Disposition recorded -Radiology files in net-access reviewed for type and number of CT scans

46. How many ER Visits has CB had since 1996?

47. Answer- 102 ER visits! Let’s break it down…

49. ER visits broken down by reason…2009: 21 visits

50. ER Visit breakdown: 201015 visits