Session #E2
October 17, 2014
Super-Utilizer, Team-Based,
Cross-Setting Care: The Future
of Healthcare Cost Reduction
Barry J. Jacobs, Psy.D.
Crozer-Keystone Family Medicine Residency Program
Springfield, PA
Emotionalsurvivalguide.com
Collaborative Family Healthcare Association 16th Annual Conference
October 16-18, 2014
Washington, DC U.S.A.
Faculty Disclosure
Please include ONE of the following statements:
• I currently have the following relevant financial
relationships during the past 12 months:
– 20% of my salary is currently covered by a proof of concept
study grant from Independence Blue Cross/Blue Shield
Learning Objectives
At the conclusion of this session, the participant will be able to:
• Identify the key components of the superutilizer approach for reducing healthcare
costs
• Describe the integrated team composition
and processes of super-utilizer programs
• Understand the implications of superutilizer programs for developing tiered care
for chronically ill patients
Bibliography / Reference
1) Gawande, A (2011). The hot-spotters. The New Yorker, January
24 downloaded 9-20-14:
http://www.newyorker.com/magazine/2011/01/24/the-hot-spotters
2) “Top 8 Best Practices,” (2014), publication of the Camden
Coalition of Healthcare Providers,
3) “Super Utilizer Summit—Common Themes from Innovative
Complex Care Management Programs” (October 2013),
downloaded from Robert Wood Johnson website on 9-20-14:
http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf40799
0
4) Coburn KD et al (2012). Effects of a Community-Based Nursing
Intervention on Mortality in Chronically Ill Older Adults: A
Randomized Control Trial, PLoS Medicine, 9(7), 1-14
5) Hoefer, D (2010) Transitions Frailty, video of presentation from
the Family Medicine Education Consortium 2010 conference
downloaded 9-20-14: http://vimeo.com/40317051
Learning Assessment
• A learning assessment is required for CE
credit.
• A question and answer period will be
conducted at the end of this presentation.
Today’s Talk
• Dr. Jeff Brenner’s story
• Who are super-utilizers and why do they
matter?
• Components of SU interventions
• The Crozer-Keystone SU programs with 3 case
illustrations
• Lessons learned
“The Hot Spotters”—1/24/11
Who is Jeff Brenner, MD?
• Closed solo family
medicine practice in
Camden, NJ
• Looked at city’s
healthcare data
• Founded Camden
Coalition of
Healthcare Providers
1%
5%
10%
$90,061
22%
$40,682
50%
$26,767
50%
65%
$7,978
97%
U.S. Population
Health Expenditures
Distribution of Health Care Expenditures for the U.S.
Population, According to Magnitude of Expenditure, 2009
The sickest 10% of patients account for 65% of the health care
expenses. Dollar amounts are annual mean expenditures per
patient. Data from the 2009 Medical Expenditure Panel
Survey, adapted from the Commonwealth Fund.
Anticipated Federal Debt
Characteristics of High-Utilizers
• Most are insured, 60%
public insurance
• Only 15% uninsured
• Over 80% have
identifiable PCPs
• More utilization of
health services in
general
• Diagnoses vary greatly
• Ages 25-44 and over 65
Usage Patterns
• ED high utilizers = >3x per year
• Often patients with trauma histories,
personality disorders, drug problems
• Inpatient high utilizers = >2 inpatient
admissions within a 6-month period
• Often social issues (e.g., housing,
transportation, chaotic families)
Components of SU Interventions
• A cross between intensive biopsychosocial care and
community organizing:
• Data mining (sometimes across health systems and
agencies) to create SU list
• Creation of collaborative multi-disciplinary teams:
physicians, nurses, case managers, pharmacists,
social workers, psychotherapists, volunteers
• Assessment procedures and outcome measures
• Relationship-building with other healthcare and
social service providers to improve care transitions
Interventions (cont.)
• Strong emphasis on addressing social
determinants of health:
• Housing, transportation, food
• Home visits essential
• Focus on trauma and addictions
• Medical visit accompaniment
• Use of community health workers
• Breaking down silos between healthcare and
social service agencies
Care Continuum Model
Hospital
Admission
s Data
•
•
•
Inclusion
Triage
Multidisciplinary care management outreach
Patients with history of ED visits/hospital admissions
and readmissions (4 admits w/in 6 mos.); social
complexities
Average 6-8 month engagement
Medical Home
CCHP Outreach
Care Coordination
High Risk
Health Coaching
Intermediate Risk
Data driven care mgt.
Patient Engagement
•
•
•
Nurse driven care transition
Patients with history of ED visits/hospital admissions
and readmissions (2+ admits w/in 6 mos.); socially
stable
Average 6-8 week engagement
Results
The Camden Study-An ED Alternative
• 5 year study of 380,000 visits at 3 EDs
• 1% of patients 40,000 visits, $46 million cost
• Top 35 utilizers generated $1.2 million in
charges each month
• After one year of SU care, costs dropped to
$531,000
South Central PA High Utilizer Collaborative
South Central PA High Utilizer Collaborative
18
SOUTH CENTRAL PA WHITE PAPER
6/14
• With 138 combined patients enrolled in
SU programs, inpatient admissions
decreased 34%
• ED utilization increased
Crozer-Keystone Health System
CKHN Inpatient and ED Stats: 2012
IP: Inpatient Visits > 3 / year = 457
Readmission > 1 = 308 (67%)
ED: Emergency Room > 4 / year = 889
1275 Individual Patients Combined IP & ED
TOTAL LOSS (Paid-Costs) = -$3,136,933
Center for Family Health
• One of two training
sites for CrozerKeystone Family
Medicine Residency
• NCQA accredited PCMH
since 2008
• SU program as overlay
on PCMH care
• Titrate up, graduate (8
months), titrate down
SD—Inpatient Super-Utilizer
• 64 yo retired electrician
living with his wife
• 13 admissions for CHF
in 2010-11 (over 12
month period)
Post-enrollment
Charges = $11,686 ; Receipts= $0.
