Homebase - The Association of Medicine and Psychiatry

Homebase at the Duke Outpatient Clinic:
Using Collaborative Care to Strengthen the
Medical Home
Natasha Cunningham, MD
Division of Social and Community Psychiatry
Division of General Internal Medicine
Duke University
10/3/2015
Objectives
• Identify four evidence based components of
collaborative care utilized in the collaborative care
intervention at the Duke Outpatient Clinic.
• Identify two outcomes from the “Homebase”
collaborative care intervention that are consistent
with the “Triple Aim” of healthcare reform.
• Identify and explain two ways in which the
collaborative care intervention at the Duke
Outpatient Clinic is innovative compared with classic
designs discussed in the literature.
Duke Outpatient Clinic
Resident Primary Care Clinic
Residents
Patients
Female
Insurance
Race
ED visits (FY13)
30 day readmission rate
70
4100-4300
60%
Medicaid 58%
Dual 6%
Uninsured 13%
Black 62%
White 33%
Other 5%
5522
20.9%
Duke Outpatient Clinic
• High rate of MH diagnoses
• MH diagnoses associated with:
↑ ED U,liza,on
↑ 30 day readmission
• Less than 2% of pts account for
nearly 20% of ED visits
DOC Redesign Proposal:
Principles and Objectives
Key Principles
1
Provide Care
• At lowest cost
• At most cost-effective
sites of service
Without sacrificing quality or
patient satisfaction; and with the
appropriate provider mix
2
Reduce Avoidable
Inpatient Admissions
Key Objectives
Critical Success Factors
• Create an integrated
Collaborative Care
Mental Health-Primary
Care model at the DOC
• Encourage and enable
patients to seek services
at the DOC first and not
the ED
• Transition to DRH as the
primary site of hospital &
ED services for DOC
patients
• Hiring clinic-based care
manager to coordinate the care
of non-Medicaid/non-CCNC
high utilizers (HUs) and
mental health patients
• Filling vacant position for
Mental Health APP at DOC
• Addition of Med-Psych attg
• Increasing DOC capability to
care for minor emergencies and
chronic pain
• Closer working relationships
with DRH & DUH ED and
Hospitalist Programs
• Reinvent Care Team Model
at DOC to increase patientprovider continuity, provider
accountability for patient
outcomes, use of best practice
• Improve care, outcomes for
DOC patients w/ co-morbid
mental health conditions
• Improve transitions of care
from hospital and ED settings
to clinic and home, particularly
for high utilizer (HU) patients
• Addition of 50:50 DOC:DRH
attending at DOC
• Collaborating w/ DOM IM
Residency Office to increase
attg-resident-patient continuity
• Improving resident physician
morale, resilience
• Coordinating care more
closely with Durham County
mental health providers
• Formalizing process for
monitoring, intervening on all
HU patients, incl pharmacy,
care manager; esp. post-disch
Page 5
Defining Successful Collaborative Care
Linkages in Care:
4 most successful components from 42 RCTs
Successful Components
• Care Management
• Enhanced
Communication
– Consultation Liaison
• Local Protocols
•
•
•
– Systematic psychiatric
assessment
– Stepped care
recommendations
Definition
Systematic Psychiatric Assessment
Use of non-physician care manager
Specialist-provided, stepped care
recommendations
6
Feller, 2011; Huffman, 2014
Collaborative Care:
Stratified Interventions for psychiatric
comorbidity
• Care Management
• Enhanced
Communication
• Local Protocols
Homebase
Higher
Intensity
Psychiatric consultation
Trauma and depression management
Algorithm supported alcohol abuse
treatment
Algorithm supported depression treatment
Care Management:
An Innovative Approach
Foundation
IMPACT (elderly, depression)
Depression Care Specialist (DCS):
Nurse or psychologist
Psychosocial history
Education and behavioral activation
Helped identify treatment preferences
Weekly or biweekly pt contact
Weekly meeting: DCS, psychiatrist and
PCP
Stepped care algorithm
Problem Solving Treatment
Psychological
support
Community
support
VA Integrated Care (SMI)
Care Manager: Nurse
Phone reminders: appts and blood tests
Escorting patients to appointments
Booking transportation
Communicating with providers in other
clinics
Picking up medications
Delivering meds or equipment to pt’s
home
General psychosocial support
ACTT (SMI)
Care Manager: Small case
loads
24h crisis support
Whole team approach
Careful medication monitoring
Individualized, in vivo care
Regular meetings
Health care
