1. Creating a Senior Medical Home
Becoming 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 is
anything else: it begins with people talking together
about 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 Conversations
CMS, 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 Atlas
Hospital 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 Complex
There is a continuous flurry of
diverse demands facing the staff
AND
There 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)

19. History of Learning from
Mann Gulch
August 1949 – Mann Gulch Forest Fire
and Disaster
September 1993 – N. Maclean’s book,
Young Men and Fire
December 1994 – Karl Weick’s article,
The Collapse of Sensemaking at Mann
Gulch
December 1999 – Dr. Berwick’s IHI talk,
The Escape Fire.
(and now Don Berwick takes the
lessons from Mann Gulch to CMS)

20. Some of Weick’s Lessons from Mann Gulch --
Four Sources of Resilience for Organizations
ALSO: Required for Medical Homes
1. 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.)

21. Characteristics of Useful
Conversations
 Listening and Talking
 Structure that invites
input
 Diversity in the group
 Learning from stories
 Take note of ideas and of
action steps

22. Sources of Actions Promoting
Resilience/ Transformation to
Effectiveness Medical Homes at CCHS
o Staff involved in continuous design of the set of services, the tools, the reporting
Improvisation / 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, behavioral
Virtual 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 of
Attitude 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 care
Respectful 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.

23. Rather than planning a long series of steps in advance
and 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

24. When we got going, the conversations
focused on: PORT3 AL
Population (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

25. 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

26. 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.

27. 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

28. Tools
Teams create, apply, and redesign the tools. This is
achieved by experience and conversation
The 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”

29. Training
Partnered with a local Community College to design a 15
week college credit course
Topics covered included:
 Common geriatric medical
conditions and preventive
measures.
 Communicating
 Medication Review/Falls
Prevention
 In home risk assessments
 Connecting with community
resources

30. References – Logic
Journal Articles
Anderson, 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.

31. References – Logic
Websites
The Plexus Institute – http://www.plexusinstitute.org
An 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.
Books
Weick, K. + Sutcliffe,K. (2001). Managing the unexpected: assuring high performance in an age of
complexity. San Francisco, CA: John Wiley & Sons.

32. 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

33. 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

34. Closing Conversation
What resources do you have in
place that could be used to improve
the care of your elderly patients?
What can you build upon?

35. QUESTIONS

36. 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

37. Limiting Our Focus – Frailty
Patients 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 activity
Fried, L., et al. Frailty in older adults: evidence for a phenotype. Journal of
Gerontology. 2001; 56A(3): M146 – M156.

38. 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

39. Two kinds of Teams—First Team
Geriatric Project Development Team
(reps from the 4 clinics):
 Providers
 Medical Assistants
 Pharmacist
 AHEC facilitator
 Consulting Geriatrician
 Care Coordinator
 Behavioral Health Consultant

40. 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)

41. 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

42. 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.

43. Pharmacist Tasks
Review patient medication list against standard criteria:
1. Reviewed accuracy of medication list
2. 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?

44. 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

45. 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

46. 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

47. 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

48. 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 $166,988
TT PMPM PMPY Project
Annual

49. 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

50. 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.