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  • 1. Creating a Senior Medical HomeBecoming as Complex as our Patients Craig Robinson, MPH Amber Crist, MS Cabin Creek Health Systems
  • 2. Cabin Creek Health Systems Craig Robinson, MPH Amber Crist, MS crobinson@cchcwv.com acrist@cchcwv.com
  • 3. Cabin Creek Health Systems An FQHC with 4 Centers in central West Virginia. 14,000 annual users 2,259 Patients 65 and older  65 – 74 = 1,298  75 – 84 = 711  85 years and older = 250 Implemented Electronic Health Record in 2008 Affiliated with the Central Counties Area Health Education Center Implemented Senior Medical Home in 2009
  • 4. Cabin Creek Health Center -- Dawes, WV
  • 5. An organization is a conversation before it isanything else: it begins with people talking togetherabout something they would like to do that is beyond their capacity to do as individuals. Anthony Suchman Leading Change in Healthcare
  • 6. Let’s Start--With Some ConversationsCMS, under Don Berwick, is promoting the Triple Aim: improve the individual patient experience, improve the health of populations, and lower cost.What are the issues in your community or organization that are barriers to meeting the triple aim for the elderly?
  • 7. Group Issues
  • 8. Why focus on elders?We had… A problem (high hospital use by seniors). Some money (Claude Worthington Benedum Foundation, AHEC). Some interest (medical staff struggling alone with complex elderly patients, PACE project failed) Some expertise (consulting geriatrician, consultant researchers, AHEC leader) Some maps. (the Medical Home model, COPC, SoC)
  • 9. The Problem: Dartmouth Health AtlasHospital discharges per 1,000 Medicare enrollees (overall 2005)http://www.dartmouthatlas.org/
  • 10. Medicare Discharges for ACSC per 1,000 - CY2005 Charleston, WV HRR = 117.0 http://www.dartmouthatlas.org/
  • 11. What’s Behind the Numbers? Complexity
  • 12. Our Patients are Complex
  • 13. Elderly Patients are Complex Multiple chronic conditions Functional and cognitive variation Many, many medicines – opportunities for harm/waste. Multiple medical providers – minimal coordination. Fat complicated medical records – error prone. PCP not told important stuff – i.e. hospital stays, ED visit... Behavioral health conditions not discovered, not treated. Gaps in patient/family health knowledge Big variation in home/family support Ambiguity over end of life care – family disagreements
  • 14. And – Primary Care Health Organizations are ComplexThere is a continuous flurry of diverse demands facing the staff ANDThere is a Culture – “How we do things around here.” Culture develops through staff interactions and relationships. It is Emergent.A common aspect of primary care culture – “We are already overloaded and you want to add what?”
  • 15. BUT - Our Care Model was Simple
  • 16. Problems Can be Simple,Complicated or Complex AND“Disasters can occur when complex issues are managed or measured as if they are merely complicated or simple.” **Brenda Zimmerman, Getting to Maybe. 2006
  • 17. Mann Gulch, on the Missouri River (138 miles east of Missoula, MT)
  • 18. History of Learning from Mann GulchAugust 1949 – Mann Gulch Forest Fireand DisasterSeptember 1993 – N. Maclean’s book,Young Men and FireDecember 1994 – Karl Weick’s article,The Collapse of Sensemaking at MannGulchDecember 1999 – Dr. Berwick’s IHI talk,The Escape Fire. (and now Don Berwick takes the lessons from Mann Gulch to CMS)
  • 19. Some of Weick’s Lessons from Mann Gulch --Four Sources of Resilience for Organizations ALSO: Required for Medical Homes1. Improvisation and Bricolage (creating with what you have).2. Virtual Role Systems (carrying the team’s roles in your head).3. The attitude of Wisdom - (understand we don’t fully understand what’s happening.)4. Respectful Interaction – (showing trust, honesty and self-respect.)
