Care Coordination by Means of Community-based
Nurse Care Management:
Impact on Health, Hospital Utilization and Cost Outcomes
Presented by:
Ken Coburn, MD, MPH
Health Quality Partners (www.hqp.org)
CEO & Medical Director
June 28,
28 2010
AcademyHealth Annual Research Meeting
O
Overview
i
• About Health Quality Partners (HQP) and the Medicare
Coordinated Care Demonstration (MCCD)
• Program Outcomes
– Health
– Utilization
– Cost
• Key Characteristics of the HQP Model
• Status of the Program within the MCCD
pp
for Partnershipp and Collaboration
• Opportunities
Health Quality Partners (HQP)
•
Not-for-profit 501c3 health care quality
improvement organization established in 2001,
based in Doylestown
Doylestown, PA
•
Mission: Improve the quality and experience of
health care for patients,
patients their families and health
care providers
•
O
Organizational
Aims:
– Improve population health outcomes through
reliable systematic delivery of evidence-based
reliable,
preventive interventions (medical, behavioral,
social and psychological)
• Team: Currently a 15 Members Management & Leadership,
Leadership Nurse
– Help Seniors live longer, more independently
Care Managers, Data Management,
and with an improved quality of life
Database Development, Analytics &
– Reduce unnecessary health care costs over
Reporting
the long term
The Medicare Coordinated Care Demonstration (MCCD)
Rigorous, randomized, controlled trial testing ‘Care Coordination’ for
chronically ill Medicare beneficiaries (BBA 1997
1997, demo start 2002)
•
15 sites across the country were competitively selected from 58 applicants – yielding a
diverse set of organizations,
g
, each with its own intervention and target
g ppopulation
p
HQP’s Model as Tested within the MCCD framework
•
Eligible Dx’s: Coronary heart disease, Heart failure, Diabetes, Asthma, High blood
pressure, High cholesterol
•
Over 2,500 participants enrolled in the study to date
•
•
•
Patients have been identified and enrolled through their Primary Care Provider
O
Once
enrolled,
ll d patients
ti t continue
ti
tto receive
i ongoing,
i llong-term
t
care manager supportt
HQP was the only site considered for possible continuation at the 8 year point
HQP Collaborating
Physician Practices &
Service Area
HQP Collaborating Partners
Doylestown Hospital (lead hospital)
HQP Main Office
Physician Practices
Changes in Cardiovascular Risks for the Intervention
Group from baseline to last follow-up
Pending Publication: NOT FOR CITATION OR DISSEMINATION
Clinical measures:
Paired data available, n (%)
Total Intervention participants N=873
Systolic BP (mmHg): 784 (90%)
Total chol (mg/dl): 759 (87%)
LDL chol (mg/dl):
( /dl) 752 (86%)
Triglycerides (mg/dl): 758 (87%)
Weight (lbs) [enroll BMI30]: 262 (30%)
* P < 0.001
0 001
Mean
follow-up
period
Years
Mean value
% at target
g goal
g
Pre-enroll
Last follow-up
Pre-enroll
Last follow-up
3.8
3.4
34
3.4
3.4
3.7
134
193
111
144
208
128 *
180 *
100 *
128 *
200 *
60.6 %
60.5 %
72 1 %
72.1
64.9 %
NA
78.2 % *
70.2 % *
82 8 % *
82.8
73.1 % *
28.6 %
Risk of death reduced 25%
All Participants Randomized
ll
d
d
Pending Publication: NOT FOR CITATION OR DISSEMINATION
Eighty-six (9.9%)
participants in the
intervention group
died compared to
111 (12.9%) in the
control group
(h
(hazard
d ratio,
ti 0
0.75,
75
95% CI, 0.57 to
1.00; P=0.05) during
follow-up
follow
up (mean, 4.2
years)
Risk of death reduced 34%
‘High Risk’ Geriatric Frailty / Complexity
Pending Publication: NOT FOR CITATION OR DISSEMINATION
Among those higher
geriatric risk
assessment scores,
46 (15.9%) versus
66 (23.7%)
participants died in
th intervention
the
i t
ti and
d
control groups,
respectively (hazard
ratio, 0.66; 95% CI,
0.45 to 0.96; P =
0.03).
