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Hamann big institution to community care

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  • 1. AMDIS Fall Symposium Boston, MA Sept. 29, 2013 Claus Hamann MD, MS, FACP Accenture LLP
  • 2. Big Institution to Community: Accountable, Collaborative, Disruptive Care Agenda and Summary  To accomplish the Triple Aim (Health, Care, Costs), we need to focus on the care of patients with complex illnesses  To succeed at the care of patients with complex illnesses, we embrace collaborative, coordinated care  How do we succeed?  Adopt proven models into accountable care  Implications for Clinical IT  Documentation  Content, Decision support  Interoperability, HIE
  • 3. Why Focus on the Care for Complex Patients?  To accomplish the Triple Aim (Health, Care, Costs), we need to focus on the care of patients with complex illnesses  Hospitals – “That’s where the money is.”  Post-Acute Care: “That’s where the variation is.”  73%, in nursing facilities, home health care and long-term-care hospitals  Compared to 27% for hospitals and 14% tests/procedures (Newhouse, 2013)  Dementia hospitalization ↑ 10 x from 2000 → 2050  Accountable Care aligns incentives  Efficient Care is key: overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, fraud and abuse (Berwick, 2012)
  • 4. Collaborative Care for Complex Patients http://www.improvingchroniccare.org/  Team care  Patients with multiple diseases, functional impairments and social challenges  Professionals from several health disciplines  Multi-  Inter-disciplinary processes  Team decision-making  Chronic care model  Historically: Pediatrics, Physiatry, Psychiatry, Geriatrics  Now mainstream with aligned incentives ?
  • 5. Accountable Care Meets Geriatric Care  15 successful geriatric care models based on 123 high-quality studies with positive outcomes (Boult, 2009)  “Fee-for-service payment is anathema to effective chronic disease care… to improve chronic care [we need] accountability and payment in synchrony.” (Kane, 2009) http://www.ncbi.nlm.nih.gov/pubmed/20121991 • Interdisciplinary primary care: 1 • Supplement primary care: 8 • Transitional care: 1 • Acute care in patients' homes: 2 • Nurse-physician teams for residents of nursing homes: 1 • Comprehensive hospital care: 2
  • 6. Collaborative Care for High-Risk and Vulnerable Populations Socially Disadvantaged Clinically Vulnerable Highly Vulnerable Source: High-Risk and Vulnerable Populations Workgroup: http://www.acolearningnetwork.org/ Socially Disadvantaged Clinically Vulnerable • Racial, ethnic minority • Native American community • Immigrant • Impoverished neighborhood • Low incomes • Low levels of education • Low health literacy • Rural area • Homeless • Non English-speaking • Dual–eligible beneficiaries • Uninsured/underinsured • Have low social supports • Complex chronic illnesses • Acute serious illnesses • Multiple chronic conditions • Disabled • Mentally ill • Substance abusers • Cognitively impaired • Frail elders • Patients nearing the end of life • Pregnant women • Very young children • High-utilizer patients • High-cost patients • Dual-eligible beneficiaries
  • 7. CareMore Succeeding at Complex and Post-Acute Care  Medicare Advantage “+”  Av. age 72, 50% <$30k income; DM 33%, HTN 40%  Intensive management of frail and chronically ill: 15% members → 70% costs,  Monitoring, management of chronic conditions to delay the onset of frailty  Costs 15% less; profitable Reuben, 2011  Contract with PCPs; handle non-urgent illness  NP’s, MA’s: evidence-based protocols  1-hr. Healthy Start visit, MA + NP/MD, comprehensive evaluation; annually  Extensivists: inpatient + post-discharge care including SNF  Specialist management  Transportation, fitness, home intervention team, caregiver support, respite care, high-intensity management for frailest 2%  EHR + wireless home monitoring  Culture of conservative management Outcomes  DM: av. A1C 7.08; amputation 78% < national av.  Hosp.: ALOS 3.0 d.; ESRD 42% Re- Hosp.: 13.6% vs. 20%  CAPHS > CA, US
  • 8. Collaborative Care for Complex Patients  Patient and caregiver at the center  Collaboration  Communication “…health system performance will increasingly depend on high-functioning, team-based approaches to care.” (Dzau, 2013)
  • 9. Enabling Success with Care of Complex Patients Role of Clinical IT  Implications for Clinical IT  Documentation  Care planning, including patient/resident choice  Minimum Data Set; Resource Utilization Groups  Decision support  Interoperability, HIE  Unique features of Nursing Home care  Not part of MU  Slower EHR adoption  Help on the way: Center for Aging Service Technologies, 2013  Needs assessment and EHR Selection Matrix comparing 36 products on ~200 features and functionalities http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2010/Apr/1380_Klinger_lessons _HIT_New_York_nursing_homes_case_study.pdf, Commonwealth Fund, 2010