navigation
Mission
Values, Principles and Tools
Values of Illness Management and
Recovery
Hope
Respect
Optimism
Confidence
Well-being
Expectations
Tools of Illness Management and
Recovery
Education
Behavioral tailoring (CBT)
Relapse prevention
Coping skills training
Social skills training
Patient driven goal setting
Motivational
Interviewing/enhancement
Principles of Patient Centered
Medical Home
Patient Centered
Accessible
Comprehensive
Coordinated
Committed to Quality and Safety
Principles of Patient Centered care
Bipsychosocial Perspective
Viewing the patient as a person
Therapeutic alliance
Viewing the provider as a person
Sharing power and responsibility
DOC Homebase Mission,
Values, Principles and Tools
Values:
Tools/Principles:
Hope
Optimism
Respect and expectations
The patient as a whole person
Self-determination
Empowerment
Education
Listening and showing that we
care
Providing non-judgmental support
Realistic patient driven, value
centered goals
Setting clear goals and
expectations
Communication with patients and
providers
Mission:
Identify unmet needs
Support patient in improving their own health
Facilitate and coordinate the navigation of the healthcare system
Summary
•
•
•
•
Patient Centered
Interdisciplinary
Care Manager Driven
Proactive Outreach
Structure
•
•
•
•
•
•
•
•
Conduct twice-weekly team meetings
Identify highest utilizers of emergency and
inpatient care
Perform 6-12 month chart review to identify
patterns of utilization
Create comprehensive care plan and flag on
medical record
Enhanced access to DOC services; including
same-day access, no appointment necessary
Access to nonemergency patient transportation
for those with significant needs
Real-time notification of ED check-in
Longitudinal monitoring
Page 12
Team
Care Manager:
Marigny Manson
Nurse Practitioner:
Julia Gamble
Med-Psych
Provider: Natasha
Cunningham
Social Worker:
Jan Dillard
Utilization Review
SOB
Psychiatrist
prescribes
pain meds
UDS pos
for cocaine
20 Percocet
1/1
Hip Pain
Cough
Fall
Wheeze
Trying to transfer
from UNC to
Duke pain clinic
SOB
60 Percocet
1/6
90 Percocet
1/14
SOB
FYI Flag: Complex Care Plan
Page 14
FYI Flag: Complex Care Plan
Real Time Notification of ED Visits
Longitudinal Patient Monitoring
Simplify
medications
Connect with
palliative care
Connect
with housing
Treat anxiety
Liaise with
burn center
Connect with
community center
Educate about
emergency
contraception
Advocate
for payee
Outcomes
Triple Aim” goal of
health care reform:
• Improve the patient
experience of care
• Improve the health of
the population
• Lower health care
costs
DOC Redesign
Objectives:
• Provide Care
– At the lowest cost
– At the most costeffective site of service
• Reduce avoidable
inpatient admissions
Lower Healthcare Costs
Total Clinic Utilization
DUH ED visits
Baseline
(FY13)
2583
Goal
Outcome
(FY14)
10% reduction 16%
Savings $177,521
DRH ED visits
2939
DUH admissions 800
5% reduction
30 day
readmission
Savings $411,835
167
134
Total Savings $589,356
10.3%
16%
114
Impact of HomeBASE on ED visits (37 patients)
Results for year one
*annualized
fewer ED visits
more ED visits
20
-0.8
-6.7
238 ED visits and 30 hospital admissions
-$58K
-$120K
Total Annual Savings = $178,000 per 37 patients
*annualized
21
Significant Decrease in ED utilization
Innovative
• Explicit focus on engagement
• Combining teaching and clinical mission
• Identifying ineffective patterns of healthcare
utilization as a marker of unmet psychosocial
needs
• Building personal relationships with focus on
supporting recovery and wellness
Propensity Score Matching:
Improved Engagement
↓ ED utilization
Homebase > Control
ALL MEDICAID, MINIMUM OF 4 ED VISITS/HOSPITAL
ADMISSIONS (N = 33)
Variables: Age, ED Visits, Mental Illness, Substance Abuse,
Diabetes, Charlson Index
Pre-Intervention
PostIntervention
Mean Diff
Control Treatme Control Treatme
Treatme
Variable Mean nt Mean Mean nt Mean Control nt
p.value
ED_Visit
s
8.7353 13.353 6.5882 8.4118 -2.1471 -4.9412 0.3174
Hosp_A
dmissio
ns
0.8824 1.9412 1.3529 2.1176 0.4706 0.1765 0.6767
Inpatient
_Days
5.9397 9.2309 7.1188 10.947 1.1791 1.7162 0.8683
DOC_Vi
sits
11.4706 8.9412 3.8824 9.2353 -7.5882 0.2941 0.0026
Admitte
d_Rate
Readmi
ssions_
Rate
0.1055 0.1292 0.1471 0.2044 0.0417 0.0752 0.5829
0.0882 0.9412 0.2941 0.4706 0.2059 -0.4706 0.1214
Hypothesis:
Control patients not using the ED are
being lost to healthcare.