Risk of death reduced 48%
Coronary Heart Disease Participants
Pending Publication: NOT FOR CITATION OR DISSEMINATION
For participants with
coronary heart
disease (n = 300),
18 (13.0%) died in
the intervention
group versus 37
(22 8%) iin th
(22.8%)
the
control group
(hazard ratio, 0.52;
95% CI, 0.30 to
0.91; P=0.02).
Financial Impact of HQP Model Among Selected Subgroups
Note: Subgroups were constructed post hoc in analyses performed by Mathematica Policy Research,
Inc. using Medicare claims data from the MCCD. Used with the permission of CMS/ORDI.
Not for citation or dissemination. (all $ amounts shown are on a per participant per month basis)
Hospitalizations
Number of Average
Enrollees number of
(Treatmen follow-up
t and
months
Control)
(T+C)
Had Three or More Chronic Conditions in
the 2 Years Prior to Randomization
Conditions Prior t o Randomization: Had
Congestive Heart Failure
Conditions Prior t o Randomization: Had
Diabetes
Conditions Prior t o Randomization: Had
Coronary Artery Disease
Prior Service Use: Was Hospitalized in
Prior Year
Prior Service Use: Two or More Hospital
Admissions in the 2 Years Prior to
R d i ti
Randomization
Self Reported Health Status: Poor or Fair
[(CAD or CHF or COPD) and 1+ hosp in
prior year] or 2+ hosps in prior 2 years
(CAD or CHF or COP D) andd 1+
1 hosp
h
i
in
prior year
(COPD or CAD or CHF or DIAB) AND 1+
Hospitalization in Prior Year
%
p
Difference Value
Monthly Medicare Expenditures,
Expenditures $
Without Program Fees
With Program Fees
Control
Group
Mean
Treatment
-Control
%
p
Difference Difference Value
TreatmentControl
%
p
Difference Difference Value
392
44
-16.4
0.14
$1329
-$199
-15.0
0.18
-$86
-6.5
0.56
215
43
-10.6
10 6
0 48
0.48
$1432
-$204
$204
-14.2
14 2
0 38
0.38
-$96
$96
-6.7
67
0 68
0.68
403
46
-9.2
0.46
$1038
-$126
-12.1
0.32
-$16
-1.6
0.90
657
47
-25.1
0.01
$1083
-$207
-19.1
0.03
-$103
-9.6
0.27
342
47
-23.1
0.06
$1210
-$315
-26.0
0.04
-$202
-16.7
0.18
181
46
-35.1
0.05
$1510
-$468
-31.0
0.08
-$354
-23.4
0.19
107
56
-34.2
0.21
$1334
-$305
-22.9
0.34
-$191
-14.3
0.55
298
47
-33.5
0.01
$1354
-$404
-29.9
0.03
-$291
-21.5
0.12
248
46
-38.8
0.00
$1441
-$511
-35.5
0.01
-$397
-27.6
0.05
267
46
0.01
-$372
<0.01
-$487
0.05
Re-hospitalization among HQP’s Medicare Coordinated
Care Demonstration Participants at Doylestown Hospital;
April 2002 thru March 2009
Intervention Grp
Control Grp
Readmissions
(within 30 days)
Total admissions
139
39
196
96
1041
1084
Readmission rate
13.4%*
18.1%
* Risk ratio=0.74 (95%CI, 0.60-0.90) P=0.003, Source: data from
Doylestown Hospital and HQP MCCD enrollment data, analyzed by
K Coburn,
K.
C b
MD,
MD MPH
A relative 26% decrease in re-hospitalizations for those
getting HQP care management; (95%CI, 10% to 40%)
Key characteristics of HQP’s model
•
Person-centered
– Needs of the patient, as defined by the patient, come first
– Build long-term relationships with patients, families, and providers based on respect and trust
•
Evidence-based / best in class interventions provided directly by nurses
–
–
–
–
Multi dimensional geriatric assessments and in
Multi-dimensional
in-home
home interventions
Monitor for variance from disease specific guidelines
Self management skills assessment and training
G
Group
model
d l iinterventions
t
ti
– interactive
i t
ti workshops,
k h
weight
i ht management,t weight
i ht
maintenance, seated exercise, gait and balance training
•
Focus on multidimensional determinants of health
•
Systems approach
– Collaborate with PCPs, hospitals, and other providers on a high information relevance basis
– Prevent
P
t or mitigate
iti t system
t errors related
l t d tto care ttransitions,
iti
medications,
di ti
miscommunications, discontinuity, etc.
