Care at Critical Transitions - Healthfirst Digital Asset Management

Care at Critical Transitions
A Patient Centered Approach
Patient-PCP-Healthfirst-Doctors on Call
PAUL ROSENSTOCK, MD
MEDICAL DIRECTOR, CEO
DOCTORS ON CALL
Doctors on Call: Critical Elements
1
 A Medical network offering in-home Medical and
Podiatric care to treat patients throughout the
healthcare continuum focusing on homebound and
chronically ill patients in Greater New York
 Focus on prevention and clinical excellence
 Program based on best practices evidence-based data
Healthfirst 2011 Fall Symposium
Integrating Healthcare: Planning and Systems to Improve Health Outcomes
Doctors On Call: Background
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 Providing home visits since 1968
Short Term or Ongoing Medical and Podiatric care
Servicing all 5 boroughs
 Close collaboration with patient’s PCP
 Ongoing coordination with patients caregiver
 Providing an “additional layer of medical care”
 Emphasis on prevention, reducing unnecessary ED visits
and hospitalizations
Healthfirst 2011 Fall Symposium
Integrating Healthcare: Planning and Systems to Improve Health Outcomes
Transitional Care: Definition
3
Transitional care includes a broad range of services
designed to ensure health care continuity, avoid
preventable poor outcomes among at risk populations,
and promote the safe and timely transfer of patients
from one level of care to another or from one setting
to another.
Healthfirst 2011 Fall Symposium
Integrating Healthcare: Planning and Systems to Improve Health Outcomes
Transitional Care: Critical Issues
4
 Twenty percent (20%) of Medicare patients are readmitted within 30 days
 Patients are at highest risk of readmission within one week of hospital
discharge
 Improved discharge processes and post discharge support can reduce
re-hospitalizations by one third,
New York Health Foundations Policy Research, Sept 2011
 Readmissions are less likely if patients see a primary care physician within 2
weeks,
Dartmouth Atlas Reports, J Hospital Medicine Sep 2010.
 Medicare beneficiaries who were re-hospitalized within 30 days of discharge,
found that more than half of them had not visited a physician’s office between
the time of discharge and being readmitted, New England Journal of Medicine ,2009
Healthfirst 2011 Fall Symposium
Integrating Healthcare: Planning and Systems to Improve Health Outcomes
Critical Transition: Underlying Factors
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 PCPs are often not aware of patient’s readmissions
 Hospitalists are increasingly managing the PCP’s inpatients
 Significant gaps of communication and coordination of care exist between:
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Patient - Hospitalist - PCP
Trend in IPA member readmissions suggestive of increase
Significant loss of patient-PCP retention to hospital-based clinics and non par PCPs
following hospitalization
Re-hospitalization results in progressive decline in patient clinical status, increased
morbidity and mortality
Fragmented and duplicative post-hospital care
Lost opportunity to promote self-management and improve health outcomes
Healthfirst 2011 Fall Symposium
Integrating Healthcare: Planning and Systems to Improve Health Outcomes
Care at Critical Transitions Pilot
6
Overall Mission of Pilot Program:
To establish an evidence-based program reducing
Healthfirst hospital readmissions, while improving
overall patient health status, self management and
strengthening the patient/PCP relationship.
Healthfirst 2011 Fall Symposium
Integrating Healthcare: Planning and Systems to Improve Health Outcomes
Rollout Of Pilot
7
Development and Planning
-Close collaboration and bi-monthly meetings with Dr. Susan Beane,
Medical Director, Healthfirst, Network Development personnel and Corinthian IPA
Senior Management, to define overall goals, tracking requirements, and roll out
 February 2011:
Pilot Initiation
-Initial Roll out of 43 High-Volume Bronx and Upper Manhattan Corinthian PCPs :
Primarily SLR affiliated
 June 2011:
-Personal in-service with PCPs and office staff in collaboration with Healthfirst Network
Development staff
-Non-mandatory participation
-Dedicated DOC Bilingual Liaisons
-Close ongoing written and verbal collaboration with PCP regarding clinical issues
-Patient participation utilizing Healthfirst’s Daily Patient Census
Rollout of program to Corinthian IPA PCPs in the Bronx
affiliated with Bronx Lebanon
 November 2011:
Healthfirst 2011 Fall Symposium
Integrating Healthcare: Planning and Systems to Improve Health Outcomes
Process
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 DOC Provider Visit: Rendered on behalf of the PCP within one week following
hospital discharge when possible
 Goal: to schedule a home visit within one week after discharge when possible.
 Flexible appointment system to accommodate patients and caregivers needs
 Patient and Caregiver contact initiated by DOC on day after admission
Home Visit Emphasis on:
- Clinical stability
- New diagnosis
- Medication reconciliation
- Assessing barriers to care: i.e. transportation
- Patient education
- Risk management
- Fulfillment of HEDIS criteria
 Consultation with PCP: any urgent care, additional home visits or coordination of
care needs
 PCP Update: simplified template conveying key clinical information
Healthfirst 2011 Fall Symposium
Integrating Healthcare: Planning and Systems to Improve Health Outcomes
Criteria for Follow Up visits
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Patients receive two additional home visits if the following are
found:
 Medication Discrepancies / Medication Management
(e.g. insulin dosaging, poorly controlled hypertension etc.)
