Re-Imagining the DOC:
FY14 Report on Implementation
August 25, 2014
Agenda
• Outcomes for FY14
– Review of Dashboard
– Analysis of HomeBASE clinic-based complex care
management program
• Priorities for FY15
– Expanding capacity for population health management
– Optimizing clinic operations
• Discussion and Next Steps
2
Brief recap
• DOC provides primary care to ~4300* patients
– Most underserved (~40% Medicaid incl duals, 15% uninsured;
minority, low SES)
– Main continuity clinic site for Duke IM Residency (70+ resids)
• Historically, patients high utilizers of care
– Frequent ED use; 30-day DUH all-cause readmit rate of 21%
– High burden of chronic illness, plus co-morbid mental health
(MH), substance abuse (SA)
• 83% of DOC pts w/ ≥3 hospitalizations had co-morbid MH/SA
• Led to comprehensive redesign, starting in July 2014
– Added dually-trained medicine-psychiatry attending; APP
– CCNC-funded clinic-based care manager
– Stead-based resident clinic groups
*Defined by 2 office visits in past 36 months, including 1 in the last 12
3
Source: Performance Services
Dashboard for FY14
DOC Redesign Dashboard FY14
Measure
Baseline
(FY13)**
Q1
Q2
Q3
Q4
Interval
Target
Timeframe: Year End
Interval
YTD Actual
YTD Target
Variance
(% of target)
Description of
Target
Source
Relevant
Dataset(s)
Patient Safety and Quality
DUH Emergency Department Visits
DUH:
2583
DRH Emergency Department Visits
DRH:
2939
584
543
497
555
<581
Quarterly
2179
2324
-6.2%
593
<661
Quarterly
593
661
-10.3%
David Chermak
10% reduction in DUH
(Performance
ED visits
Services)
DSR DUH ED visits &
DOC patient list
DSR DRH, same
5% reduction in DUH
hospitalizations
David Chermak
(Performance
Services)
DSR DUH
hospitalizations &
DOC patient list
2% reduction in DUH
30-day readmits
David Chermak
(Performance
Services)
DSR DUH readmits
& DOC patient list
Maestro no-show
DOC clinic report
DUH:
800
197
171
177
129
<200
Quarterly
674
697
-3.3%
Total 30-day Readmits to DUH (#)
167
41
32
29
12
41
Quarterly
114
134
-14.7%
30-day Readmit Rate to DUH (%)
20.9%
22.4%
20.5%
16.9%
20.3%
18.9%
Quarterly
20.0%
18.9%
5.8%
17%
14.1%
11.5%
10.4%
13.5%
15%
Quarterly
12.0%
15%
-20.0%
David Chermak
2% reduction in clinic
(Performance
no-show rate
Services)
(<40%)
44.6%
50.2%
54.6%
53.0%
40%
Quarterly
50.7%
40%
26.8%
40% of return visits
with resident PCP
82.0%
75%
Quarterly
83.3%
75%
11.1%
75% of reachable pts
Holly Causey/ Mark REDCap post-disch
discharged to home
Dakkak (DOC)
database
w/o existing Rx mgmt
93.0%
75%
Quarterly
89.7%
75%
19.6%
75% of reachable pts
discharged to home
DUH & DRH ED visits
& HomeBASE list
DUH & DRH
hospitalizations &
HomeBASE list
DUH Inpatient Hospitalizations (total)
Clinic No-Show Rates
Patient ↔ Provider Continuity
Pharmacy post-discharge encounters for
medication reconciliation (% of discharges)
n/a
% of post-discharge follow-up appointments
within 14 days (of discharged patients)
59.0%
84.6%
83.2%
88.3%
95.3%
David Chermak
(Performance
Services)
Christa
Rutledge/Mark
Dakkak (DOC)
DSR DOC encounter
list & resident
provider table
(+Gamble)- manual
Excel ( -Mar);
REDCap post-disch
database
Familiar Faces ED Utilization Rate
(DUH + DRH ED visits/FF/y)^
12.2
8.6
5.7
11.0
Quarterly
5.7
11.0
-48.2%
10% reduction in ED
visits (from 9/1/13Alex Cho/Mark
6/30/14) compared to
Dakkak (DOC)
same period in FY13:
387/38
Familiar Faces Hospitalization Rate
(DUH + DRH admits/FF/y)^
2.2
1.2
1.4
1.7
Quarterly
1.4
1.7
-19.7%
