Care CoordinationA Key to sustainable

Healthcare

Irv Zeitler, D.O., VPMASandra Morales, RN, MSN, CCMShannon Medical Center

Total Health Expenditure 2008

OECD health data 2012 http://www.oecd.org/els/healthpoliciesanddata/oecdhealthdata2012-frequentlyrequesteddata.htm

Total Health Expenditure 2008

Share of National Health Care Expenditures

IOM (Institute of Medicine). 2010. The Healthcare Imperative:Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington,DC: The National Academies Press.

19.1% of Medicare patients are readmitted within a month of hospital discharge.

56% percent are readmitted within 6 months.

Approximately half of the patients with chronic conditions like heart disease or asthma actually either miss doses or don’t take their medications as ordered. Non-adherence to medical regimens accounts for a great deal of wasted spending and potentially avoidable costly admissions.

A New Model of Care

• A patient-centric strategy based on what we refer to as the Shannon Care Coordination program (SCC)

• The SCC is a model that we believe will be a cost-effective extension of our community hospital that will impact patient care beyond the walls of the hospital.

Pre-med students are engaged in a formal credit-based training program that enables them to serve as health coaches supervised by Shannon Care Coordination team (SCC)

Students are formally trained by a faculty comprising of physicians, a nurse coordinator, social worker, psychologists, nutritionists, and other healthcare professionals.

Upon completion, these students begin a practicum by shadowing members of the interdisciplinary team and are thereafter progressively deployed to serve as health coaches within the community.

How it Works

Under team supervision, each health coach’s primary responsibility is to inspire and motivate our patients to become more actively engaged in their health and well-being.

Health Coaches work with SCC health professionals (Physician, nurses, social workers, dieticians, etc) to reduce what ultimately falls though the cracks and causes costly care that could be avoided.

The Health Coach’s Role

Health Coaches do not get paid — but they receive college credits for their participation in both the didactic sessions and practicum. They also benefit from real world experience — experience that could impact the success of our future healthcare workforce.

Our patients benefit from a reliable dedicated patient-centered continuum of care.

Our physicians receive the support they need for helping to

care for patients with a myriad of challenges.

Angelo State University could ultimately see an increase in students in their healthcare programs who want to participate in this program.

Our community realizes enhanced overall health and well-being.

Everyone Wins

Why Care Coordination?

People with multiple health and social needs are high consumers of health care services, and thus drivers of high health care costs.

The elevated cost of care in this population offers a tremendous opportunity to craft a service delivery plan that meets their needs more effectively at a significantly lower cost.

We believe Care Coordination is a strategy that will be effective, affordable and sustainable. 

The Process Identify patients thru data review/screening Obtain consent Home visit Collaborative development of a plan Deploy health coaches- begin follow up

visits- Tele- health/medication boxes Weekly review sessions Monthly report cards Quarterly updates

Data reviewDatabase of high risk diagnosis

Diabetes, heart failure, coronary artery disease, Pulmonary disease(COPD)

Disease specific readmissions

Network within the facility

Focus on the 5%

Identification

Socioeconomic

Cognitive/ Educational level

Medical/ Mental health

Adherence potential

Psychosocial stressors

Support

Screening Tool

Gather additional medical history to determine the

appropriateness of the program for the patient

Patient Review

Overview of the program explained

Consent and permission to discuss

completed

Notification of enrollment sent to PCP

SCC schedules initial home visit

Obtain Informed Consent

Completed by SCC Nurse

Medication reconciliation

Discharge instruction review

Comprehensive health profile (CHP)

Review rights and responsibilities

Discuss initial goals

Initial Home Visit

Strategy development and documentation-

based on the patients needs and goals

Care Coordination Plan

Plan of action is discussed with the patient

Goals are set in collaboration with the patient

Implementation begins based on agreed upon plan and goals

Utilize Med minder medication box

Implementation of the Plan

Health coach accompanies SCC team member on visits

The health coach continues to accompany a team member until both parties are comfortable

Health coach does not see patient alone until cleared by SCC.

Deploy Health Coaches

Guidelines: Health coach sees patient weekly in their

home A Health coach may accompany the patient to

physician appointment Progress note is documented at each visit A summary of the visit is emailed to SCC

team immediately after the visit

Health Coaches

DO NOT: Provide transportation Exchange any type of money or gifts Contact the physician for the patient

Health Coaches are under the direction of the SCC team and contact a team member for any issue that arises.

Health Coaches

Progress report from health coach

Progress report from SCC team members

Individual patients discussed

Strategies updated as needed

Weekly Review

Scores progress on goals Medical, Behavioral, nutritional, activity

Scale of 0-5:0= goal is met 1= some improvement 2= stable; maintain strategies 3= stable; new plan needed 4= worsened 5= plan suggested patient declined work in this

area

Report Card

CHP

Medication reconciliation

Outcomes tracking review

Quarterly update

Example

Patient E.H.

Data review

Information from the high risk database: • 3 of the high risk diagnosis

• (DM, CAD, COPD)

6 ER visits for 2013 fiscal year

6 additional ER visits that resulted in admission

E.H. 42 year old disabled female

History includes: Obstructive sleep apnea- does not wear CPAP

consistently Diabetes last A1C 11.8 (3/20/14) COPD- 02 dependent CAD HTN Hyperlipidemia Smokes PPD

Height 5’1 Weight 249lbs = BMI 47

Patient Review

E.H was approached while in the hospital and offered the program

Agreed to the program -consent was signed

Screening tool completed

Obtain Consent

Comprehensive health profile- Reveals poor diet, poor health prevention, sedentary, relies on

others for assist with self care

Medication Reconciliation 5 large boxes of medications- 37 medications- Forgets to take meds on occasion- no one helps her to

remember – stressor for the patient

Review of Physician orders Pt to wear CPAP anytime she sleeps- has not been doing so

Initial goals identified Lose weight, increase activity (wants to swim), “get out

of depression”

Initial home visit

Primary focus: Medical stability Stop smoking- reduce cigarettes by 1 per day Wear CPAP during the day if she sleeps- ask spouse to

remind her to put it on! Improve lung function- increase activity – 5 steps more a day!Medication reconciliation- determine correct medications

Secondary focus: Nutrition/ Activity Diet education- take the patient shopping/ budget for

healthy foods – reduce Dr. Pepper intakeStart Gardening- increases activity, provides healthy

food, improves self esteem

Care Coordination Plan

Follow up visitPatient agreed to use Nicotine patch more

frequently- will keep count of # of days used versus days smoking

Agrees to plant 1 tomato plant in a pot in her yard with plans to add more

Reports she has not been napping during the day since last visit and is wearing CPAP at night

Expressed concerns about food supply due to temporary loss of food stamps – obtained perishable food items appropriate for diet

Care Coordination Plan

Small Pilot program this summer

Plan on additional 30 patients in the Fall with 17 returning students to be health coaches

Additional staff and technology

Going Forward

There are three kinds of men:

The ones that learn by reading.

The few who learn by observation.

The rest of them have to pee on the electric fence

and find out for themselves.

-Will Rogers 

QUESTIONS