Hotspotting in Aurora Angela Green, PsyD Heather Logan, MSW

Director of Behavioral Health Director of Accountable Care & Bridges to Care

Erin Loskutoff, MPH, MSN, AGNP-C B2C Nurse Practitioner

MCPNEvery touch, every time.

MCPNEvery touch, every time.

MEDICAL REPORT

THE HOTSPOTTERS

Can we lower medical costs by giving the neediest patients better care?by Atul Gawande JANUARY 24, 2011

The Round Table:Aligning the Partnerships

What are we trying to accomplish here?

• Identify WHY patients over-utilize the hospital: Build a model around the WHY

• Stabilize, Coordinate, Improve Care, Reduce Cost

• Reduce ER visits and Inpatient stays through a community intervention

Helping people one at a time to empower themselves with tools, knowledge, and confidence to take responsibility for their own physical and psychological health.

The Bridges to Care Vision

Bridges to Care Model• Hybrid of the Hospital Discharge, ED, Home,

and Community Based Models• Intervention begins at bedside• 60 day model: Patient graduates from the

program• 8 visits minimum• Collect information at each step to

evaluate/improve program• Inclusion/Exclusion Criteria• MCPN’s model includes 2 unique

components

Medical Providers

Behavioral Health Providers

CriteriaINCLUSION

• Live in Aurora• 3 Hospital Visits (ER & IP) in

last 6 months• Adults• Non-violent offenders,

homeless, BH are all ok

EXCLUSION

• Acute visits (?)• Pregnancy• HIV (?)• Malignancies• Primary dx of personality disorder• Post-surgical• Primary diagnoses of substance

abuse• Diminished capacity• Pediatrics • Violent offenders/sex offenders• Care giver as primary decision

maker or Power of Attorney

Updated8/5/13 SA

Pre-enrollment #1 #2 #3 #4 #5 #6 #7 #8

333333#

Pre-Graduation Visit –HC

Review graduation checklist - Teach-back Opportunities

Any combination of NP/BHP/CCC/PNP/HC

Enrollment 24-72hrs post d/c CHW/CCC

Present giveaways and B2C contact info

Complete Enrollment forms

Medical Visit w/ NP

(w/in a week of hospital d/c- if possible)

Any combination of NP/BHP/CCC/PNP/HC

30 days Assessment HC

Complete 30 day assessment and Outcome forms

B2C Home Visit Timeline

Any combination of NP/BHP/CCC/PNP/HC

Graduation Celebration –CCC

Present giveaways and home clinic contact information Complete -60 day assessment and Outcome forms

60 day model (Minimum of 8 visits) More home visits may be needed to graduate the patient from the program

NOT ALL PATIENTS WILL FOLLOW THIS TIMELINE EXACTLY.

Complete pre-enrollment forms (Track Via) - CHW Schedule: 1st Home Visit (Enrollment w/CCC) 2nd Home Visit - NP visit

Behavioral Health:An Essential Component

• SDAC data revealed nearly 80% of Medicaid patients in this data set had a behavioral health component to condition

AIM-C Approach

• Assess – SBIRT, PHQ, initial visit, CPCQ, risk stratification, enrollment evaluation, CCC assessment• Intervene – brief counseling, meds,

referrals, coaching • EMpower – educate, activate,

validate, participate, motivate• Connect – relationship, resources,

referrals

Outcomes/Deliverables• 1. Enroll our 689 patients• 2. Demonstrate cost savings• - Reduce re-hospitalizations • - Decrease Illness Burden• 3. Transition patients from home visits to clinic

visits• 4. Establish health homes for patients• 5. Demonstrate sustainability/develop a

sustainability plan

Demographics

Demographics

Demographics

Doubling Up7%

Homeless Shelter

1%

None13%

Not Homeless54%

Other21%

Street2%

Transitional1% Unknown

1%

B2C Homeless Status

Encounters By Type & Team Member

CHW26%

Med16%

CCC28%

Health Coach15%

BH4%

Psych NP5%

MA 6%

Encounters by Type & Provider

Physically Unhealthy Days

After 30 days After 60 Days After 180 days0

20

40

60

80

100

120

38

23

14

30

1612

65

94

107

Increase Unchanged DecreaseN = 133

29%

23%

49%

17%

71%

12% 11% 12%

80%

Chronic DiagnosesB2C Status More than 1 Chronic DX Frequency PercentageActive 36 38 95%Graduated 239 244 98%Lost to Follow 83 106 78%Total 358 388 92%

ICD9 Description Freq1 401.9 Unspecified essential hypertension 1832 305.1 Nondependent tobacco use disorder 1413 311 Depressive disorder, not elsewhere classified 1034 300.00 Anxiety state, unspecified 955 250.00 Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled 906 272.4 Other and unspecified hyperlipidemia 887 493.90 Asthma, unspecified, unspecified 798 300.4 Dysthymic disorder 609 530.81 Esophageal reflux 58

10 278.00 Obesity, unspecified 56

11 309.81 Posttraumatic stress disorder C 50

12 250.02 Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled 42

13 496 Chronic airway obstruction, not elsewhere classified 40

14 300.01 Panic disorder without agoraphobia 38

15 296.80 Bipolar disorder, unspecified 37

16 244.9 Unspecified hypothyroidism 36

17 428.0 Congestive heart failure, unspecified 33

18 305.00 Nondependent alcohol abuse, unspecified drunkenness 31

19 296.32 Major depressive disorder, recurrent episode, moderate 28

20 346.90 Unspecified migraine without mention of intractable migraine 27

Top 20 Chronic Diagnoses (All statuses)

• An overwhelming proportion of B2C patients suffer from chronic illnesses (92%)

B2C Patients with BH Diagnoses

78% of Active patients

86 % of Graduates

81% of All B2C Patients

69% of Lost to Follow

Mentally Unhealthy Days

After 30 days After 60 Days After 180 days0

10

20

30

40

50

60

70

80

90

33 33

15

37

30

39

63

70

79

Increase Unchanged DecreaseN = 133

25%28%

47%

25%23%

53%

11%

29%

59%

Current B2C – Utilization Trend Data

Current B2C – Utilization Trend Data

What We Already Know About Cost Savings

“Health centers save $1,263 perperson per year, lowering costs across the delivery system‒from ambulatory

care settings to the emergency department to hospital stays”

Source: NACHC analysis based on Ku L et al. Using Primary Care to Bend the Curve: Estimating the Impact of a Health Center Expansion on Health Care Costs.GWU Department of Health Policy. Policy Research Brief No. 14. September 2009.

Lessons Learned

• You need good people to do hard work!• Systems are not designed for innovative work!• Chances are no one has gotten this far before!• Sometimes being a gardner is all you can do!• Be realistic about what change means!• Buy in is crucial, it just may not always come

from the top or look the way you envisioned!

Constantly Evolving: Don’t use pen!

Achieving the Triple Aim“The integrator’s role includes at least five components:

1. Partnership with individuals and families,

2. Redesign of primary care,

3. Population health management,

4. Financial management, and

5. Macro system integration. “

Health Aff May 2008 vol. 27 no. 3 759-769

Thank you.