20% reduction in
hospitalizations
compared to same
period in FY13: 2.2
Alex Cho/ Mark
Dakkak (DOC)
Number of FFs w/ detailed complex care plan
n/a
16
32
15
Quarterly
32
40
-20.0%
40 meets, 50+ exceeds
Natasha
HomeBASE list
Cunningham (DOC)
Care manager FF case load (at steady-state)
n/a
43
56
n/a
(cumulative)
56
50
12.0%
50 meets (20
new/quarter), 60+
exceeds
Natasha
HomeBASE list
Cunningham (DOC)
4
Dashboard for FY14 (cont’d)
DOC Redesign Dashboard FY14
Measure
Baseline
(FY13)**
Q1
Q2
Q3
Timeframe: Year End
Interval
Target
Q4
Interval
YTD Actual
YTD Target
Variance
(% of target)
Description of
Target
Source
Relevant
Dataset(s)
Finance and Growth
APP number of same-day access visits
n/a
n/a
54
80
73
75
Quarterly
207
175
18.3%
175 visits, prorated to
Emmanuel Brown
start in late 11/2013
(Perf Svcs)
(annual target is 225)
DOC encounter list
(incl sched & actual
visit dates; for
Gamble)
Number of Medicare Transitional Care
Management (TCM) Visits (billed for)
n/a
44
45
39
16
45
Quarterly
145
150
-3.3%
145 TOC visits (billed
for), prorated to data Melissa Sangster
through April 2014
(PRMO)
(annual target is 180)
PRMO report
Cost Trends***
• DUH ED Direct Costs Avoided
n/a
$ 70,826 $ 44,534 $ 62,161
$ 26,567
Quarterly
$
177,521 $ 79,702
122.7%
• DUH Inpatient Direct Costs Avoided
n/a
$ 71,279 $277,197 $ 63,359
$ 81,954
Quarterly
$
411,835 $ 245,862
67.5%
• Total Direct Costs Avoided by DUH
n/a
$142,105 $321,731 $125,520
$ 108,521
Quarterly
$
589,356 $ 325,564
81.0%
10% reduction in ED
utilization
5% reduction in
inpatient utilization
Josh Worrell/ Joe
DUH Finance report
Kowalski (Finance)
Patient Satisfaction
Patient received appointment for care
needed right away (CGCAHPS)
n/a
68.8%
64.7%
55.6%
60.7%
65%
Quarterly
62.7%
65%
-3.5%
Meet/ exceed nat'l
avg for AMC clinics
Brandie Johnson
(DOC)
Press Ganey Online
Routine care appointment as soon as needed
(CGCAHPS)
n/a
70.6%
69.6%
83.7%
66.4%
69%
Quarterly
70.5%
69%
2.2%
Meet/ exceed nat'l
avg for AMC clinics
Brandie Johnson
(DOC)
Press Ganey Online
Tier 1 (PRMO)
Tier 1
rating
Meets
Work Culture
Employee Satisfaction
Tier 1
rating
Resident Satisfaction-LPS Survey
36%
% residents scheduled with one of their clinic
Stead attendings for each block
n/a
Tier 1
rating
45%
90.9%
85.6%
Annually
Tier 2 (Clinic)
DNM
Tier 1 rating on annual Brandie Johnson
work culture survey (DOC)
42%
50%
Semi-annual
44%
50%
-13.0%
>50% rating value of
overall clinic
experience as
'Excellent' or 'Very
Good'
84.2%
75%
Quarterly
86.8%
75%
15.7%
75%
Work Culture
Survey
Denise Duan-Porter LPS Snapshot, Year(DGIM)
End surveys
Lauren Dincher
(MedRes)
Med Res Office data
Last updated: 8/23/2014
Notes
*Timeframe is annual except for: Pharmacy (Q4 used new tracking system), APP same-day access visits (first full month (Dec 2013) is reported); FF program began Q2; readmits -Apr 2014; TCM and inpatient admits -May; %resident sched Q4 from Apr-May
**Baseline data are from FY13 except for: 30-day readmits (FY11), resident PCP continuity (historical), 14-day post-discharge appts (FY11)
^YTD reported as total ED, inpatient utilization (DUH + DRH) one month after enrollment in HomeBASE through 6/30/14, prorated to days enrolled/365.25
***Calculated as the difference between DUH ED and inpatient encounters for FY14 vs. FY13, multipled by observed FY14 direct cost for each. Despite the direct cost per hospitalization having risen, an overall drop of $384K in total costs vs. FY13 was achieved.