  • 20. Characteristics of UsefulConversations Listening and Talking Structure that invites input Diversity in the group Learning from stories Take note of ideas and of action steps
  • 21. Sources of Actions Promoting Resilience/ Transformation toEffectiveness Medical Homes at CCHS o Staff involved in continuous design of the set of services, the tools, the reportingImprovisation / and the training. o Diverse staff members participate in program assessment and planning meetings. Bricolage o New roles are defined by planning groups for MAs/nurses, pharmacist, behavioralVirtual Roles health, care coordinator, patients. o Medical providers/leaders respect new (expanded) roles. o Staff determine their gaps in knowledge and skills and help to decide content ofAttitude of training. o Regular staff meetings at the clinics to review progress (data) and problems. Wisdom o Outside experts invited to give different perspectives. o Enlarged the team boundary and created processes for sharing patient careRespectful information among team members. o Referrals and requests flow back and forth among all team members. Interaction o Leaders model norms of effective communication and cooperation. o Rules for meetings: Listen and talk; agendas and minutes, everybody invited to talk/share.
  • 22. Rather than planning a long series of steps in advanceand getting anxious when things start to go off course,we can just plan one step at a time and pause after each one to notice what’s happened and only then plan the next step. The plan emerges as we go. Anthony Suchman Leading Change in Healthcare
  • 23. When we got going, the conversationsfocused on: PORT3 ALPopulation (who are we working with) Objectives (what are our aims) Relationships (With patients/staff/resources) Tasks (how do we do it) Training (how do we do it) Tools (how do we do it) Administrative (what support is needed) Logic (why will it work?) Developed by C. Robinson, Cabin Creek Health Systems
  • 24. Senior Medical Home – 2 Populations - Frail Elders = 100 - Risk of Falls and Meet 3 of the 5 criteria - Low physical activity - Exhaustion - Unintentional Weight Loss - Failed Time Walk Test - Failed grip strength - Multiple Chronic Conditions = 540 - Patients with diabetes and at least one other chronic condition
  • 25. Senior Medical Home - Objectives Describe the population in terms of health issues and health status. Patients and caregivers are highly satisfied with their care. Minimize re-hospitalizations. Improve adherence to clinical standards for chronic conditions and preventive measures. Minimize adverse drug events. Improve the experience for the medical staff.
  • 26. Who’s on the Team - Relationships Medical Provider Medical Assistant  Administers screenings, tests, and preventive care review Behavioral Health Consultant  Address behavior change issues related to health risks to serious mental illness, arrange for the next level of care if needed Care Coordinator  Patients main point of contact Pharmacist  Conducts drug utilization reviews for patients at risk for adverse drug events
  • 27. ToolsTeams create, apply, and redesign the tools. This is achieved by experience and conversationThe GCT reviews and endorses tools.The Clinical teams actually apply the tools and give feedback about their usefulness and feasibility POV and Assessment forms Electronic Surveys Patient Registry and templates in the EMR Computer Notification of Hospitalization –“real time”
  • 28. Training Partnered with a local Community College to design a 15 week college credit courseTopics covered included:  Common geriatric medical conditions and preventive measures.  Communicating  Medication Review/Falls Prevention  In home risk assessments  Connecting with community resources
