The I PiCC Program(Integrated Patient Centered Care)

Karyn Rizzo RN, CHPN, GCNS

No Army, no Navy, no Education Department – just those three programs.

Twice I have asked Alan Greenspan what he considers the greatest threat to the U.S. economy,

and both times he has answered immediately with a single word: Medicare.

It's a multitrillion-dollar problem that's about to get dramatically worse.

In the next President's first term, Medicare Part A will go cash-flow-negative, and it's all downhill from there.

As the country ages, Medicare and Medicaid will devour growing chunks of US economic output.

Then by 2070, when today's kids are retiring, Medicare, Medicaid, and Social Security will consume the entire federal budget,

with Medicare taking by far the largest share.

"

"Geoff Colvin, Senior Editor, Fortune MagazineMarch 4, 2008

• Annual US healthcare expenditures have grown to over $2 trillion per year, and are expected to double in 10 years

• Only 10% of patients account for nearly 70% of healthcare expenditures• Shift away from PCP reimbursement, fewer MD’s moving towards primary care role• Current PCP model does not meet the needs of the aging client

The Drivers are Clear

Admissions account for the majority of healthcare expenses • 13% of population is 65+, yet account for 36% of total healthcare expenses

Re-admissions only exacerbate the problem• 1 in 5 are readmitted in 30 days• 75% are preventable and related to medications

Chronic illnesses causing over-utilization and contributing to PCP crisis• 44% of total healthcare expenditures and second biggest driver of admissions

• Medicare and private insurance companies are focused on preventing admissions and re-admissions– In 2009 Medicare is requiring mandatory reporting of readmissions and in 2010 is proposing

hospital penalties– National payers are focused on incentives (PCMH, Transitions, Chronic Illness management) to

reduce admissions and improve health management programs for complex patients– Tufts Health Plan (MA) is making discharge transition programs mandatory in 2009

A primary care system on the verge of crisis

Patient-Centered Medical Home (PCMH) model “accepted” by Medicare was developed by

NCQA staff in concert with the ACP, AAFP, AAO and AOP as well as other stakeholders to

address improvements by the development of specific standards in patient centered care

The PPC-PCMH has 9 standards (see Appendix 4 of the NCQA document), each of which has

multiple elements.

Major principles of the Patient-Centered Medical Home

• Personal MD for each patient

• Physician directed, interdisciplinary teams of care

• Whole person orientation – acute care, chronic care, preventive, end of life

• Coordinated and Integrated Care – across all elements of health care system and

community

• Quality and Safety

• Enhanced Access to Care

• Reimbursement for added value provided to patients

*Drawback of PCMH is that it is NOT patient centered

*Very heavy focus on EMR

Project “Setting”: Patient-Centered Medical Home

Extending PCPs reach via IPiCC Pilot

Rehab

Complex Care ManagementSupporting patients between PCP visits

Transition ServicesSupporting patients following discharge

APN led (in-home assessment); focus on chronic

illnesses mgt. and red flag awareness education.

PharmD led (in-home assessment); focus on

medication optimization and red flag awareness education

Ongoing RN and PCC support;PharmD support as needed

Ongoing RN and PCC support;PharmD support as needed

Ongoing RN and PCC support;PharmD support as needed

[month 1]

[months 2-4]

[month 1]

Faulkner Primary CareOpt. 1 Opt. 2

Questions:How to measure outcomes (e.g. admits avoided)?

Questions:How to know when a patient is admitted?Does the practice have enough admits to support project ramp up?

Why Lead Transitions with PharmD?Dovetail outcomes (pharmacy intervention)

Med Adherence Issues

Med Omission, 4%

Dose Specific, 26%

Drug Specific, 70%

Reconciliation Issues

ex. warfarin and coumadin

ex. med was left off discharge summary

ex. instructions not understood, can't afford meds

Systemic Issue, 40%

Non-Intentional, 4%

Intentional, 56%ex. Discharged with med but no Rx

ex. Did not fill Rx, refuses to take med

ex. dosage was changed

94% of Dovetail clients have medication adherence issues

identified during initial pharmacy assessment

75% of Dovetail clients have medication reconciliation issues identified during initial pharmacy

assessment

Dovetail's focus on medications has reduced readmissions to less than 10% (N=100)

Project goals

• Reduce overall healthcare expenses by focusing on the most common cost drivers (admissions and readmissions and chronic illness)

• Increase patient satisfaction by offering personalized, targeted interventions to improve overall health from a consistent team of healthcare providers

• Increase PCP satisfaction with their job overall as well as their ability to care for complex patients

• Help primary care practices take steps toward Patient-Centered Medical Home accreditation by providing specific services identified in NCQA guidelines

Project Timeline and Ramp-Up Schedule

Feb. Mar. Apr. May Jun. Jul. Aug. Sep.

5 5 5 5 - - - -

- 10 10 10 10 - - -

- - 10 10 10 10 - -

- - - 10 10 10 10 -

- - - - 5 5 5 5

Monthly Total

5 15 25 35 35 25 15 5

Unique Total

5 15 25 35 40 40 40 40

Sep. 08

Concept and operations development

Jan. 09 Feb. 09

Staff hiring and training

Implementation strategy Kick-off

Sep. 09

Service delivery

May 10

Outcomes and recommendations

Patient data collection Data analysis / program evaluation

Outcomes measures and tracking systems

Patient Ramp-Up Schedule

Measuring clinical outcomes

Measure Source Collected By Frequency

Patient perception of healthSF-36

(patient)Dovetail RN Initial and final visits

Patient satisfactionDovetail survey

(patient)Dovetail PCC

Prior to initial visit and within 30 days after final visit

Physician satisfactionDovetail survey

(physician)Project Assistant

Prior to initial visit and within 30 days after final visit

Utilization (hospitalization, ED visits, PCP visits, specialty care, VNA, Falls, Dovetail

interactions, etc)

Patient/family/RN report; medical record review

Dovetail RN With each patient interaction

Healthcare costsEstimated based on average

utilization costs; SF-36 analysisProject Assistant At end of project

IT utilization (use by MD, client, Dovetail)

Gateway System Project Director Monthly review

NCQA PCMH Standards Met NCQA PCMH Standards Project Director Prior to Program/Post

The clinical centered tool (CCT)

• Collects interventions as well as outcomes

• Embedded SF-36 for pre and post intervention data

• TTM evaluation

• Incorporates all areas of geriatric domain concerns

• Has report functionality

• Guides clinicians in using a strength based approach to in home coaching (“Framing the visit in the positive”)

• Client centered

• Excel spreadsheet database which allows for great flexibility in data collection and interpretations

Value proposition: selling complex patient management to payer and provider groups under risk contracts

Top 5% of highest cost / highest risk patients

2,000 patients qualify for services

50% accept services

1,000 patients enrolled in program

40,000 Medicare Advantage members

2000 admissions / 1,000 among patient group per year

1,000 patients in program will have 2000 admissions ($10,000 each-AHRQ)

$20M problem ($41.66 pmpm)

1,000 patients enrolled for 4 months each ($450 per month)

$1.8M program cost ($3.75 pmpm)

12% reduction in admissions = $2.4 M avoided cost [+600K)

15% reduction in admissions = $2.25M avoided cost [+$3M]

25% reduction in admissions = $3.75M avoided cost [+$5M]

Patient Identification

Size of Problem

Program Cost

ROI

Questions / Discussion