1. INTEGRATING POPULATION HEALTH INQUIRY TRANSFORMS (IPHIT) FAMILY MEDICINE COMPLEXITY AT NORTHEAST Northeast Education Afternoon March 27, 2014 Jennifer Edgoose

2. DO YOU FEEL LIKE THIS?

3. Email on 1/21/4 to Lou and Jennifer We deal with complexity

4. TRYING TO QUANTIFY THE WORK WE DO: THE ARNDT SCALE

5. WHY? Fair distribution of patients Appropriate scheduling of patients Appropriate distribution of staff Quality measures could include attention to effort as well as outcome Burnout

6. TRYING TO QUANTIFY COMPLEXITY Current measures Face-to-face workload E.g. work relative value units (wRVUs) based on the Centers for Medicare and Medicaid Services Resource Based Relative Value Scale Insurance claims data try to predict future utilization, cost, mortality and quality of life Chronic Disease Score, Charleston Index, etc. What about non face-to-face work? E.g. Telephone calls, electronic communication, supervision of nurse visits, medication refills Increased work associated with poverty Patient characteristics

7. Perceived Overall Encounter Workload Encounter TypeWeight Standard Deviation 95% Confidence Interval Hospital1.810.43(1.78, 1.90) Emergence room1.480.56(1.36, 1.60) Off-site facility (home or nursing home) 1.190.58(1.07, 1.32) Office visit (serving as baseline)1.00-- Urgent care0.890.35(0.81, 0.96) OB visit0.680.38(0.60, 0.76) Telephone0.450.28(0.39, 0.51) Online communication0.390.32(0.32, 0.46) Laboratory test ordered0.300.26(0.25, 0.36) Medication refill0.260.24(0.21, 0.32) Patient letters0.240.25(0.19, 0.29)

8. Description Average Ranking Standard Deviation 95% Confidence IntervalWeight Unspecified psychiatric condition8.643.76(7.83, 9.46)1.33 Uninsured8.144.04(7.27, 9.01)1.25 Having more than 10 types of medication 7.533.93(6.68, 8.38)1.16 Five or more no-show or cancelled appointments * *** *** *** 1.14 Schizophrenia7.363.63(6.58, 8.15)1.13 Interpreter services needed7.193.43(6.45, 7.93)1.11 Medicare patient whose age is less than 65 (e.g., disability or end-stage renal disease) 6.893.17(6.21, 7.58)1.06 Diabetes6.753.22(6.06, 7.45)1.04 Dementia/cognitive impairment6.743.17(6.06, 7.43)1.04 Chronic kidney disease6.713.41(5.97, 7.44)1.03 Depression/anxiety/bipolar6.513.06(5.84, 7.17)1.00 Chronic opioid/stimulant use6.254.46(5.28, 7.21)0.96 Chronic heart failure6.193.53(5.43, 6.95)0.95 Asthma/COPD6.054.65(5.07, 7.05)0.93 Ranking of Challenging Patient Characteristics

9. How to Calculate Arndt Scale (Step 1) The encounter workload score for a patient is equal to the sum of all individual encounter scores computed during a time period. Example: A patient had 1 emergency department visit, 4 office visits, 6 phone calls, 10 medication refills, 2 lab orders, and 2 lab results letters Encounter Score: (1  1.48 + 4  1.00 + 6  0.45 + 10  0.26 + 2  0.30 + 2  0.24) = 11.86 * Look up weights in the “Overall Encounter Workload” table

10. How to Calculate Arndt Scale (Step 2) The challenging characteristics score for a patient is equal to the sum of all chronic conditions, medications burden, and socioeconomic characteristics computed during a time period. Example: An uninsured patient with diabetes and chronic kidney disease who has no-showed or cancelled five or more appointments. Challenging Characteristics Score: (1.25 + 1.05 + 1.03 + 1.14) = 4.47 * Look up weights in the “Ranking of Challenging Patient Characteristics” table

11. How to Calculate Arndt Scale (Step 3) The overall complexity score for a patient is determined by adding the encounter workload score to the total patient characteristics score. In this example, the patient would have a total complexity score of 16.33 (=11.86 + 4.47).

13. The 30 most complex patient panels in the entire statewide DFM Northeast has 33 % Wingra has 13%

15. NORTHEAST

16. WHAT DOES THIS MEAN? Systematic QI processes are important We could ask further questions of the data. What primarily drives our high complexity? Examples: Number of ED visits? % of patient under 65 who are disabled? The mental health comorbidity of our patients? Should we use this to leverage more support E.g. more staff?