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Super-Utilizer, Team-Based, Cross-Setting Care: The Future of Healthcare Cost Reduction Barry J. Jacobs, Psy.D. Crozer-Keystone Family Medicine Residency.

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Presentation on theme: "Super-Utilizer, Team-Based, Cross-Setting Care: The Future of Healthcare Cost Reduction Barry J. Jacobs, Psy.D. Crozer-Keystone Family Medicine Residency."— Presentation transcript:

1 Super-Utilizer, Team-Based, Cross-Setting Care: The Future of Healthcare Cost Reduction Barry J. Jacobs, Psy.D. Crozer-Keystone Family Medicine Residency Program Springfield, PA Collaborative Family Healthcare Association 16 th Annual Conference October 16-18, 2014 Washington, DC U.S.A. Session #E2 October 17, 2014

2 Faculty Disclosure Please include ONE of the following statements: I currently have the following relevant financial relationships during the past 12 months: –20% of my salary is currently covered by a proof of concept study grant from Independence Blue Cross/Blue Shield

3 Learning Objectives At the conclusion of this session, the participant will be able to: Identify the key components of the super- utilizer approach for reducing healthcare costs Describe the integrated team composition and processes of super-utilizer programs Understand the implications of super- utilizer programs for developing tiered care for chronically ill patients

4 Bibliography / Reference 1) Gawande, A (2011). The hot-spotters. The New Yorker, January 24 downloaded 9-20-14: 2) “Top 8 Best Practices,” (2014), publication of the Camden Coalition of Healthcare Providers, 3) “Super Utilizer Summit—Common Themes from Innovative Complex Care Management Programs” (October 2013), downloaded from Robert Wood Johnson website on 9-20-14: 0 4) Coburn KD et al (2012). Effects of a Community-Based Nursing Intervention on Mortality in Chronically Ill Older Adults: A Randomized Control Trial, PLoS Medicine, 9(7), 1-14 5) Hoefer, D (2010) Transitions Frailty, video of presentation from the Family Medicine Education Consortium 2010 conference downloaded 9-20-14:

5 Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

6 Today’s Talk Dr. Jeff Brenner’s story Who are super-utilizers and why do they matter? Components of SU interventions The Crozer-Keystone SU programs with 3 case illustrations Lessons learned

7 “The Hot Spotters”—1/24/11

8 Who is Jeff Brenner, MD? Closed solo family medicine practice in Camden, NJ Looked at city’s healthcare data Founded Camden Coalition of Healthcare Providers


10 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.

11 Anticipated Federal Debt

12 Characteristics of High-Utilizers Most are insured, 60% public insurance Only 15% uninsured Over 80% have identifiable PCPs More utilization of health services in general Diagnoses vary greatly Ages 25-44 and over 65

13 Usage Patterns ED high utilizers = >3x per year Often patients with trauma histories, personality disorders, drug problems Inpatient high utilizers = >2 inpatient admissions within a 6-month period Often social issues (e.g., housing, transportation, chaotic families)

14 Components of SU Interventions A cross between intensive biopsychosocial care and community organizing: Data mining (sometimes across health systems and agencies) to create SU list Creation of collaborative multi-disciplinary teams: physicians, nurses, case managers, pharmacists, social workers, psychotherapists, volunteers Assessment procedures and outcome measures Relationship-building with other healthcare and social service providers to improve care transitions

15 Interventions (cont.) Strong emphasis on addressing social determinants of health: Housing, transportation, food Home visits essential Focus on trauma and addictions Medical visit accompaniment Use of community health workers Breaking down silos between healthcare and social service agencies

16 CCHP Outreach Hospital Admission s Data Nurse driven care transition Patients with history of ED visits/hospital admissions and readmissions (2+ admits w/in 6 mos.); socially stable Average 6-8 week engagement Multidisciplinary care management outreach Patients with history of ED visits/hospital admissions and readmissions (4 admits w/in 6 mos.); social complexities Average 6-8 month engagement Intermediate Risk High Risk Care Coordination Data driven care mgt. Patient Engagement Medical Home Health Coaching Inclusion Triage Care Continuum Model

17 Results The Camden Study-An ED Alternative 5 year study of 380,000 visits at 3 EDs 1% of patients 40,000 visits, $46 million cost Top 35 utilizers generated $1.2 million in charges each month After one year of SU care, costs dropped to $531,000

18 South Central PA High Utilizer Collaborative 18South Central PA High Utilizer Collaborative

19 SOUTH CENTRAL PA WHITE PAPER 6/14 With 138 combined patients enrolled in SU programs, inpatient admissions decreased 34% ED utilization increased

