CARE COORDINATION

1. CARE COORDINATION An Approach for High Risk Patients

2. Goals for Today • Discuss unique heath care needs of individuals with disabilities and the frail elderly. • Learn about two models of care delivery targeted at high risk patients • Understand how health reform affects the development of care coordination models • Describe provider engagement and it’s importance • Define “relevant response” and “life geography” in the context of care coordination.

3. Changing Landscape • Health care reform is driving new models of care • Lessons learned in case management and MSHO care coordination are being replicated in the broader Medicare and commercial settings. • Face to face assessments • Community based services • Care giver support

4. Health Care Reform Continuum

5. Making the Transition

6. Care on the Continuum Risk/Frailty and High Cost Patient Population Patients with Chronic Disease and Acute Episodes >50% medical spend

7. Care on the Continuum Risk/Frailty and High Cost Patient Population High Utilization 87% Patients with Chronic Disease and Acute Episodes >50% medical spend 13% Year 1

8. Care on the Continuum Risk/Frailty and High Cost Patient Population High Utilization 87% Patients with Chronic Disease and Acute Episodes >50% medical spend 13% Year 1 Year 2

9. Care on the Continuum Risk/Frailty and High Cost Patient Population Clinic Medical Home High Utilization 87% Regression to mean -acute episodes -well-managed chronic disease Patients with Chronic Disease and Acute Episodes >50% medical spend 13% Year 1 Year 2

10. Care on the Continuum Risk/Frailty and High Cost Patient Population Clinic Medical Home High Utilization 87% Patients with Chronic Disease and Acute Episodes >50% medical spend Bluestone population Complex social/behavioral/medical Chronic High Spend Higher % on public programs Frail/elderly/vulnerable High incidence dementia Underserved 13% Year 1 Year 2

11. Care on the Continuum Risk/Frailty and High Cost Patient Population Clinic Medical Home High Utilization 87% Patients with Chronic Disease and Acute Episodes >50% medical spend Bluestone population Complex social/behavioral/medical Chronic High Spend Higher % on public programs Frail/elderly/vulnerable High incidence dementia Underserved 13% Year 1 Year 2

12. Care on the Continuum Risk/Frailty and High Cost Patient Population Facility Partners Assisted Living and Group Homes Clinic Medical Home NP/PA Services MD Services Care Coordination Services Social Support High Risk Care Coordination On-site Primary Care Care Coordination PLUS Bluestone Vista

13. Bluestone Physician Services was established in 2006 in Stillwater, MN to meet the needs of patients who were not being well serviced in the traditional medical system. • Bluestone Physician Services is the largest provider to Assisted Living Facilities in Minnesota, • Provides primary care and care coordination to 4,500 residents in over 150 assisted living communities, group homes and in their own homes. • The first Geriatric Certified Health Care Home in the country. • 17 providers, 26 nurses including a full time psychiatrist. • Designed customized technology including online orders, family email and monitoring systems.

14. Bluestone Care Coordination

15. Bluestone Care Coordination High Risk as Organizing Principle • MSHO/SNBC • MSHO-Primary care model-Residential Care • SNBC-Community Model-Disability/income • Health Care Home-Residential Care • Integration with Primary Care • Integration with facilities • Medicare Advantage/At risk contracting • Predictive modeling

16. Patient Identification-Who’s in? • High Risk Patients • Life Geography-HCH • Where they live-Residential Care • Life events • Socio-economic • Diagnosis- i.e. Dementia • Assignment by payer-MSHO/SNBC • Self selected-all • Claims/predictive modeling-Risk contracts

17. Care Coordination Across Systems • Residential Care • Facility based • Engage the true decision maker • One care coordinator across facility • Staff education • Waiver and HCH services • Community Based • Coordination with “external” case management • How to find other care coordinators

18. Medical-Behavioral Integration • Interdisciplinary Team Meetings (IDT) • Based on hospice model • “assure” primary care • Regularly scheduled case consultation meetings • Best practice • Medical advice-follow up at next IDT • Triggers • Population specific

19. Patient Engagement • Timely communication • Accurate communication • Trust built on “small” accomplishments • Realistic expectations • Role clarity • Persistence

20. Care Coordination Plus Model Self-care Care Plan Optimized Empowerment Pt. and family Needs Hierarchy Action Hierarchy

21. Optimized Care Plan • Comprehensive • Medically sound • Realistic • Relevant • Accessible • Transferable • Integrated

22. Health Care Home • Bluestone Physician Services was certified as HCH in 2010. • Care Coordination-”A function not a person” • RN care coordination added 2012 • Use of technology for care team communication across systems • Bluestone Bridge

23. Health Care Home in the Geriatric Setting • Unique residential model brings unique care coordination challenges. • Facility based • Responsible parties • Complex health issues • Quality measures do not consistently apply

24. Positive Changes in Geriatric/Disability care • MAPCP Demonstration • Resource Toolkit • MNCM • Upcoming care coordination measures-an opportunity for collaboration! • Follow up after hospital discharge • Advance Care Planning