Homebase patients are developing
more effective utilization patterns.
↓ PCP
engagement
↑ PCP
engagement
Explicit focus on engagement →
Improved patient experience of care
Medical Home
http://www.orlandohealthdocs.com/orlandointernalmedicinegroup/files/2012/12/orlando_i
nternal_medicine_practice_is_patient_centered_medical_home.jpg
Combining teaching and clinical mission:
IM residents feel underprepared to address social and mental
health issues
Clinical
Teaching
Clinical and
Teaching
1. Wiest et al. Preparedness of Internal Medicine and Family Practice Residents to Treat
Common Conditions. JAMA 2002; 288: 2609-2614
2. Park E et al. Perceived preparedness of to provide preventive counseling: Reports of
Page
26 Primary Care Residents. J Gen Intern Med 2005; 20: 386-391
Graduating
Identifying ineffective patterns of
healthcare utilization as a marker of
unmet psychosocial needs
Psychiatric
Diagnosis or
Positive
Screen
Undiagnosed
or Complex
Behavioral
Health or
Social Issues
Case Finding:
> 6 ED visits in
3 months
Psychiatric Symptoms or Social Disadvantage
Affect Behavior or Access to Healthcare
Seeing the Big Picture:
Advantage of a Biopsychosocial Model
1/15/15 shoulder pain
1/13/15 shoulder pain
1/10/15 shoulder pain
12/29/14 URI
12/22/14 facial pain
12/16/14 URI
12/12/14 Sinusitis,
homelessness
12/6/14: Headache,
chest pain
11/22/14 Neck pain
10/18/14 sore throat
10/15/14 URI
10/13/14 Cough
9/27/14 low mg,
alcohol abuse
9/23/14 sore throat
9/16/14 muscle cramps
11/28/14 Head injury,
seizure
10/17/14 Depression
10/16/14 Seizure
8/17/14 Seizure, UTI
6/30/14 Seizure
6/10/14 Seizure
5/6/14 Headache
3/12/15 Syncope,
seizure
12/9/13 Anxiety, chest
pain
11/18/13 Headache
1/1/15 Asthma
11/15/14 dysphagia,
asthma
11/13/14 Asthma
attack
10/23/14 Asthma
exacerbation
10/13/14 Asthma,
anxiety, chest pain
9/25/14 Asthma attack
9/13/14 Asthma
exacerbation
8/31/14 COPD
8/14/14 Obstructive
airway
8/10/14 SOB
7/3/14 SOB
5/18/14 Shoulder pain
Alcohol Dependence
Homelessness
Head and neck CA in
remission
Vascular dementia
Anxiety
Seizures and
pseudoseizures
Schizophrenia
Asthma
Anxiety/PTSD
12/1/14 Chest pain
syndrome
11/22/14 Unstable
angina
9/26/14 Chest pain, CAD
7/27/14 Unstable angina
4/11/14 Unstable angina
3/30/14 Chest pain
12/16/13 Chest pain,
SOB
11/30/13 Chest pain,
pre syncope
11/17/13 Chest pain,
anxiety/depression,
chronic pain
PTSD
Chronic
pain/fibromyalgia
CAD
Building personal relationships with focus
on supporting recovery and wellness
Increases patient and provider satisfaction
Protects against provider burnout
Success Stories
Story 1: 36yo woman with history of
locally advanced cervical cancer
diagnosed in 1/2012 along with prior
DV and stillbirth. Underwent
brachytherapy at Duke complicated by
uretal strictures, kidney injury and
radiation cystitis and proctitis. Frequent
admissions for nausea and vomiting.