5
HomeBASE Evaluation of
Impact on Healthcare Use
One year preenrollment
Pre-intervention annual encounter rate:
- PCP visits at DOC
- ED Visits
- Hospital Admissions
- Inpatient Days
Post-intervention annual encounter rate =
(Number of encounters in evaluation
period / Length of evaluation period) * 365
HB
enrollment
1 month postenrollment
6/30/2014
Encounter Costs
Outpatient Visit
$55
ED Visit
$479
Inpatient Day
$2,000
Based on average cost for DOC patients receiving care at DUH during FY13 and FY14.
Source: Josh Worrell, Finance
6
Impact of HomeBASE on ED visits
Average change =
6.7 fewer ED visits* per
HomeBASE patient
*annualized
fewer ED visits
more ED visits
7
Impact of HomeBASE on Inpatient days
Average change =
0.8 fewer inpatient days*
per HomeBASE patient
*annualized
fewer inpatient days
more inpatient days
8
-0.8
-6.7
-0.5
-$58K
-$120K
-$1K
9
10
Duke University Health System Encounters
Priorities for FY15: Population health management
• HomeBASE
– Continuing to formalize HomeBASE process (e.g., care plans)
– Broadening scope of clinic-based care mgmt to uninsured
• Requires addt’l non-CCNC support ($16K) for DOC care
manager (Marigny) to expand scope beyond Medicaid
– Non-emergent patient transportation pilot
• Early results promising
• Transfer of donated van; recruitment of volunteer driver(?)
– New formalized complex care evaluation option
• Part of creation of add’tl stratified collaborative care interventions
• For any high-need patient who meets criteria for HomeBASE but
does not have Medicaid
• Covering medication-related issues, psych, housing/food, etc.
• Performed jointly by SW (Jan) & MH NP (Julia)
• To help PCPs address needs, connect patients with resources
– Ongoing analysis of HomeBASE impact
11
Stratified Collaborative Care Interventions
Higher
Intensity
HomeBASE
Complex care
evaluation and consultation
Psychiatric consultation
Diabetes and depression management
Algorithm supported alcohol abuse treatment
Algorithm supported depression treatment
12
Population health mgmt (cont’d):
Uninsured DOC patients
• Partner again w/ PADC to refer pts to exchanges
– Did this in February of this year; affordability an issue
• Referral by Pharmacy of Medicare Part D-eligible
patients not enrolled/who qualify for addt’l assistance
• Broaden role of SAM (Brandie) in coordination of
coverage-related activities
– Ultimately reducing costs of uninsured to DUHS
• Possible pilot w/ DUH hospitalists to provide PCMH for
selected complex uninsured pts discharged from DUH
– Requires addt’l non-CCNC support for clinic-based care mgr
– Could be good use of SOAR counselor (w/ dedicated time?);
LATCH, too
PADC = Project Access Durham County; SAM = Service Access Manager; PCMH = primary
care medical home; SOAR = SSI/SSDI Outreach Access & Recovery
13
14
Population health mgmt (cont’d)
• Mental Health-Primary Care (MH-PC) next steps
– Collaborative care model expansion
• Diabetes and depression management pilot (IMPACT model)
• Treatment for alcohol abuse (@DOC: 39% SA; 8% EtOH)
• Chronic pain
– Cont’d involvement in leadership of DUHS Opioid Safety
Taskforce (clinical pharmacists Holly/Ben, Larry Greenblatt)
• Uniform policies, med safety, use of NC CSRS, etc.