  • 29. References – LogicJournal ArticlesAnderson, R. & McDaniel, R. Managing health care organizations: where professionalism meets complexity science. Health Care Management Review. 2000; 25(1): 83 – 92.Boult, C., Counsell, S., Leipzig, R., & Berenson, R. The urgency of preparing primary care physicians to care for older people with chronic illnesses. Health Affairs. 2010; 29(5): 811 – 818.Fried, L., Tangen, C., Walston, J., Newman, A., Hirsch, C., Gottdiener, J., Seeman, T., Tracy, R., Kop, W., Burke, G., & McBurnie, M.A. Frailty in older adults: evidence for a phenotype. Journal of Gerontology. 2001; 56A(3): M146 – M156.Jordan, M., Lanham, H., Crabtree, B., Nutting, P., Miller, W., Stange, K. & McDaniel, R. The role of conversation in health care interventions: enabling sensemaking and learning. Implementation Science. 2009; 4 (15): 25 – 38.Lanham, H., McDaniel, R., Crabtree, B., Miller, W., Stange, K., Tallia, A., Nutting, P. How improving practice relationships among clinicians and non-clinicians can improve quality in primary care. The Joint Commission Journal on Quality and Patient Safety. 2009; 35(9): 457 – 466.Nelson, K., Pitaro, M., Tzellas, A., & Lum, A. Transforming the role of medical assistants in chronic disease management. Health Affairs. 2010; 29(5): 963 – 965.Nutting, P., Miller, W., Crabtree, B., Jaen, C., Stewart, E., & Stange, K. Initial lessons from the first national demonstration project on practice transformation to a patient –centered medical home. Annals of Family Medicine. 2009; 7(3): 254 – 260.Pham, C. & Dickman, R. Minimizing adverse drug events in older patients. American Academy of Family Physicians. 2007; 76: 1837 – 1844.Tallia, A., Lanham, H., McDaniel, R., & Crabtree, B. Seven characteristics of successful work relationships. Family Practice Management. 2006: 47 – 50.Parkerson, G., Broadhead, W., & Tse, C. The duke health profile: a 17 – item measure of health and dysfunction. Med Care . 1990; 28(11): 1056 – 1072.
  • 30. References – LogicWebsitesThe Plexus Institute – http://www.plexusinstitute.orgAn organization that is dedicated to fostering the health of individuals, families, communities, organizations, and our natural environment by helping people use concepts emerging from the new science of complexity.The Dartmouth Atlas of Health Care - http://www.dartmouthatlas.org/The project uses Medicare data to provide information and analysis about national, regional, and local markets, as well as hospitals and their affiliated physicians.BooksWeick, K. + Sutcliffe,K. (2001). Managing the unexpected: assuring high performance in an age of complexity. San Francisco, CA: John Wiley & Sons.
  • 31. ROI for the Health Center Job enhancement for Medical Assistants. Opportunity for more learning and independence. Increase job satisfaction for primary care provider. Builds community support for the health center. Team members learn a systems approach to understanding problems and solutions – carries over to other problems. Preparation for Health Reform - Medical Homes and Accountable Care Organizations
  • 32. The Money is Coming…… Affordable Care Act Initiatives that Provide Resources for Care Coordination  Accountable Care Organizations  Medicaid Health Home Initiative with enhanced federal match  FQHC Advance Primary Care Demonstration Project  CMS Healthcare Innovation Challenge Programs  Community Care Transition Programs
  • 33. Closing ConversationWhat resources do you have inplace that could be used to improvethe care of your elderly patients?What can you build upon?
  • 34. QUESTIONS
  • 35. Senior Medical Home – Numbers Currently 640 patients  263 home visits enrolled  3,120 care coordinator Avg age 82, 74% female contacts  87% Diabetic  10 ramps built  90% Hypertension  84 grab bars installed  68% Heart Disease  30 trips to visit patients in  42% Chronic Pain the hospital  56% Psychiatric Diagnosis  Linking patients with Drug Utilization Reviews outside resources Completed  Educating all about health  Avg # meds in the care reform beginning = 10.3  Avg # of meds today = 8.1
  • 36. Limiting Our Focus – FrailtyPatients identified as frail have a significantly higher health service and hospital use compared to those adults the same age who are not considered frail.  Presence of three or more of the following components  Weight loss  Weakness  Poor endurance and energy  Slowness  Low physical activityFried, L., et al. Frailty in older adults: evidence for a phenotype. Journal ofGerontology. 2001; 56A(3): M146 – M156.