•
Integrated management, process monitoring, and organizational learning system
– Standardizing for performance & reliability
HQP’s model has evolved greatly over 12 years and 3
settings;
g ;
Health Quality Partners
it takes a robust SET of interventions
to- MCCD
be effective
PennCARE
Program Components
s
University of
Pennsylvania
1997
1998
1999
2000
2001
2002
Disease Specific Care Managers
2003
Time
2004
2005
2006
2007
2008
2009
Geriatric Specific Care Managers
Integrated Disease & Geriatric Care Managers
Patient Referrals through Claims and Practice Data
Stratification - Diagnosis based
Patient Referrals by Physicians
Prioritization - Claims and Other Data
Stratification - Geriatric & Disease Risk Assessment
Comprehensive Assessments
1:1 Education & Self Management
Group Education
Lifestyle Physicial Activity & Exercise
Aggregate Data Analysis
Structured Weight Loss
FallProof Balance & Mobility Program
Data Analysis- cohort, patient, management
Care Transitions Protocol
Interventions: one on one and group models - in the home and in the community
(physician, HQP and community based settings)
Nurse care manager
g contacts ((n=771*))
Contact types
yp
Group**
Count
Mean contacts p
per p
pt-yr
y
13,994
4.7
Home visits
6,891
2.3
Office visits
5,636
1.9
Total in-person
26,521
8.9
Telephone
25,552
8.5
42
0.0
25,594
8.5
Email
a
Total remote
*Participants enrolled thru 03/2006 with follow-up thru 03/2008
**39% of participants in one or more groups
Total P
Populatioon /
Multiple Measures
Process/Outcome Dashboards; Web-based Report Combines
Process Reliability and Outcomes
Click
Sinngle meaasure byy
nurse ppanel
By Nurse Care Manager Caseload – LDL
One Preventive Care Measure Example Flu vaccination
Web-based statistical
process control
charting is used
extensively to robustly
compare
p pperformance
between groups or
over time; here’s a
‘cross-sectional’
cross sectional ppchart of flu vaccination
coverage by nurse
CM
Davis
Detweiler
Doncsecz
Goodwin
Graefe
Haynes
K ll
Keller
Rice
Weisser
94.7%
Caseload
36
95
114
107
72
127
34
92
95
Received
31
90
106
103
65
120
31
86
88
Allergy
1
1
3
1
2
0
0
1
2
Refused
3
3
4
3
5
3
0
5
4
PhysRestrict
NotAddressed
1
0
0
0
0
0
0
0
0
0
1
1
0
0
4
3
0
1
Care Manager / Team Performance
Another crosssectional p-chart
comparing the rate
of monthly “no
contacts” by care
contacts
manager; we use
identification of
meaningful
i f l
variation and root
cause analysis for
organizational
learning
HQP seeks new partners and collaborators
• CMS will (contingent on agreement of final terms &
conditions) extend its support of the HQP program
an additional 3 years within the MCCD
– Targeting higher-risk, higher-savings cohort (TBD)
– Regional partners in Eastern Pennsylvania
• Potential for replication of the model outside of
the MCCD context at other locations
To explore collaborative opportunities contact:
Sherry Marcantonio at Health Quality Partners 267
267-880-1733
880 1733 ext.
ext 27,
27
Marcantonio@HQP.org or Ken Coburn at Coburn@HQP.org
HQP Thanks
Th k CMS, Mathematica Policy Research, Inc., Aetna, U.S.
Representatives Patrick Murphy and Allyson
Schwartz MGMA,
Schwartz,
MGMA hundreds of physicians,
physicians thousands
of patients and their families, Fritz Wenzel, Rich Reif
& Doylestown
D l t
H
Hospital,
it l Mary
M Naylor,
N l th
the entire
ti HQP
Board, Ron Barg, Chad Boult, United Way SEPA,
GlaxoSmithKline, MERCK Journey for Control and
private donors