Gary Maras

Theresa Kisiel

Payor Model

Patient Care Model

NO YES

Isolated Episodic

Care

Chronic Disease

Management

• Trauma

• OB

• General Surgery

• Ortho

• Acute infections

• Viral illnesses

• CV Disease: • CAD

• HF

• Vascular

• Valvular

• Stroke

• Diabetes

• COPD

• Renal

Design systems to care for these two populations: ◦ Episodic Care:

Require a focused treatment that terminates with a "fix" or a

"cure“

◦ Chronic Care:

Ongoing care that treats, relieves or defers symptoms of a

progressive ailment

Does not terminate

4

Redesign systems to deliver the most effective and appropriate

care for chronic illnesses

◦ Right care

◦ Right place

◦ Right time

◦ Right cost

Requires coordination across the entire continuum

Synergistic with other initiatives:

◦ Medical Home (PCP)

◦ Care Management (CM) enhancements

◦ Health Plan Care Manager

◦ Outpatient clinics

◦ Community benefit activities

Prepare for Population Management (ACO)

5

Term to indicate focus on managing patients with chronic diseases/conditions across the continuum

Many synonyms: Population health management, care/case management, transition management, coach, navigators

The interface with service lines, programs and payers is key ◦ Compliments CM (hospital and payer)

During inpatient hospitalization:

Dedicated, specialized patient and family education

Core Measure compliance

Collaborate on outpatient plan

Outpatient coordination

Post discharge phone calls

Resource for primary care offices

Work with home care, SNFs, rehab, etc.

6

For patients with chronic conditions, levels of chronicity exist that require different management strategies ◦ At risk for developing the condition = focus on early detection

CV disease: HTN, hyperlipidemia, obesity, diabetes

Screenings, database queries, questions at routine appointments

◦ New diagnosis of the condition = standard therapy

All chronic diseases: evidence based treatment guidelines followed

◦ Patient with a chronic condition = compliance (patient, practitioner)

Telephonic management, clinics, coaching

Coordination of care across the continuum with all providers, providing support and education for patient and family

7

Patient Health (greater width = better health)

Each ring

represents

another

admission,

complication,

compliance

waiver

Death

Healthcare costs (greater width = higher cost)

Each ring

represents

another

admission,

complication,

compliance

waiver

Death

Patient Health (greater width = better health)

Better therapy,

Better compliance,

Fewer episodes,

Sustained health,

Delayed decline,

Fewer costs,

Increased lifespan

Early Detection

Earlier

Therapy,

Better

Health

status

Death

Death

Health Care

(↑ QOL years)

Palliative Care

(End of Life

Management)

Primary Prevention

Early

Detection

Screenings

Symptoms IP

OP

Diagnosis

Therapy

Recovery Secondary

Prevention

Medical

Interventional

Surgical

IP

OP

CM

Post Acute Care

PCP

Specialist

Clinic

Self, PCP

Population Management Continuum (Chronic Disease Mgmt.)

Patient

Compliance

with care

Disease Management

In over 50% of the patients, their heart attack or death was their first recognized symptom

Over 60% of diabetics between the age of 18 and 79 in the US reported having diabetes for 10 years or less. (CDC)

Every diabetic patient was pre-diabetic first, likely undiagnosed and untreated

The correlation between the presence of atherosclerosis in the carotid artery and coronary arteries is over 50%

The correlation in femoral arteries may be even higher.

Ultrasound screening of carotid arteries as a surrogate of coronary disease is simple and inexpensive.

Programs designed for early detection of disease processes

Community based

◦ Women’s heart program

◦ Heart disease

◦ Vascular disease

Family program: offered to families of HVI patients

Corporate health

◦ Worksite wellness programs

◦ Firefighter and police program

◦ Executive health

Cash pay

◦ Vascular screening: Over 6000 patients screened – 80%

evidence of plaque

15

Referral to PCP for a reimbursed office visit

Full reimbursable diagnostic studies are approved for the presence of plaque over 20%

Annual Studies are approved for plaque over 50%

Therapy is simple and inexpensive ◦ ASA, Generic Lipitor, Lifestyle Modifications

MNT ◦ ACA inclusion

Health Coaching

Expanded coverage under the ACA

◦ Recognized strategy for chronic disease management

Services provided by a Registered Dietician

◦ Initial nutrition and lifestyle assessment and follow up

through one-on-one nutritional counseling

Patient populations:

◦ Chronic kidney disease

◦ Diabetes

◦ Digestive disorders (Gastroparesis, etc.)

