Care Coordination A Key to sustainable Healthcare

1. Care Coordination A Key to sustainable Healthcare Irv Zeitler, D.O., VPMA Sandra Morales, RN, MSN, CCM Shannon Medical Center

2. Total Health Expenditure 2008 OECD health data 2012 http://www.oecd.org/els/healthpoliciesanddata/oecdhealthdata2012-frequentlyrequesteddata.htm

3. Total Health Expenditure 2008

4. Share of National Health Care Expenditures IOM (Institute of Medicine). 2010. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington, DC: The National Academies Press.

6. 19.1% of Medicare patients are readmitted within a month of hospital discharge. • 56% percent are readmitted within 6 months. • Approximately half of the patients with chronic conditions like heart disease or asthma actually either miss doses or don’t take their medications as ordered. Non-adherence to medical regimens accounts for a great deal of wasted spending and potentially avoidable costly admissions.

8. A New Model of Care • A patient-centric strategy based on what we refer to as the Shannon Care Coordination program (SCC) • The SCC is a model that we believe will be a cost-effective extension of our community hospital that will impact patient care beyond the walls of the hospital.

9. Pre-med students are engaged in a formal credit-based training program that enables them to serve as health coaches supervised by Shannon Care Coordination team (SCC)

10. How it Works • Students are formally trained by a faculty comprising of physicians, a nurse coordinator, social worker, psychologists, nutritionists, and other healthcare professionals. • Upon completion, these students begin a practicum by shadowing members of the interdisciplinary team and are thereafter progressively deployed to serve as health coaches within the community.

12. The Health Coach’s Role • Under team supervision, each health coach’s primary responsibility is to inspire and motivate our patients to become more actively engaged in their health and well-being. • Health Coaches work with SCC health professionals (Physician, nurses, social workers, dieticians, etc) to reduce what ultimately falls though the cracks and causes costly care that could be avoided.

13. Everyone Wins • Health Coaches do not get paid — but they receive college credits for their participation in both the didactic sessions and practicum. They also benefit from real world experience — experience that could impact the success of our future healthcare workforce. • Our patients benefit from a reliable dedicated patient-centered continuum of care. • Our physicians receive the support they need for helping to care for patients with a myriad of challenges. • Angelo State University could ultimately see an increase in students in their healthcare programs who want to participate in this program. • Our community realizes enhanced overall health and well-being.

14. Why Care Coordination? People with multiple health and social needs are high consumers of health care services, and thus drivers of high health care costs. The elevated cost of care in this population offers a tremendous opportunity to craft a service delivery plan that meets their needs more effectively at a significantly lower cost. We believe Care Coordination is a strategy that will be effective, affordable and sustainable. 

18. The Process • Identify patients thru data review/screening • Obtain consent • Home visit • Collaborative development of a plan • Deploy health coaches- begin follow up visits- Tele- health/medication boxes • Weekly review sessions • Monthly report cards • Quarterly updates

19. Identification • Data review • Database of high risk diagnosis Diabetes, heart failure, coronary artery disease, Pulmonary disease(COPD) • Disease specific readmissions • Network within the facility Focus on the 5%

20. Screening Tool Socioeconomic Cognitive/ Educational level Medical/ Mental health Adherence potential Psychosocial stressors Support

21. Patient Review Gather additional medical history to determine the appropriateness of the program for the patient

22. Obtain Informed Consent • Overview of the program explained • Consent and permission to discuss completed • Notification of enrollment sent to PCP • SCC schedules initial home visit

23. Initial Home Visit Completed by SCC Nurse • Medication reconciliation • Discharge instruction review • Comprehensive health profile (CHP) • Review rights and responsibilities • Discuss initial goals

24. Care Coordination Plan Strategy development and documentation- based on the patients needs and goals

25. Implementation of the Plan • Plan of action is discussed with the patient • Goals are set in collaboration with the patient • Implementation begins based on agreed upon plan and goals • Utilize Med minder medication box

26. Deploy Health Coaches • Health coach accompanies SCC team member on visits • The health coach continues to accompany a team member until both parties are comfortable • Health coach does not see patient alone until cleared by SCC.

27. Health Coaches Guidelines: • Health coach sees patient weekly in their home • A Health coach may accompany the patient to physician appointment • Progress note is documented at each visit • A summary of the visit is emailed to SCC team immediately after the visit

28. Health Coaches DO NOT: • Provide transportation • Exchange any type of money or gifts • Contact the physician for the patient Health Coaches are under the direction of the SCC team and contact a team member for any issue that arises.

29. Weekly Review • Progress report from health coach • Progress report from SCC team members • Individual patients discussed • Strategies updated as needed

30. Report Card • Scores progress on goals • Medical, Behavioral, nutritional, activity • Scale of 0-5: • 0= goal is met • 1= some improvement • 2= stable; maintain strategies • 3= stable; new plan needed • 4= worsened • 5= plan suggested patient declined work in this area

31. Quarterly update • CHP • Medication reconciliation • Outcomes tracking review

32. Example Patient E.H. Data review Information from the high risk database: • 3 of the high risk diagnosis • (DM, CAD, COPD) • 6 ER visits for 2013 fiscal year • 6 additional ER visits that resulted in admission

33. Patient Review • E.H. 42 year old disabled female History includes: • Obstructive sleep apnea- does not wear CPAP consistently • Diabetes last A1C 11.8 (3/20/14) • COPD- 02 dependent • CAD • HTN • Hyperlipidemia • Smokes PPD Height 5’1 Weight 249lbs = BMI 47

34. Obtain Consent • E.H was approached while in the hospital and offered the program • Agreed to the program -consent was signed • Screening tool completed

35. Initial home visit • Comprehensive health profile- • Reveals poor diet, poor health prevention, sedentary, relies on others for assist with self care • Medication Reconciliation • 5 large boxes of medications- 37 medications- • Forgets to take meds on occasion- no one helps her to remember – stressor for the patient • Review of Physician orders • Pt to wear CPAP anytime she sleeps- has not been doing so • Initial goals identified • Lose weight, increase activity (wants to swim), “get out of depression”

36. Care Coordination Plan Primary focus: Medical stability • Stop smoking- reduce cigarettes by 1 per day • Wear CPAP during the day if she sleeps- ask spouse to remind her to put it on! • Improve lung function- increase activity – 5 steps more a day! • Medication reconciliation- determine correct medications Secondary focus: Nutrition/ Activity • Diet education- take the patient shopping/ budget for healthy foods – reduce Dr. Pepper intake • Start Gardening- increases activity, provides healthy food, improves self esteem

37. Care Coordination Plan Follow up visit • Patient agreed to use Nicotine patch more frequently- will keep count of # of days used versus days smoking • Agrees to plant 1 tomato plant in a pot in her yard with plans to add more • Reports she has not been napping during the day since last visit and is wearing CPAP at night • Expressed concerns about food supply due to temporary loss of food stamps – obtained perishable food items appropriate for diet

38. Going Forward • Small Pilot program this summer • Plan on additional 30 patients in the Fall with 17 returning students to be health coaches • Additional staff and technology

39. There are three kinds of men: The ones that learn by reading. The few who learn by observation. The rest of them have to pee on the electric fenceand find out for themselves. -Will Rogers

40. QUESTIONS