1 The Health Coach Model A novel approach to provide comprehensive primary health care George Samraj M.D., Marvin Dewar M.D., JD Laura Gruber, MBA, MHS For more information about this project or to receive copies of the slide set, please contact Laura Gruber at

2 UF & Shands Health System Approximately 1,000 faculty physicians, over 600 residents and fellows $394M research awards annually 74,000 discharges 1.2 million outpatient/clinic visits; 80+ outpatient sites Trauma, Movement, Transplant, Diabetes Centers Proton Therapy, Genetics, Cancer, Aging, CTSI, Emerging Pathogens, Brain Institutes Approximately 1,000 faculty physicians, over 600 residents and fellows $394M research awards annually 74,000 discharges 1.2 million outpatient/clinic visits; 80+ outpatient sites Trauma, Movement, Transplant, Diabetes Centers Proton Therapy, Genetics, Cancer, Aging, CTSI, Emerging Pathogens, Brain Institutes Two Academic medical centers: Shands at UF, Shands Jacksonville Specialty hospitals: Shands Vista, Shands Rehabilitation Hospital, UF&Shands Childrens Hospital Colleges: Dentistry Medicine Nursing Pharmacy Public Health & Health Professions Veterinary Medicine Shands Jacksonville 695 beds Shands at UF, Shands Children’s Hospital, and Shands Cancer Hospital 853 beds Shands Vista 81 beds Shands Rehab 40 beds

3 University of Florida Physicians One of largest and most diverse multispecialty physician practices in the Southeastern United States Excusive clinical practice arm of the University of Florida College of Medicine Almost 600,000 outpatient visits annually 73 specialty, subspecialty, and sub- subspecialty areas

4 Patient Centered Medical Home (PCMH) models are not alike Family Medicine model: patient-centered, physician-directed Unifying goal of PCMH models is to provide care that is: Accessible Continuous Coordinated Comprehensive Patient centered Patients in PCMHs are managed centrally by a primary care physician Great Outcomes Practice Organization Patient Experience Health Information Technology Quality Measures AAFP Family Medicine Medical Home Model

5 TransforMED: 2-year national project (2006) in 36 practices CIGNA and Dartmouth: launched a medical home pilot in New Hampshire in 2008 Massachusetts Coalition of Primary Care Reform: established a framework for a medical home model Geisinger Health Care: piloted a medical home program in Pennsylvania CMS: initiated a Medical Home demonstration to improve service quality United HealthCare, Aetna, Blue Cross and Blue Shield: all developing Medical Home pilots Multiple other pediatric and adult pilot programs across country Examples of some Patient Centered Medical Home (PCMH) models

6 Medical Home: a place or a program? All patients Typical PCMH Chronic conditions Disease Management Programs Enhanced needs patients High Needs PCMH Practice sited Externally or practice sited Practice sited

7 Origin of the IMPACT (Improving Patient Care and Treatment) project Project origination Redirection of hospital LIP funding for competitive grant award process Awards prioritized for projects designed to reduce unnecessary ER visits and hospitalizations Competitive application Project submissions from hospitals, academic medical centers, health departments, and social service groups located in all areas of the Florida Competitive review $750K awarded to each of four selected projects Two given to UF&Shands

8 IMPACT Two medical homes for high needs patients embedded within existing primary care residency practice sites – FM & IM Patients selected hierarchically for membership in one of the participating practices PLUS high risk medical conditions (asthma, diabetes, COPD, HTN, heart failure) PLUS frequent system ED and hospital utilization Study is a randomized IRB-approved study in two residency programs to reduce hospital visits and improve health care for patients with one of the five target conditions (asthma, COPD, CHF, diabetes, and hypertension) Health coaches (RNs) hired to recruit, enroll, and manage a high risk panel of patients 200 patients recruited each to intervention and control groups Patient ER visits, hospital admits, patient satisfaction, health outcomes, HEDIS measures monitored semiannually for two years

9 The UF&Shands proposal Recruitment process Initial recruitment packet by mail with consent and phone follow-up “Natural” randomization by practice pod assignment Current recruitment Total sample size: 341 Family Medicine site: 97 control, 102 intervention Internal Medicine site: 81 control, 61 intervention 65% female Mean age: 58 years Study Intervention Patients given IMPACT coach contact information Materials provided IMPACT coaches receive daily lists of patients in ED, hospital and who are scheduled for any clinical visits

10 IMPACT: Intervention Protocol

Weekly IMPACT Coach Report University of Florida & Shands Study Protocol Medical Home Care IMPACT Program Overview The Project The Intervention Pre-interview Chart Review I. First Interview I I. Social Issue Evaluation I II. Follow-up Interviews IV. Documentation V. Contacting Difficult to Reach Patients V I. Ineligible Patients Pre, Initial, and Follow-up Interviews – Quick View Appendix A. FAQ About the Medical Home B. Initiating First-Interview Letter Template C. Contacting Difficult to Reach Patients Letter Template D. Ineligibility Letter Template E. Pre-Interview Chart Review Checklist from EPIC F. Medical Homes First Interview Checklist from EPIC

12 IMPACT coaches – key to any success IMPACT coaches work directly with primary physician, reducing demands on physician time Panel size patients Primary responsibilities Initial comprehensive chart review Medications and social history review Evaluations of standards of medical care Patient encounters – face to face and phone Self management action plan Communicate with PCP Facilitate health care access EMR records and weekly notes Acute care and consultations follow up Supervised by Medical director

13 Weekly IMPACT Coach Report

14 Weekly IMPACT Coach Report

15 IMPACT : Study Outcomes Primary Outcomes: ER visits Hospital admissions 80% power to detect 20% difference in primary outcomes at 18 months Secondary Outcomes: Key HEDIS (Healthcare Effectiveness Data Information Set) indicators for chronic medical conditions CAHPS® (Consumer Assessment of Health Care Providers and Systems) scores

16 IMPACT: Preliminary Learnings Select the right IMPACT coach - optimal background not clear IT coordination across hospital and practice challenging Heavy need for social services Difficult for patients to address medical needs when dealing with social needs Examples – phone, lights, meds, rides Difficult to contact some patients IMPACT coaches use more electronic interaction than we anticipated When you turn a good idea into a “clinical trial” Takes longer than expected (should) Consenting process Full IRB review Intervention validity across sites Can’t always just “do the best thing”

17 Contact information For more information about this project or to receive copies of the slide set, please contact Laura Gruber at Thanks to our IMPACT team: R. Whit Curry, MDElizabeth Shenkman, PhD Eric Rosenberg, MDJacqueline Baron Lee, PhD Sally WalkerVera Brecken-Marquis Vera Brecken-Marquis