  • 37. Our Team’s Definition of Frailty Risk of falls – determined by the provider AND  Patient meets 3 of the 5 following criteria:  Low physical activity  Exhaustion  Unintentional weight loss (≥ 10 pounds in last years)  Failed timed walk test (≥ 7 seconds to walk 15 feet)  Failed grip strength (based on BMI) Enrolled first frail patient April 2009
  • 38. Two kinds of Teams—First TeamGeriatric Project Development Team (reps from the 4 clinics):  Providers  Medical Assistants  Pharmacist  AHEC facilitator  Consulting Geriatrician  Care Coordinator  Behavioral Health Consultant
  • 39. Two kinds of Teams – Second Team Care teams at each of 4 clinic sites. Composed of those doing the work at each site.  Medical Provider  Medical Assistant (trained in geriatric care)  Care Coordinator (shared)  Pharmacist (shared)
  • 40. Medical Assistants Tasks Administer screenings, tests, and preventive care review – at routine PCP visits. Conducted quarterly home visits – ck risk for falls, med reviews, education Regular phone call check-ins with enrolled patients. Made referrals to Care Coord. Completed notes in the Electronic Health Record
  • 41. Geriatric Care Coordinator Tasks  Develop working relationships with outside resources.  Telephone resource for care givers – for benefits, legal issues, medications, access to medical care.  Link patients with health center services  Contact hospitalized patients - in person or by phone and arranges follow-up PCP visit.  Enter notes and data in the EMR.
  • 42. Pharmacist TasksReview patient medication list against standard criteria:1. Reviewed accuracy of medication list2. Beers Criteria: i.e. to identify drugs with potential for adverse outcomes in older patients.3. Hamdy Review:  Still indicated?  Duplication?  Prescribed for adverse reactions?  Is Dosage subtherapeutic or toxic due to age or renal status?  Possible Drug-Drug interactions?4. Lower Cost options available?
  • 43. Assessing for Frailty Patient assessed during regular primary care visit  Duke Health Profile  Vulnerable Elders Survey  Timed walk test  Grip strength assessed with a dynameter
  • 44. Duke Health Profile Clinically valid instrument Reference values for primary care patients 66 – 92 User friendly, self administered Questions relate to events of the past week – easy to remember Responsive to real change in health related quality of life Items are generic, not disease specific
  • 45. Duke Health Profile – Data Variables Baseline 8 Months CCHS National Norm Norm *Physical 19.7 26.8 42.5 49.9 Health **Anxiety- 51.5 61.3 33.8 26.3 Depression*Higher the score the better**Lower the score the better
  • 46. 73 patients enrolled over 8 months Average Age = 79.7  17% have had a fall in the 80% Female previous year Average number of  70% depression/anxiety medications = 9.1  52% chronic pain 63% need assistance with  45% diabetes ambulation  20% dementia 60% hospitalized or  85% hypertension visited the ER in the  Avg # prescriptions = 9.5 previous year
  • 47. Senior Medical Home Cost Projection Total project participants= 200 Cost Cost Annual Personnel Costs PMPM PMPY Cost SMH Care Coordinator $24.00 $288.00 $57,600 Med Assist (service/training) $17.07 $204.78 $40,960 Pharmacist $7.11 $85.33 $17,070 Medical Director - (physician) $3.56 $42.67 $ 8,533 Total Personnel Costs $51.73 $620.78 Other Expenses Travel $3.33 $40.00 $8,000 Home safety equipment $4.17 $50.00 $10,000 Administrative overhead 20% $10.35 $124.16 $24,831 Total Other Expenses $17.85 $214.16 $42,831 Total All Expenses $69.58 $834.94 $166,988TT PMPM PMPY Project Annual
  • 48. Utilization Data Primary Care Visits = 4.6 per patient per year Medical Home Visits = 2.5 per patient per year Care Coordinator Contacts = 4.7 per patient per year Hospital Admission Rate = 719 per 1,000 per year (Compared to 433.5, Medicare rate for our HRR) NO patients were re-hospitalized within 30 days of discharge Emergency Room Visit Rate = 68 per 100 per year Avg # prescription meds = 9.5 at start, 8.5 after 8 months
  • 49. ROI – Lessons for Change Step by step. Build on what we did and what we learned. Stay with it. Keep talking and listening. Models are helpful but must customize. Be mindful of everything else going on in the primary care setting. “Bricolage” – taking advantage of what we had.