 New Diagnosis
 Clinical Instability
(whether or not related to previous hospitalization)
 Patients are encouraged to see their PCPs during this timeframe to
maximize successful therapeutic outcomes.
Healthfirst 2011 Fall Symposium
Integrating Healthcare: Planning and Systems to Improve Health Outcomes
Results to Date
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Patients Receiving Initial Home Visits:
 691 eligible patients
(excluding substance abuse and labor and delivery)
 296 out of 691 (43%) patients had an initial visit
Patients Refusals or Non-visits:
 58 out of 691 (8%) already had or will shortly have appointments with their PCP
 50 out of 691 (7%) felt well or refused visits without giving a reason
 Incorrect Contact Information : 20%
Trends to Date:
 Patients who had initial home visits in proximity to hospitalization had fewer readmissions than
patients who were not evaluated.
 Patients who had initial and one and or two follow-up home visits had a sizeable decrease in
readmissions
 Positive Feedback from PCPs: Appreciation of clinical excellence, usefulness and clarity of clinical
templates
Healthfirst 2011 Fall Symposium
Integrating Healthcare: Planning and Systems to Improve Health Outcomes
Case Study #1
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 72 y.o. male, history of multiple malignancies
 Squamous cell CA in oral cavity, Hepatocellular Carcinoma
 Evaluation by numerous specialists, last PCP visit less than
one month
 PEG tube insertion x 2 weeks
 Caregiver not available to assist in feedings and ADL’s
 Weight loss of 11 pounds in past week
 PCP contacted via telephone and e-mail
 Requesting urgent referral for HHA
 Outcome: Patient’s ongoing needs met
with PCP collaboration
Healthfirst 2011 Fall Symposium
Integrating Healthcare: Planning and Systems to Improve Health Outcomes
Case Study #2
14
 64 y.o. Female, with h/o mild to moderate CHF
BP 148/74, Pulse 88/min, RR of 26-28/min, patient anxious about SOB
 Concern over SOB has been a long-established trigger for
emergency room visits
 Limited access to PCP
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Home visits results in:
Medication reconciliation
Improved patient self management
ED visit prevented
Clinical Update to PCP
Healthfirst 2011 Fall Symposium
Integrating Healthcare: Planning and Systems to Improve Health Outcomes
Lessons Learned to Date
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Ingredients for Success:
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Seamless Bridge of Communication with Healthfirst’s :
-Medical Director
-Network Development
-Medical Management
Ongoing collaboration with PCP and office staff to ensure optimal information handoff
Medical Checklists highlighting medication reconciliation, new diagnoses, and clinical
stability
 Facilitation of urgent PCP visits and transportation
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Barriers:
Inability to obtain timely and accurate discharge dates
Difficulty in contacting patients and scheduling home visits within first week after
discharge
 Insufficient number of patients for statistically significant conclusions
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Healthfirst 2011 Fall Symposium
Integrating Healthcare: Planning and Systems to Improve Health Outcomes
Next Steps / Proposed Strategies
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Maintain and Improve:
 Involvement of all stakeholders
 Ongoing communication to Healthfirst and PCPs
 Development of statistically valid data sets
 Design strategies for preventing high risk patient readmission
 Rx reconciliation needs (e.g.. was RX refilled)
Establish Hospital Onsite Non-Clinical Liaisons:
 To confirm accurate hospital discharge dates in a timely fashion
 To schedule visits on behalf of the PCP at patient’s bedside
 To establish the Home Visit as part of the discharge plan
 To enable scheduling and documentation of visits made within 7 to 30 days
Program Expansion:
 Increase program access to more patients and PCPs
 Establish statistical significance
Healthfirst 2011 Fall Symposium
Integrating Healthcare: Planning and Systems to Improve Health Outcomes
Doctors on Call
Key Contact Information
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 Paul Rosenstock, MD
Medical Director, CEO
 Charlotte Punski, RN PA MPH
Director of Business Development
 Lidia Virgil, MD
Director of Operations
 Tania Valoy
Customer Service Liaison
 Main Intake Telephone Number:
Doctors on Call Website :
www.doctorsoncallnyc.com
Healthfirst 2011 Fall Symposium
Integrating Healthcare: Planning and Systems to Improve Health Outcomes
(917) 807-3350
(917) 450-1822
(718) 238-2100 Ext. 229
(718) 238-2100 Ext. 209
(718) 238-2100
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Thank You for Your
Attention and Interest
Healthfirst 2011 Fall Symposium
Integrating Healthcare: Planning and Systems to Improve Health Outcomes