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Hotspotting in Aurora Angela Green, PsyDHeather Logan, MSW Director of Behavioral HealthDirector of Accountable Care & Bridges to Care Erin Loskutoff,

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Presentation on theme: "Hotspotting in Aurora Angela Green, PsyDHeather Logan, MSW Director of Behavioral HealthDirector of Accountable Care & Bridges to Care Erin Loskutoff,"— Presentation transcript:

1 Hotspotting in Aurora Angela Green, PsyDHeather Logan, MSW Director of Behavioral HealthDirector of Accountable Care & Bridges to Care Erin Loskutoff, MPH, MSN, AGNP-C B2C Nurse Practitioner

2 MCPN Every touch, every time.

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4 MEDICAL REPORT THE HOTSPOTTERS Can we lower medical costs by giving the neediest patients better care? by Atul Gawande JANUARY 24, 2011Atul Gawande

5 The Round Table: Aligning the Partnerships

6 What are we trying to accomplish here? Identify WHY patients over-utilize the hospital: Build a model around the WHY Stabilize, Coordinate, Improve Care, Reduce Cost Reduce ER visits and Inpatient stays through a community intervention

7 Helping people one at a time to empower themselves with tools, knowledge, and confidence to take responsibility for their own physical and psychological health. The Bridges to Care Vision

8 Bridges to Care Model Hybrid of the Hospital Discharge, ED, Home, and Community Based Models Intervention begins at bedside 60 day model: Patient graduates from the program 8 visits minimum Collect information at each step to evaluate/improve program Inclusion/Exclusion Criteria MCPN’s model includes 2 unique components

9 Medical Providers

10 Behavioral Health Providers

11 Criteria INCLUSION Live in Aurora 3 Hospital Visits (ER & IP) in last 6 months Adults Non-violent offenders, homeless, BH are all ok EXCLUSION Acute visits (?) Pregnancy HIV (?) Malignancies Primary dx of personality disorder Post-surgical Primary diagnoses of substance abuse Diminished capacity Pediatrics Violent offenders/sex offenders Care giver as primary decision maker or Power of Attorney

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14 Behavioral Health: An Essential Component SDAC data revealed nearly 80% of Medicaid patients in this data set had a behavioral health component to condition

15 AIM-C Approach Assess – SBIRT, PHQ, initial visit, CPCQ, risk stratification, enrollment evaluation, CCC assessment Intervene – brief counseling, meds, referrals, coaching EMpower – educate, activate, validate, participate, motivate Connect – relationship, resources, referrals

16 Outcomes/Deliverables 1. Enroll our 689 patients 2. Demonstrate cost savings - Reduce re-hospitalizations - Decrease Illness Burden 3. Transition patients from home visits to clinic visits 4. Establish health homes for patients 5. Demonstrate sustainability/develop a sustainability plan

17 Demographics

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20 Encounters By Type & Team Member

21 Physically Unhealthy Days

22 Chronic Diagnoses B2C StatusMore than 1 Chronic DXFrequencyPercentage Active363895% Graduated % Lost to Follow % Total % ICD9DescriptionFreq Unspecified essential hypertension Nondependent tobacco use disorder Depressive disorder, not elsewhere classified Anxiety state, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other and unspecified hyperlipidemia Asthma, unspecified, unspecified Dysthymic disorder Esophageal reflux Obesity, unspecified Posttraumatic stress disorder C Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Chronic airway obstruction, not elsewhere classified Panic disorder without agoraphobia Bipolar disorder, unspecified Unspecified hypothyroidism Congestive heart failure, unspecified Nondependent alcohol abuse, unspecified drunkenness Major depressive disorder, recurrent episode, moderate Unspecified migraine without mention of intractable migraine27 Top 20 Chronic Diagnoses (All statuses) An overwhelming proportion of B2C patients suffer from chronic illnesses (92%)

23 B2C Patients with BH Diagnoses 78% of Active patients 86 % of Graduates 81% of All B2C Patients 69% of Lost to Follow

24 Mentally Unhealthy Days

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26 Current B2C – Utilization Trend Data

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28 What We Already Know About Cost Savings “Health centers save $1,263 per person per year, lowering costs across the delivery system‒from ambulatory care settings to the emergency department to hospital stays” Source: NACHC analysis based on Ku L et al. Using Primary Care to Bend the Curve: Estimating the Impact of a Health Center Expansion on Health Care Costs. GWU Department of Health Policy. Policy Research Brief No. 14. September 2009.

29 Lessons Learned You need good people to do hard work! Systems are not designed for innovative work! Chances are no one has gotten this far before! Sometimes being a gardner is all you can do! Be realistic about what change means! Buy in is crucial, it just may not always come from the top or look the way you envisioned!

30 Constantly Evolving: Don’t use pen!

31 Achieving the Triple Aim “The integrator’s role includes at least five components: 1. Partnership with individuals and families, 2. Redesign of primary care, 3. Population health management, 4. Financial management, and 5. Macro system integration. “ Health Aff May 2008 vol. 27 no

32 Thank you.


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