– Developing relationship w/ Duke Pain Medicine
– Referral to AIM Health Services for addiction treatment;
clinic-based suboxone treatment for selected patients
• Social determinants of health
– Tracking socioeconomic barriers faced by DOC patients
(literacy, housing, food insecurity, transportation, adult
maltreatment, hx of child abuse, ineffective self-mgmt)
15
Diabetes and depression management
Case Finding:
- DOC patients with uncontrolled DM by HbA1c
Evaluation (Nurse Practitioner, Julia):
- Medication adherence
- Barriers to care
- Screen for depression (PHQ-9)
- Evidence based DM treatment (algorithm driven)
Intervention:
Plus :
- Adjust medications per DM algorithm
If pt has positive depression screen (PHQ > 9):
- Communicate medication
- Evidence based depression treatment
recommendations with PCP
(algorithm based)
- Connect pt with DM education (DOC DM
- Refer for brief CBT
group, CCNC phone coaching, Durham
- 2-4 week return for goal setting and
Diabetes coalition)
behavioral activation
- Develop DM self management goal
Monitoring:
- Registry: HbA1c, PHQ-9s, appropriate medications, frequency of visits (Q3 months)
Outcomes:
16
- HbA1c, PHQ-9
Population health mgmt (cont’d)
• Advanced analytics to understand, respond to
needs of important patient subpopulations
– Updated (and updating) DOC primary care patient list
– DOC database (of clinical, socioeconomic variables)
• Has been built; will load DEDUCE/DSR, be annually updated
– Use of visualizations
• Including for planned chronic kidney disease (CKD) project
– AAMC “hot spotting” project
• AAMC-supported minigrant using Macarthur “Genius” awardwinner Jeff Brenner’s Camden Coalition method for
understanding high-need patients’ stories
– Transition to Healthy Planet (when available, fully
functional)
17
18
19
DOC
DRH
Main
Lincoln
20
Priorities for FY15: Clinic Operations
• Outreach to “lapsed” or “hard-to-reach” patients
– SAM-led response to Six Sigma Green Belt project/CGCAHPS
• Clarified routing to existing diabetes-related services
• Continued elevation in level of care provided on-site
– RNs completing certifications for placement of peripheral IVs
– New Procedure Clinic (joint injects, cryotherapy, punch biopsy)
– GIM Consultation Clinic
• Revenue enhancement
– TCM billing; initial barrier addressed w/ PRMO
– Pharmacy billing for visits (new)
• Quality of resident experience
– Changed intern scheduling in clinic to full days
– Renewed focus on clinic communications
– Further refining role of Stead-based clinic groups
• Participating in Transforming Primary Care Collaborative
– including Joint Commission PCMH certification
21
Diabetes-related services
Sheila White
22
Clinic Operations (cont’d):
Optimizing use of clinical pharmacy capacity
• End of FY14 saw loss of 0.9 FTE PharmD
• In FY15:
– Efforts to improve process efficiency, task-skill match
• e.g., modifying CII contract management process
– Continued facilitation of group visits (w/ SW; diabetes,
hypertension, chronic pain)
– Face-to-face visits to include anticoagulation,
diabetes/hypertension/hyperlipidemia, medication
management, and pain medication (CII) mgmt
– Targeting pharmacy post-discharge medication
reconciliation encounters to needier patients
• Goal for FY15: 50% of all discharges
– Billing for clinical pharmacist visits
• Start date: September 1
23
Discussion and Next Steps:
Requested FY15 investments
• Support for possible pilot of providing PCMH to
“medically homeless” complex uninsured patients
– Cont’d support for/ dedicated time of SOAR worker to help
uninsured DOC patients (plus addt’l social work needs)
• Direct support for clinic-based care manager ($16K)
– Would allow expansion of Marigny’s work outside Medicaid
(e.g., “medically homeless” pilot)
• Preservation of budgeted clinic staffing allocation
• Non-emergent patient transportation
– Van donated from DFC; cost of insurance ($110/mo) + fuel
– Volunteer driver?
• Support for participation in planned TPC Collaborative
– Contribution req’d to cover both DFM and DOC ($20K)
24
FY14 Accomplishments
• Reduced inappropriate ED and inpatient utilization
– Avoided direct costs of $489K (and savings of $384K)
• Successfully established clinic-based complex care
management program, on-site mental healthprimary care collaborative care model
• Increased resident satisfaction
• Rebecca Kirkland Award (DUHS PSQC)
• It Takes a TEAM Award (DUH)
• Podium presentation at Society for General Internal
Medicine (SGIM) Annual Meeting
• AAMC Hotspotting Minigrant
25
Discussion
Additional Slides
OVERALL, how would you RATE the VALUE of
your PRIMARY CARE CLINIC EXPERIENCE?