  • 10.  “Last week Mrs. S. spiked a fever of 100.2 and was not eating much.  The nursing supervisor immediately contacted the resident’s physician offsite  Viewed via Internet Mrs. S.’s full clinical record over the last week  Real-time data being entered at the bedside by the nursing team and direct-care staff  Record of all her medications and when she had taken them  Plan made between the nursing home care team and physician to give Mrs. S. intravenous fluids for 24 hours to avoid dehydration  “Give fever-reducing medication, monitor her vital signs, inform physician.”  Physician viewed progress from offsite  If hospitalization were indicated, it could have immediately been carried out.  Mrs. S.’ temperature became normal over 24 hours and she began to eat, drink.  Treatment plan appropriate  No hospitalization.” Enabling Success with Care of Complex Patients Role of Clinical IT – Patient Vignette http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2010/Apr/1380_Klinger_lessons _HIT_New_York_nursing_homes_case_study.pdf, Commonwealth Fund, 2010
  • 11. Transitions of Care Clinical IT Challenges for Long-Term Post-Acute Care (LTPAC) 1 of 3  Health IT adoption spectrum for long-term post-acute care (LTPAC): systems for federally required assessments for payment and quality >> systems for care  Health IT-enabled facilities: Data feeds to an exchange, secure messaging  Low/no IT-adopted facilities  Web-based portals for secure messaging, information query with hospitals and other care partners  Simple clinical documentation tools to facilitate electronic capture of LTPAC data shared at transitions  EHRs: integrated connectivity is evolving; CCHIT modular certification growing  Standards: 5 Transition of Care data sets to meet needs of most types of transitions
  • 12. Transitions of Care Clinical IT Challenges for Long-Term Post-Acute Care (LTPAC) 2 of 3  Clinical Workflow: paper/fax  electronic solutions  To assess patient acuity, service needs and staffing levels, on- site administrator and nursing leader and off-site medical director all need access to information  Better identify and ensure services for patients with high medical complexity and resource utilization patterns with data from multiple episodes of care and settings  Urgent ED evaluations: via DIRECT  Secure message and change in condition documentation earlier in the care episode, detailing symptoms and events leading up to the transfer  Communicate assessments performed in the ED to both the nursing facility and the attending medical provider, for safe transition to sending facility
  • 13. Transitions of Care Clinical IT Challenges for Long-Term Post-Acute Care (LTPAC) 3 of 3  Staffing and User Access  Core team: administrator, director of nursing, assistant director of nursing, compliance leader and senior charge nurse vs. Care managers or Nursing coordinators  High staff turnover: train multiple staff, work with very small user groups in well-defined phases  Value Proposition: Too early in adoption phase for ROI  Avoid penalties for readmissions, improve staff efficiency and reduce staff time, reduce burden on patients and families  More accurate and timely medication reconciliation, better access to all anticoagulation results, fewer missed wound/therapy treatments http://www.healthit.gov/sites/default/files/challengegrantslessonslearnedltpac_paper.pdf 2013
  • 14. Supporting Collaborative, Coordinated Care Socially Disadvantaged Clinically Vulnerable Clinical Documentation Care Planning Practice Technology EHR • Software / database • Functionality • Configuration tools http://www.nationalehealth.org/ckfinder/userfiles/files/Improving%20Care%20Coordination%20Slide%20Deck.pdf Content • Evidence-based • Intentional automation • Integrated interprofessional care Workflow Design Culture Change
  • 15. Conclusion Incentives are aligned ! Complexity is us ! Culture is ready ?
  • 16. References  Newhouse JP, et al. (2013). Variation in health care Spending: Target Decision Making, Not Geography: http://www.nap.edu/catalog.php?record_id=18393  Berwick DM, Hackbarth AD. Eliminating Waste in US Health Care. JAMA. 2012;307(14):1513-1516. doi:10.1001/jama.2012.362  Zilberberg MD, Tjia J. Growth in Dementia-Associated Hospitalizations Among the Oldest Old in the United States: Implications for Ethical Health Services Planning. Arch Int Med 2011; 171; 1850-1851.  Boult C, et al. (2009), Successful Models of Comprehensive Care for Older Adults with Chronic Conditions: Evidence for the Institute of Medicine's “Retooling for an Aging America” Report. Journal of the American Geriatrics Society, 57: 2328–2337. doi: 10.1111/j.1532-5415.2009.02571.x  Kane RL (2009), What Can Improve Chronic Disease Care? Journal of the American Geriatrics Society, 57: 2338–2345. doi: 10.1111/j.1532-5415.2009.02569.x  Reuben DB (2009), Better Ways to Care for Older Persons: Is Anybody Listening?. Journal of the American Geriatrics Society, 57: 2348–2349. doi: 10.1111/j.1532-5415.2009.02574.x  Reuben DB (2011). Physicians in Supporting Roles in Chronic Disease Care: The CareMore Model. Journal of the American Geriatrics Society 59:158–160  Dzau VJ, et al. Transforming Academic Health Centers for an Uncertain Future. N Engl J Med 2013 369;991-992.  CareMore, 2012: http://www.wellpoint.com/prodcontrib/groups/wellpoint/@wp_news_main/documents/wlp_assets /pw_e181475.pdf  Center for Aging Service Technologies, 2013: http://www.leadingage.org/uploadedFiles/Content/About/CAST/Resources/2013_CAST_EHR_For_LT PAC_A_Primer_on_Planning_and_Vendor_Selection.pdf

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