Hamann big institution to community care


Published on

Published in: Health & Medicine
1 Like
  • Be the first to comment

No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Hamann big institution to community care

  1. 1. AMDIS Fall Symposium Boston, MA Sept. 29, 2013 Claus Hamann MD, MS, FACP Accenture LLP
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 15. Conclusion Incentives are aligned ! Complexity is us ! Culture is ready ?
  16. 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
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.