70
2013 Full LPS
% responses
60
2014 Snapshot
50
2014 Full LPS
40
30
20
10
0
Excellent
Very Good
Adequate
Fair
Poor
28
29
30
Complex Care Evaluation
Case Finding:
- Patients who meet HomeBASE criteria but do not have Medicaid
- Patients with uncontrolled illness or significant barriers to care who do not meet
HomeBASE criteria (internal referral)
Evaluation:
-
Social Work (Jan) and Nurse Practitioner (Julia)
One time joint evaluation: Connect with resources and communicate with PCP
Medication adherence
Financial barriers to medical care (transportation, medications, insurance status)
Financial barriers to self care (homelessness, food instability)
Psychiatric barriers to care (mood disorders, cognitive impairment)
Other barriers to care (domestic violence)
Outcomes:
- In development
- Markers of chronic disease management (BP, HbA1c, ED visits/hospitalizations)
31
Complex Care Evaluation
Intervention:
-
-
Nurse Practitioner (Julia)
Psychiatry: Initiate medication and
recommend titration schedule to PCP
Cognitive limitations: Refer for
neuropsych or cognitive evaluation as
needed
Medications: Medication
reconciliation (esp for low-literacy
patients), provide pill box, help with
organization; connect with Pharmacy
as needed
-
-
-
Social Work (Jan)
Transportation: Connect with Access
Food: Connect with community
resources
Psychiatry: Connect with community
resources, introduce to therapy
Safety: Follow up on APS referrals,
connect with resources for domestic
violence
Medications: Connect with financial
resources, sponsorship
Either Provider
- APS referral
- Create list of housing resources and provide to patient
Refer to LATCH, DukeWELL, Durham Diabetes Coalition or other resources
32
0.11
0.15
0.16
0.54
0.10
0.48
0.12
0.39
0.29
0.70
0.13
0.20
0.04
0.17
0.06
0.15
0.13
0.21
0.11
0.44
0.21
0.24
0.37
0.10
0.44
0.67
0.07
0.80
0.21
0.24
0.58
0.26
0.19
0.40
0.14
0.05
0.04
0.09
0.03
0.08
0.02
0.12
0.02
0.04
0.02
0.03
0.09
0.07
0.02
0.03
0.02
0.12
0.02
0.02
0.03
0.10
0.07
0.06
0.02
0.03
0.06
0.06
0.02
0.03
0.04
0.05
0.04
0.01
33
Alcohol abuse treatment
Referral for behavioral intervention plus algorithm guided medication management:
If your patients
has…
Uncomplicated
alcohol
dependence.
Significant alcohol
cravings*
A supportive person
who they live with
involved in their
recovery
AND no severe
medical problems
Mood disorder,
migraines or
significant irritability
with abstinence
Then try….
Naltrexone
Naltrexone or
Acamprosate
Antabuse
After 4-6 week if pt Then add….
has…..
Ongoing severe
Gabapentin or
cravings
Topamax
Ongoing cravings OR Gabapentin or
significant anxiety** Topamax
Cravings
Acamprosate
Significant anxiety
Gabapentin
Significant problems Switch to another
with adherence
medication
Topamax
Ongoing cravings
Naltrexone or
Acamprosate
34
DOC Patients
Disease Network
35
36
Diabetes care
• Clarified referral paths, indications for in-clinic and
outside diabetes-related services
• Six Sigma Green Belt Project (Shah, Simo)
– Finding “lapsed” patients
• Implementing IMPACT model for 25 patients w/
uncontrolled DM
37
Premium support for exchange-eligible uninsured
• NC decision not to expand Medicaid limited
coverage gains to those >100% FPL who could
afford to purchase exchange plans w/ subsidies.
• However, many people eligible for exchange plans
cannot afford even this, even w/ subsidies provided.
• In March 2014, of 23 exchange-eligible patients at
DOC referred to PADC navigator, only 6 were able
to afford their offer of coverage and sign up.
• A proposal is being developed that would provide
premium support for selected medically needy
exchange-eligible individuals to purchase coverage.
– Follows prior precedent set when e.g., COBRA coverage
was purchased by Duke on behalf of an uninsured
hospitalized patient.
38
Additional factor to consider
• We have recently seen a rise in patients who have
obtained insurance through the Affordable Care Act
requesting assistance with the cost of their meds
• While uninsured, they qualified for assistance from
the manufacturer (Patient Assistance Programs)
• Once insured, copays may be as high as $150 or
more for some medications (e.g. insulin)
• If premiums are paid for insurance for patients, there
may be a hidden cost through a rise in requests for
hospital sponsored meds
39
Source: UHC Research Institute
40