25. Bluestone Measurement Framework • Quality indicators: -advanced care plan completion -appropriate chronic disease management -optimal medication management • Cost indicators: -ED/Hospital utilization Aging in place: -Days out of home (AL) setting -%deaths in home (AL) setting

26. Utilization Management • Acute/ER Reduction • Action Plans • Contracts • Accompanied visits • Scheduled primary care visits • Pharmacy • Internal med reviews • Advance Care Planning • POLST

27. Residential Care Utilization

28. Care Coordination Utilization

29. Bluestone-next steps • Assist other health systems implement residential care models • Fairview • Continue to develop dementia care model • Identification End of life care. • Residential care forums • Targeted to entire residential care community • High risk care coordination provision/consulting

30. Courage Center Primary Care Clinic: Health Care Home for Persons with Disabilities

31. Courage Center Guided by the vision that one day, all people will live, work, learn and play in a community based on abilities, not disabilities.

32. Courage Center • A comprehensive rehabilitation and resource center for persons with disabilities service individuals with lifelong and newly acquired conditions at every point in the life cycle since 1928 • Largest nonprofit provider of rehabilitation services in Minnesota

33. Courage Center • Serves 12,500 people with disabilities and complex health conditions annually at 4 sites in the Minneapolis and St. Paul metropolitan area • Has long recognized the unmet need for primary care for our patients • Research staff are located within the Public Affairs and Research Department, a unique linkage to advocacy and public affairs.

34. Target Population Identified for our HCH • Persons with disabilities or complex health conditions • Require combination of medical and social services to live successfully and participate fully in their home communities • Require multiple services that span the continuum from acute to long-term medical care

35. Cost of Care for Individuals with Disabilities • 16% of people reporting a disability accounted for • Nearly half of all hospital discharges • 62% of hospital days • 34% of all adult physician visits • 41% of all adult drug prescriptions (Anderson, et al., 2011) • This population is expensive, but does not experience good health.

36. The 50% of the population that costs the least. The 5% of the population that costs the most.

37. Why do this at Courage? • Co-locate primary care with physiatry and psychiatry, which are the two common specialties seen by this population • “Reverse engineer” primary care into a setting designed for this population, and where medical and social supports are already present, rather than trying to take an existing primary care clinic and add social supports

39. Planning for the Clinic

40. Other things we knew • Using the model put forth by DHS for reimbursement (FFS with care coordination fee calculated on complexity of clients), this clinic will never break even • We would need some kind of shared savings to make the clinic self-sufficient • We needed to include new payment methods as we built the clinic

41. Clinic Staffing • We serve a relatively small population • Primary care physician .4 FTE • Nurse Practitioners 2 FTE • RN Care Coordinators 3 FTE • LSW Care Coordinator 1 FTE • CMAs 3 FTE

42. Care Coordination • Each client is assigned a care coordinator • Care coordinator develops care plan with client • Care coordinators make quarterly contacts • Assist clients with managing day to day conditions • Care coordinators are first contact if there are problems, although they can also call triage line • Providers available 24/7 through office number • We encourage clients to stop by when they are at Courage for other reasons

43. Different kinds of Care Coordination • Extended Primary Care – care coordination to provide coordinated care, connect with social supports • SNBC Care Coordination – contracts with private insurers to manage their SNBC clients – puts all care coordination in one spot, although they may still have other coordinators/case managers • We provide both types of care coordination at Courage, and one doesn’t look much different than the other, except SNBC has documentation for the insurance company

44. Designing the Clinic • The clinic is fully accessible • Fully accessible facility • Exam rooms have a full turning radius for a power wheelchair • 6X8 high/low matts for exam tables • Accessible OB/Gyn high low table • Hoyer lifts • Accessible scale

45. Care pathways • Developed pathways prior to bringing on physicians or nurse practitioners • The care pathways have undergone revision • Pneumonia as an example • Seizures as another example • Included Patient Activation Scores as part of the care pathways

46. Healthy Days • Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? • Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

47. Patient Activation Measure • Measure of the knowledge, skills, and confidence a patient has that allows them to become engaged in their care • Assessment of patient activation is a way to structure the interaction of team members with the patient, to provide the “just right” amount of support for patients experiencing exacerbations in health conditions.

48. Patient Activation Measure • Patients with high levels of activation are four times more likely to get care when they need it as patients with low levels of activation (AARP, 2009). • Patients with low levels of activation are also twice as likely to experience a medical error, and twice as likely to experience a hospital re-admission within 30 days of discharge.

49. Patient Activation Levels • Level 1 – individuals are starting to take a role, but don’t feel confident, and tend to be passive recipients of care • Level 2 – individuals are building knowledge and confidence, but lack understanding of their health or recommended changes • Level 3 – individuals have the key facts and are beginning to take action but need support to implement and maintain behaviors • Level 4 – individuals have adopted new behaviors, but may need help to maintain them in times of stress or illness

50. Patient Activation Measure • A change of 1 point is associated with • 1.7% decline in hospitalizations • 1.8% gain in A1c control • 3.4% gain in A1c testing or LDL testing • We see an average of 12 point improvement over the first 6 months of enrollment in the clinic