Inpatient: 0; ED visits:3
Length of Stay
1 year pre-enrollment
Charges= $520,000;
Receipts= $90,000;
Inpatient:12; ED visits:7
• IP Admit
• ED Visit
CB—ER Super-Utilizer
• 60 yo on disability for
chronic pain due to
fibromyalgia; also
remote history of mild
CVA
• Worked as welfare case
manager for over 30
years
• Pastor/pastoral
counselor
CB (cont.)
• Between 1996-2012,
had 102 ER visits
• Included 21 visits in
both 2008 and 2009
• Had 112 CT scans,
including 71 head CTs
CB (cont.)
• Gradually decreasing her habit of going to ER
through increasing her awareness of mindbody connections, decreasing her anxiety,
reducing family support for utilization
• 2012: 8
• 2013: 5
• 2014: 1 (thus far)
Our Team
Patient Selection
Identification
• Inpatient Census
• PCP Referral
• Insurance High-Risk Lists
• CKHS Financial Reports
• (Note 6-12 month lag time)
Selection
• Inclusion
• Two or more inpatient admissions in
past 6 months
• Exclusion
• Mental Health Only
• Oncology
• Surgery
• Pregnancy
Screening & Assessment Visit
Introduction
• Team Members
• Goals of program
• Care Agreement
• Record Release
Engagement
• Willingness to answer phone calls
• Allow home visit
• # of no shows for PCP in last year
• # of previous PCPs in last year
• Goal alignment
Activation
Readiness to
Change
• URICA Tool
• Patient Activation Measurement (PAM)
Clinical Process
Visit 1
Visit 2
• Assessments
• Psychology
• Social Work
• Pharmacy
• SU Team
Leaders
• Review Goals
• Review Care
Plan
HUDDLE
Communicate with
PCP
Initial Note in EMR
Scan RR and CA to
EMR
Results (11 patients)
•
•
•
•
•
•
•
•
ER visits per patient per month:
Before: 0.207 During: 0.16
OBS visits per patient per month:
Before: 0.025 During: 0.147
Inpatient visits per patient per month:
Before: 0.323 During: 0.046
Inpatient LOS per patient per month:
Before: 1.096 During 0.16
IBC Medicare Advantage SU
Program
• Crozer-Keystone was approached by
Independence Blue Cross in spring of 2013 to
create a 1-year- proof of concept, superutilizer intervention for IBC’s Medicare
Advantage patients within the CrozerKeystone Health System
• Brenner excludes patients over age 80
• We drew on works of Ken Coburn, Dave Moen
and Dan Hoefer
• Coburn taught us power
of home-based nursing
intervention
• Moen taught us power
of home-based
physician care
• Hoefer taught us cost
savings and increased
life span with
widespread palliative
care
Our Process
• Analyzed IBC and CK utilization data
• Chose 13 patients on basis of utilization, cost to IBC,
losses to CK
• Reached out to primary care physicians
• Nurse case manager engages patients, conducts
assessments and weekly visits
• Uses multidisciplinary team as advisors during
weekly Huddle
• Includes family medicine fellows/residents;
psychology, social work, pharmacy students
• CO, 88 year old widow
who lives in a multigenerational home.
• Co-morbidities include:
DM, CHF, HTN, CAD,
Obesity, Peripheral
Neuropathy & edema
• Chaotic home
environment
• Patient having
increased episodes of
confusion
Baseline utilization x 6 mos for CO
8
7
6
5
INPT
LOS 4
OBS
ER
3
Engagement
2
1
0
9/4/13






11/4/13
1/4/14
3/4/14
10/4/13 – Admitted for bilateral lower extremities cellulitis
11/20/13 – ER for Edema
11/24/13 – OBS for arm cellulitis
1/7/14 - Admitted pneumonia and CHF
2/5/14 – Admitted for change in mental status/Anemia/UTI
Enrolled in Crozer Connections to Health Team program 2/12/14
5/4/14
Deep Dive
• Social milieu/uncoordinated care
– Family refused to have homecare RN visits posthospitalization
– Our team has great concerns about caregiver
burden and capacity, but the family didn’t want
increased support services at this point
• Possible dementia versus delirium
– Family concerned about increasing confusion
CO’S Outcomes Thus Far
• Patient now sleeps upstairs with legs up—
decreased cellulitis
• Blood sugars better controlled
• No hospitalizations from 1/14-8/14
• 8/14: hospitalization for possible CVA; turned out
to be Bell’s palsy
• Family has accepted home nursing for wound
care
• Primary caregiver still contending with burnout
Lessons Learned
• Interdisciplinary team-based, cross-setting
care has resulted in mostly great success—but
also spectacular failures
• Patient engagement still key—takes 2 months
• Graduating patient from SU care and return to
PCMH takes careful planning or risks reversion
to previous level of utilization
• SU is essential overlay for PCMH to address
most complex, expensive patients
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!