AMDIS Fall Symposium

Boston, MA

Sept. 29, 2013

Claus Hamann MD, MS, FACP

Accenture LLP

Big Institution to Community: Accountable, Collaborative, Disruptive Care Agenda and Summary

To accomplish the Triple Aim (Health, Care, Costs), we need to focus on the care of patients with complex illnesses

To succeed at the care of patients with complex illnesses, we embrace collaborative, coordinated care

How do we succeed?

Adopt proven models into accountable care

Implications for Clinical IT

Documentation

Content, Decision support

Interoperability, HIE

Why Focus on the Care for Complex Patients?

To accomplish the Triple Aim (Health, Care, Costs), we need to focus on the care of patients with complex illnesses Hospitals – “That’s where the money is.” Post-Acute Care: “That’s where the variation is.”

73%, in nursing facilities, home health care and long-term-care hospitals Compared to 27% for hospitals and 14% tests/procedures (Newhouse,

2013)

Dementia hospitalization ↑ 10 x from 2000 → 2050

Accountable Care aligns incentives Efficient Care is key: overtreatment, failures of care

coordination, failures in execution of care processes, administrative complexity, pricing failures, fraud and abuse (Berwick, 2012)

Collaborative Care for Complex Patients

http://www.improvingchroniccare.org/

Team care Patients with multiple diseases,

functional impairments and social challenges

Professionals from several health disciplines

Multi- Inter-disciplinary processes

Team decision-making

Chronic care model

Historically: Pediatrics, Physiatry, Psychiatry, Geriatrics

Now mainstream with aligned incentives ?

Accountable Care Meets Geriatric Care

15 successful geriatric care models based on 123 high-quality studies with positive outcomes (Boult, 2009)

“Fee-for-service payment is anathema to effective chronic disease care… to improve chronic care [we need] accountability and payment in synchrony.” (Kane, 2009)

http://www.ncbi.nlm.nih.gov/pubmed/20121991

• Interdisciplinary primary care: 1

• Supplement primary care: 8

• Transitional care: 1

• Acute care in patients' homes: 2

• Nurse-physician teams for residents of nursing homes: 1

• Comprehensive hospital care: 2

Collaborative Care for High-Risk and Vulnerable Populations

Socially Disadvantaged Clinically Vulnerable

Highly Vulnerable

Source: High-Risk and Vulnerable Populations Workgroup: http://www.acolearningnetwork.org/

Socially Disadvantaged Clinically Vulnerable

• Racial, ethnic minority

• Native American community

• Immigrant

• Impoverished neighborhood

• Low incomes

• Low levels of education

• Low health literacy

• Rural area

• Homeless

• Non English-speaking

• Dual–eligible beneficiaries

• Uninsured/underinsured

• Have low social supports

• Complex chronic illnesses

• Acute serious illnesses

• Multiple chronic conditions

• Disabled

• Mentally ill

• Substance abusers

• Cognitively impaired

• Frail elders

• Patients nearing the end of life

• Pregnant women

• Very young children

• High-utilizer patients

• High-cost patients

• Dual-eligible beneficiaries

CareMore Succeeding at Complex and Post-Acute Care

Medicare Advantage “+” Av. age 72, 50% <$30k income; DM

33%, HTN 40% Intensive management of frail and

chronically ill: 15% members → 70% costs,

Monitoring, management of chronic conditions to delay the onset of frailty

Costs 15% less; profitable

Reuben, 2011

Contract with PCPs; handle non-urgent illness

NP’s, MA’s: evidence-based protocols

1-hr. Healthy Start visit, MA + NP/MD, comprehensive evaluation; annually

Extensivists: inpatient + post-discharge care including SNF

Specialist management

Transportation, fitness, home intervention team, caregiver support, respite care, high-intensity management for frailest 2%

EHR + wireless home monitoring

Culture of conservative management

Outcomes

DM: av. A1C 7.08; amputation 78% < national av.

Hosp.: ALOS 3.0 d.; ESRD 42% Re-Hosp.: 13.6% vs. 20%

CAPHS > CA, US

Collaborative Care for Complex Patients

Patient and caregiver at the center

Collaboration

Communication

“…health system performance will increasingly depend

on high-functioning, team-based approaches to care.” (Dzau, 2013)

Enabling Success with Care of Complex Patients Role of Clinical IT Implications for Clinical IT

Documentation Care planning, including patient/resident choice

Minimum Data Set; Resource Utilization Groups

Decision support

Interoperability, HIE

Unique features of Nursing Home care Not part of MU

Slower EHR adoption

Help on the way: Center for Aging Service Technologies, 2013

Needs assessment and EHR Selection Matrix comparing 36 products on ~200 features and functionalities

http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2010/Apr/1380_Klinger_lessons_HIT_New_York_nursing_homes_case_study.pdf, Commonwealth Fund, 2010

“Last week Mrs. S. spiked a fever of 100.2 and was not eating much.

The nursing supervisor immediately contacted the resident’s physician offsite

Viewed via Internet Mrs. S.’s full clinical record over the last week

Real-time data being entered at the bedside by the nursing team and direct-care staff

Record of all her medications and when she had taken them

Plan made between the nursing home care team and physician to give Mrs. S. intravenous fluids for 24 hours to avoid dehydration

“Give fever-reducing medication, monitor her vital signs, inform physician.”