◦ Obesity

◦ CV risk factors (high cholesterol, high blood pressure)

◦ Others

17

Actual current reimbursement:

◦ Initial session: average $32 per unit, from 1 – 4 units

per session

◦ Follow up sessions: average $25 per unit, from 1 – 4

units per session

Variable number of sessions per year, between

3 and unlimited

2 full time and 2 part time RDs

◦ Must be credentialed with health plans

Some payers require hospital based sites

Glucose, HgbA1c

March 23, 2016, Department of Health and Human Services announced that Medicare will reimburse for the CDC’s diabetes prevention program

“Individuals with prediabetes or diabetes should receive individualized MNT, preferably administered by a registered dietitian knowledgeable about the components of diabetes MNT”

CDC-recognized program recently certified for Medicare

reimbursement, no coverage details available yet ◦ Developed to prevent Type 2 diabetes

Meant for people who have prediabetes or are at risk for type 2

diabetes but who are not already diagnosed with diabetes

Year-long lifestyle change program focused on long-term

changes and lasting results

◦ Suggested format includes patients with an impaired fasting glucose of 110 to 125 mg/dl

◦ Would also include maintenance sessions with lifestyle

(health) coaches indefinitely

Programs can apply for certification through the CDC and

would be eligible for future Medicare and possibly other

payments

20

Provide full spectrum of diabetes educational

services ◦ One-on-one sessions

◦ Small group classes

◦ Insulin pump support

◦ Adjunct in endocrinology office

◦ Gestational diabetes care

◦ Local link to quaternary maternal-fetal high risk services

Inpatient services currently provided by inpatient DM

4 certified diabetes educators (2 full time, 2 part time)

21

Inpatient Admissions ◦ Patient diagnosis

◦ Family Risk

Outpatient Care ◦ PCP

◦ Specialists

Community ◦ Individual

◦ Business

◦ Groups

Police, Fire, Church

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Medical

Home

PCP

DM

CV diseases

COPD

Diabetes

Stroke

Renal

CFHL

Card Rehab

D. Ornish

Corp H.

Empl H.

Screen

Post Acute

Care Partners

Care

Management

DM @ UPMC Hamot

Pharmacy

Inpatient DM ◦ AMI, HF, CABG

◦ COPD

◦ Diabetes

◦ Pharmacy support

Outpatient DM ◦ Diabetes Institute

◦ Screenings

◦ Health Coaching

◦ Medical Nutrition Therapy

◦ APP clinics

◦ Pharmacy support

◦ Coordination of care: locally and regionally

24

Daily identification of appropriate patients

Assess patients and family, design education appropriate for

them, deliver education and follow up as necessary

◦ Utilization of health coaching principles

◦ Contract with patient/family for one lifestyle change to begin

Link patient and family with appropriate outpatient resources

to ensure continued care after discharge

Communication with medical staff/midlevel providers

regarding deviations without documentation

Post discharge communication with PCPs and outpatient

DM and Clinics

4 staff in house each day

25

Post Acute Care Patients:

Provide telephonic follow up care for additional discharge

teaching and identification of barriers to self management

◦ 48-72 hours post discharge

◦ Ongoing contact with patients at high risk for readmissions

◦ Telephonic communication to extended care facilities

Skilled nursing, rehab and long term acute care facilities

◦ Closer collaboration with home care

Contact person identified at HHC for patient issues to front load

high risk patients

In person, one-on-one sessions

Liaison between patient, PCP, outpatient clinics and HHC

Staffing variable

26

Disease management staff has obtained health coaching certification ◦ Identified as a key process improvement by a staff member

◦ Scholarships provided through CV Foundation funds

Recognized as a best practice during a recent TJC disease specific recertification visit

Can be described as helping patients gain the knowledge, skills, tools and confidence to become active participants in their care ◦ Begins to address the issues surrounding compliance with care

Can be implemented in either the inpatient or outpatient setting ◦ Longitudinal follow up by outpatient DM staff regardless of

original site

27

Ensure patient/family understand the key concepts of

the disease process, treatments and goals

Ensure patient/family understand medication

management strategy

Ensure patient/family understand importance of

follow-up care and timing of that care

Reinforce with patient/family how to recognize and

respond to worsening signs and symptoms,

Establish goals for care and health status

Maintain use of the personal health record to

organize key information for all care encounters

28

PCP

Local

Hospital

Regional

Hospital

Palliative

Care

Spititual

Leader

Specialty

Physicians

Insurance

Patient

30

31

32

PCP

Regional

Specialists

Tertiary

Hospital

Tertiary

Specialists

Recovery/

Rehab Patient

CHF

CHF Valve Rhythm Vascular

CHF

Expanded Model (Other)

Center for Disease Management through Healthy Living

HF

Clinic

Valve

Clinic

Vascular

Clinic

Metabolic

Clinic

Rhythm

Clinic

XX

Clinic

XX

Clinic

XX

Clinic

Transition of existing employee base

IP and OP services

Credentials

Job Description

Outcomes Metrics

Transition from IP to OP

MNT changes in reimbursement ACA

Readmission rates below national average in all measured categories ◦ No readmission penalties

◦ Including overall readmission rate

Ongoing LOS reductions in all groups

Advanced Heart Failure Certification by TJC

HF Gold Plus and Target Heart Failure awards by American Heart Association