Resistant to psychiatric care despite
significant trauma.
Intervention:
• Proactive outreach with ED
diversion strategy.
• Team meeting with patient and
urologist to discuss medical status.
• Encouragement of medication
adherence and symptom selfmanagement.
• Short term supportive therapy.
18
16
14
12
10
8
6
4
2
0
1
3
5
7
9
11
13
15
17
19
21
23
25
27
Success Stories
Story 3: 54yo man with history of
esophageal carcinoma, hidradenitis
suppurativa, lymphedema, recurrent
cellulitis, fibromyalgia, PTSD and
hypochondriasis. Frequent ED visits for
pain, cellulitis and anxiety. Behavioral
issues around narcotics.
Intervention:
• Communication with ED not to
provide narcotics.
• Stabilized narcotic dosing and
clarified behavioral expectations.
• Encouraged patient to come to DOC
for medical issues and promoted
engagement.
• Connected patient with brief
psychotherapy and consistent
psychiatric care.
12
10
8
6
4
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Thank You!
•
•
•
•
Adia Ross, MD, MHA
Alex Cho, MD, MBA
Sarah Rivelli, MD
Lynn Bowlby, MD
•
•
•
•
Marigny Manson, RN
Julia Gamble, NP
Jan Dillard, LCSW
Mark Dakkak, MS3
• CCNC, PDC and Duke
Hospital Leadership
• DOC Team
Behrouz and Tickles Moo
Page 32
Questions?
References
•
•
•
•
•
•
•
•
•
•
•
Bailey ML. Care coordination in managed care. Creating a quality continuum for high-risk elderly
patients. Nurs Case Manag. 1998;3:172–180.
Burns T. The rise and fall of assertive community treatment? Int Rev Psychiatry. 2010;22(2):130–137.
Burns BJ and Santos AB. Assertive community treatment: an update of randomized trials. Psychiatr
Serv. 1995;46(7):669-75.
Druss BG. et al. Integrated medical care for patients with serious psychiatric illness. Arch Gen
Psychiatry. 2001;58:861-868.
Fuller JD. et al. Effectiveness of service linkages in primary mental health car: a review part 1. BMC
Health Services Res. 2011;11:72.
Harpole LH. et al. Improving depression outcomes in older adults with comorbid medical illness. Gen
Hosp Psychiatry. 2005;27:4-12.
Huffman JC. et al. Essential articles on collaborative care models for the treatment of psychiatric
disorders in medical settings: a publication by the academy of psychosomatic medicine research and
evidence-based practice committee. Psychsomatics. 2014;55(2): 109-122
Lagoe RJ. et al. Hospital readmissions at the communitywide level: implications for case management. J
Nurs Care Qual. 2000;14:1–15.
Park E et al. Perceived preparedness of to provide preventive counseling: Reports of Graduating Primary
Care Residents. J Gen Intern Med 2005;20: 386-391
Poole PJ. et al. Case management may reduce length of hospital stay in patients with recurrent
admissions for chronic obstructive pulmonary disease. Respirology 2001;6:37–42.
Wiest et al. Preparedness of Internal Medicine and Family Practice Residents to Treat Common
Conditions. JAMA 2002; 288: 2609-2614
34
Addendum
Innovative?
Defining Successful Collaborative Care
67 Essential articles on collaborative care:
Benefit in multiple domains
Definition
• Systematic Psychiatric
Assessment
• Use of non-physician
care manager
• Specialist-provided,
stepped care
recommendations
Huffman, 2014
Redesign Outcomes Monitoring
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
38
(cumulative)
56
50
12.0%
50 meets (20
new/quarter), 60+
exceeds
Natasha
HomeBASE list
Cunningham (DOC)
“…Circulatory, respiratory, and digestive disorders
accounted for a majority of readmissions… This
information suggested that case management efforts to
reduce readmissions can focus on a limited range of
clinical diagnoses.”
Precedent for case management
interventions targeting high utlizers
Assertive Community Treatment Teams
>3 COPD admissions over 2 yrs
>65yo with
chronic medical
issue