20 Crozer-Keystone Health System

21 CKHN Inpatient and ED Stats: 2012 IP: Inpatient Visits > 3 / year = 457 Readmission > 1 = 308 (67%) ED: Emergency Room > 4 / year = 889 1275 Individual Patients Combined IP & ED TOTAL LOSS (Paid-Costs) = -$3,136,933

22 Center for Family Health One of two training sites for Crozer- Keystone Family Medicine Residency NCQA accredited PCMH since 2008 SU program as overlay on PCMH care Titrate up, graduate (8 months), titrate down

23 SD—Inpatient Super-Utilizer 64 yo retired electrician living with his wife 13 admissions for CHF in 2010-11 (over 12 month period)

24 1 year pre-enrollment Charges= $520,000; Receipts= $90,000; Inpatient:12; ED visits:7 Post-enrollment Charges = $11,686 ; Receipts= $0. Inpatient: 0; ED visits:3 Length of Stay IP Admit ED Visit

25 CB—ER Super-Utilizer 60 yo on disability for chronic pain due to fibromyalgia; also remote history of mild CVA Worked as welfare case manager for over 30 years Pastor/pastoral counselor

26 CB (cont.) Between 1996-2012, had 102 ER visits Included 21 visits in both 2008 and 2009 Had 112 CT scans, including 71 head CTs

27 CB (cont.) Gradually decreasing her habit of going to ER through increasing her awareness of mind- body connections, decreasing her anxiety, reducing family support for utilization 2012: 8 2013: 5 2014: 1 (thus far)

28 Our Team


30 Identification Inpatient Census PCP Referral Insurance High-Risk Lists CKHS Financial Reports (Note 6-12 month lag time) Selection Inclusion Two or more inpatient admissions in past 6 months Exclusion Mental Health Only Oncology Surgery Pregnancy Patient Selection

31 Team Members Goals of program Care Agreement Record Release Introduction Willingness to answer phone calls Allow home visit # of no shows for PCP in last year # of previous PCPs in last year Engagement Goal alignment Activation URICA Tool Patient Activation Measurement (PAM) Readiness to Change Screening & Assessment Visit

32 Visit 1 Assessments Psychology Social Work Pharmacy SU Team Leaders Visit 2 Review Goals Review Care Plan HUDDLE Communicate with PCP Initial Note in EMR Scan RR and CA to EMR Clinical Process

33 Results (11 patients) ER visits per patient per month: Before: 0.207 During: 0.16 OBS visits per patient per month: Before: 0.025 During: 0.147 Inpatient visits per patient per month: Before: 0.323 During: 0.046 Inpatient LOS per patient per month: Before: 1.096 During 0.16

34 IBC Medicare Advantage SU Program Crozer-Keystone was approached by Independence Blue Cross in spring of 2013 to create a 1-year- proof of concept, super- utilizer intervention for IBC’s Medicare Advantage patients within the Crozer- Keystone Health System Brenner excludes patients over age 80 We drew on works of Ken Coburn, Dave Moen and Dan Hoefer

35 Coburn taught us power of home-based nursing intervention Moen taught us power of home-based physician care Hoefer taught us cost savings and increased life span with widespread palliative care

36 Our Process Analyzed IBC and CK utilization data Chose 13 patients on basis of utilization, cost to IBC, losses to CK Reached out to primary care physicians Nurse case manager engages patients, conducts assessments and weekly visits Uses multidisciplinary team as advisors during weekly Huddle Includes family medicine fellows/residents; psychology, social work, pharmacy students

37 CO, 88 year old widow who lives in a multi- generational home. Co-morbidities include: DM, CHF, HTN, CAD, Obesity, Peripheral Neuropathy & edema Chaotic home environment Patient having increased episodes of confusion

38 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

39 Deep Dive Social milieu/uncoordinated care – Family refused to have homecare RN visits post- hospitalization – Our team has great concerns about caregiver burden and capacity, but the family didn’t want increased support services at this point Possible dementia versus delirium – Family concerned about increasing confusion

40 CO’S Outcomes Thus Far Patient now sleeps upstairs with legs up— decreased cellulitis Blood sugars better controlled No hospitalizations from 1/14-8/14 8/14: hospitalization for possible CVA; turned out to be Bell’s palsy Family has accepted home nursing for wound care Primary caregiver still contending with burnout

41 Lessons Learned Interdisciplinary team-based, cross-setting care has resulted in mostly great success—but also spectacular failures Patient engagement still key—takes 2 months Graduating patient from SU care and return to PCMH takes careful planning or risks reversion to previous level of utilization SU is essential overlay for PCMH to address most complex, expensive patients

42 Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!

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