Physician viewed progress from offsite

If hospitalization were indicated, it could have immediately been carried out.

Mrs. S.’ temperature became normal over 24 hours and she began to eat, drink.

Treatment plan appropriate

No hospitalization.”

Enabling Success with Care of Complex Patients Role of Clinical IT – Patient Vignette

http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2010/Apr/1380_Klinger_lessons_HIT_New_York_nursing_homes_case_study.pdf, Commonwealth Fund, 2010

Transitions of Care Clinical IT Challenges for Long-Term Post-Acute Care (LTPAC) 1 of 3

Health IT adoption spectrum for long-term post-acute care (LTPAC): systems for federally required assessments for payment and quality >> systems for care

Health IT-enabled facilities: Data feeds to an exchange, secure messaging

Low/no IT-adopted facilities Web-based portals for secure messaging, information query with hospitals and other care

partners

Simple clinical documentation tools to facilitate electronic capture of LTPAC data shared at transitions

EHRs: integrated connectivity is evolving; CCHIT modular certification growing

Standards: 5 Transition of Care data sets to meet needs of most types of transitions

Transitions of Care Clinical IT Challenges for Long-Term Post-Acute Care (LTPAC) 2 of 3

Clinical Workflow: paper/fax electronic solutions

To assess patient acuity, service needs and staffing levels, on-site administrator and nursing leader and off-site medical director all need access to information

Better identify and ensure services for patients with high medical complexity and resource utilization patterns with data from multiple episodes of care and settings

Urgent ED evaluations: via DIRECT Secure message and change in condition documentation earlier in the care episode,

detailing symptoms and events leading up to the transfer

Communicate assessments performed in the ED to both the nursing facility and the attending medical provider, for safe transition to sending facility

Transitions of Care Clinical IT Challenges for Long-Term Post-Acute Care (LTPAC) 3 of 3

Staffing and User Access

Core team: administrator, director of nursing, assistant director of nursing, compliance leader and senior charge nurse vs. Care managers or Nursing coordinators

High staff turnover: train multiple staff, work with very small user groups in well-defined phases

Value Proposition: Too early in adoption phase for ROI

Avoid penalties for readmissions, improve staff efficiency and reduce staff time, reduce burden on patients and families

More accurate and timely medication reconciliation, better access to all anticoagulation results, fewer missed wound/therapy treatments

http://www.healthit.gov/sites/default/files/challengegrantslessonslearnedltpac_paper.pdf 2013

Supporting Collaborative, Coordinated Care

Socially Disadvantaged Clinically Vulnerable

Clinical Documentation

Care Planning

Practice Technology

EHR • Software /

database

• Functionality

• Configuration tools

http://www.nationalehealth.org/ckfinder/userfiles/files/Improving%20Care%20Coordination%20Slide%20Deck.pdf

Content • Evidence-based

• Intentional automation

• Integrated interprofessional care

Workflow Design

Culture Change

Conclusion

Incentives are aligned !

Complexity is us !

Culture is ready ?

References Newhouse JP, et al. (2013). Variation in health care Spending: Target Decision Making, Not

Geography: http://www.nap.edu/catalog.php?record_id=18393

Berwick DM, Hackbarth AD. Eliminating Waste in US Health Care. JAMA. 2012;307(14):1513-1516. doi:10.1001/jama.2012.362

Zilberberg MD, Tjia J. Growth in Dementia-Associated Hospitalizations Among the Oldest Old in the United States: Implications for Ethical Health Services Planning. Arch Int Med 2011; 171; 1850-1851.

Boult C, et al. (2009), Successful Models of Comprehensive Care for Older Adults with Chronic Conditions: Evidence for the Institute of Medicine's “Retooling for an Aging America” Report. Journal of the American Geriatrics Society, 57: 2328–2337. doi: 10.1111/j.1532-5415.2009.02571.x

Kane RL (2009), What Can Improve Chronic Disease Care? Journal of the American Geriatrics Society, 57: 2338–2345. doi: 10.1111/j.1532-5415.2009.02569.x

Reuben DB (2009), Better Ways to Care for Older Persons: Is Anybody Listening?. Journal of the American Geriatrics Society, 57: 2348–2349. doi: 10.1111/j.1532-5415.2009.02574.x

Reuben DB (2011). Physicians in Supporting Roles in Chronic Disease Care: The CareMore Model. Journal of the American Geriatrics Society 59:158–160

Dzau VJ, et al. Transforming Academic Health Centers for an Uncertain Future. N Engl J Med 2013 369;991-992.

CareMore, 2012: http://www.wellpoint.com/prodcontrib/groups/wellpoint/@wp_news_main/documents/wlp_assets/pw_e181475.pdf

Center for Aging Service Technologies, 2013: http://www.leadingage.org/uploadedFiles/Content/About/CAST/Resources/2013_CAST_EHR_For_LTPAC_A_Primer_on_Planning_and_Vendor_Selection.pdf