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 reviewInformation 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
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