1. Innovative Funding for High- Utilizer Initiatives: Residency- Insurance Co Partnerships William Warning II, MD Barry J. Jacobs, Psy.D. Katherine Mahon, MD Kimberly McGuinness, CRNP

2. Disclosures The Crozer-Keystone Family Medicine’s Residency Program’s Frail Elderly Super- Utilizer Program was fully supported by two one-year grants from Independence Blue Cross

3. Objectives Describe high-utilizer interventions and their impact on healthcare cost and quality Identify ways to collaborate with insurance companies on high-utilizer programs Discuss benefits of a Super-Utilizer fellowship

4. Anticipated Federal Debt

5. 1% 5% 10% 50% 22% 50% 65% 97% $26,767 $90,061 $40,682 U.S. Population Health Expenditures $7,978 Distribution of Health Care Expenditures for the U.S. Population, According to Magnitude of Expenditure, 2009 The sickest 10% of patients account for 65% of the health care expenses. Dollar amounts are annual mean expenditures per patient. Data from the 2009 Medical Expenditure Panel Survey, adapted from the Commonwealth Fund.

7. Crozer-Keystone Health System 5-hospitals, 6800 employees in an inner ring, socioeconomically and culturally diverse Philadelphia suburb 10-10-10 residency, founded in 1984; two family health centers, one an FQHC SU programs since 2011; SU fellowship--in conjunction with Dr. Jeff Brenner’s Camden Coalition of Healthcare Providers--since 2012

8. Hot-Spotting and Super- Utilizer Fellowship Program

9. Crozer-IBC SU Program In spring of 2013, our SU team was approached by a physician executive at Independence Blue Cross, the largest Philadelphia area insurer, to create a proof-of-concept, intensive care coordination program for 10 IBC Medicare Advantage patients with PCPs in the Crozer-Keystone Health System

10. IBC’s Goals Test a team-based model for lowering readmission rates of frail elderly subscribers Determine whether insurer-funded high- utilizer work should be organized on local health system level Gauge degree of engagement/cooperation of primary care providers with local team

11. Crozer-IBC Model Based on work of Drs. Ken Coburn (warm- spotting, nurse as point person), Dave Moen (medical home visits) and Dan Hoefer (palliative care) Hired nurse case manager to do weekly home visits, medical visit accompaniment, family meetings

12. Crozer-IBC Model (cont.) Interprofessional team of advisors/interveners: family medicine, nurse practitioner, psychology, social work, pharmacy, volunteer Weekly huddles Additional communication through EMR, texting

13. Frail Elderly Program Ran 1/1/4-12/31/15 Total of 20 pts; 3 died Avg. age: 80 Dxs: CHF, COPD, DM Issues: $, family, home

14. Patient CO 89 yo widow Blue collar Multi-generational home DM, CHF, CAD, edema Sleeps in recliner at night Sits in recliner all day

15.  10/4/13 – Admitted for bilateral lower extremities cellulitis  11/20/13 – ER for Edema  11/24/13 – OBS for arm cellulitis  1/7/14 - Admitted pneumonia and CHF  2/5/14 – Admitted for change in mental status/Anemia/UTI  Enrolled in Crozer Connections to Health Team program 2/12/14

16. Pt/Family Assessment Engagement challenges Frequent hospital visits Leg edema/cellulitis recurrences Diffusion of family responsibility Medication non-adherence Confusion at night Caregiver duress

17. Care Coordination Plan Weekly visits and physical assessments Medication reconciliation/education Sleep hygiene Mx visit accompaniment Define family roles Weekly PsyD visits Caregiver support

18. Outcomes Sleep hygiene improved Cellulitis prevented or treated before need for hospitalization Improved family coordination of care Medication compliance Greater family engagement with team Challenges: falls, still confusion at night

19. Outcomes (cont) Only 2 hospitalizations in over 2 years for Bell’s palsy and chest pain (following suicide of pt’s daughter-in-law) No ED visits since 8/14 Pt feels well Family has greater confidence

20. Outcomes for All Enrolled Pts Before program (20 pts): During 342 months, 17 ER, 17 OBS, 60 inpatient, 277 days LOS After program (20 pts): During 243 months, 13 ER, 4 OBS, 20 inpatient, 113 days LOS

22. Program Outcomes (cont.)

23. Residency-Insurer Partnerships Common interest: Use high-utilizer approaches for Triple Aim and education Create small-scale project with targeted population (e.g., frail elderly, Medicaid) Invite your own health system’s financial managers and local insurer executives to presentations of model and outcomes

24. Partnerships Offer residency as R&D lab Seek direct funding, not shared savings Deliver metrics but, more importantly, stories of patients, processes, and challenges Learn together with eye toward scaling up in future

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