2. Big Institution to Community:
Accountable, Collaborative, Disruptive Care
Agenda and Summary
To accomplish the Triple Aim (Health, Care, Costs), we need to
focus on the care of patients with complex illnesses
To succeed at the care of patients with complex illnesses, we
embrace collaborative, coordinated care
How do we succeed?
Adopt proven models into accountable care
Implications for Clinical IT
Documentation
Content, Decision support
Interoperability, HIE
3. Why Focus on the Care for Complex Patients?
To accomplish the Triple Aim (Health, Care, Costs), we need to
focus on the care of patients with complex illnesses
Hospitals – “That’s where the money is.”
Post-Acute Care: “That’s where the variation is.”
73%, in nursing facilities, home health care and long-term-care hospitals
Compared to 27% for hospitals and 14% tests/procedures (Newhouse,
2013)
Dementia hospitalization ↑ 10 x from 2000 → 2050
Accountable Care aligns incentives
Efficient Care is key: overtreatment, failures of care
coordination, failures in execution of care processes,
administrative complexity, pricing failures, fraud and abuse
(Berwick, 2012)
4. Collaborative Care for Complex Patients
http://www.improvingchroniccare.org/
Team care
Patients with multiple diseases,
functional impairments and
social challenges
Professionals from several
health disciplines
Multi- Inter-disciplinary
processes
Team decision-making
Chronic care model
Historically: Pediatrics,
Physiatry, Psychiatry, Geriatrics
Now mainstream with
aligned incentives ?
5. Accountable Care Meets Geriatric Care
15 successful geriatric
care models based on
123 high-quality studies
with positive outcomes
(Boult, 2009)
“Fee-for-service payment
is anathema to effective
chronic disease care…
to improve chronic care
[we need] accountability
and payment in
synchrony.” (Kane, 2009)
http://www.ncbi.nlm.nih.gov/pubmed/20121991
• Interdisciplinary primary care: 1
• Supplement primary care: 8
• Transitional care: 1
• Acute care in patients' homes: 2
• Nurse-physician teams for
residents of nursing homes: 1
• Comprehensive hospital care: 2
6. Collaborative Care for High-Risk and Vulnerable
Populations
Socially Disadvantaged Clinically Vulnerable
Highly
Vulnerable
Source: High-Risk and Vulnerable Populations Workgroup: http://www.acolearningnetwork.org/
Socially Disadvantaged Clinically Vulnerable
• Racial, ethnic minority
• Native American community
• Immigrant
• Impoverished neighborhood
• Low incomes
• Low levels of education
• Low health literacy
• Rural area
• Homeless
• Non English-speaking
• Dual–eligible beneficiaries
• Uninsured/underinsured
• Have low social supports
• Complex chronic illnesses
• Acute serious illnesses
• Multiple chronic conditions
• Disabled
• Mentally ill
• Substance abusers
• Cognitively impaired
• Frail elders
• Patients nearing the end of life
• Pregnant women
• Very young children
• High-utilizer patients
• High-cost patients
• Dual-eligible beneficiaries
7. CareMore Succeeding at Complex and Post-Acute Care
Medicare Advantage “+”
Av. age 72, 50% <$30k income; DM
33%, HTN 40%
Intensive management of frail and
chronically ill: 15% members → 70%
costs,
Monitoring, management of chronic
conditions to delay the onset of
frailty
Costs 15% less; profitable
Reuben, 2011
Contract with PCPs; handle non-urgent
illness
NP’s, MA’s: evidence-based protocols
1-hr. Healthy Start visit, MA + NP/MD,
comprehensive evaluation; annually
Extensivists: inpatient + post-discharge
care including SNF
Specialist management
Transportation, fitness, home
intervention team, caregiver support,
respite care, high-intensity
management for frailest 2%
EHR + wireless home monitoring
Culture of conservative management
Outcomes
DM: av. A1C 7.08; amputation
78% < national av.
Hosp.: ALOS 3.0 d.; ESRD 42% Re-
Hosp.: 13.6% vs. 20%
CAPHS > CA, US
8. Collaborative Care for Complex Patients
Patient and caregiver
at the center
Collaboration
Communication
“…health system performance
will increasingly depend
on high-functioning, team-based
approaches to care.” (Dzau, 2013)
9. Enabling Success with Care of Complex Patients
Role of Clinical IT
Implications for Clinical IT
Documentation
Care planning, including patient/resident choice
Minimum Data Set; Resource Utilization Groups
Decision support
Interoperability, HIE
Unique features of Nursing Home care
Not part of MU
Slower EHR adoption
Help on the way: Center for Aging Service Technologies, 2013
Needs assessment and EHR Selection Matrix comparing 36
products on ~200 features and functionalities
http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2010/Apr/1380_Klinger_lessons
_HIT_New_York_nursing_homes_case_study.pdf, Commonwealth Fund, 2010
10. “Last week Mrs. S. spiked a fever of 100.2 and was not eating much.
The nursing supervisor immediately contacted the resident’s physician offsite
Viewed via Internet Mrs. S.’s full clinical record over the last week
Real-time data being entered at the bedside by the nursing team and direct-care staff
Record of all her medications and when she had taken them
Plan made between the nursing home care team and physician to give Mrs. S.
intravenous fluids for 24 hours to avoid dehydration
“Give fever-reducing medication, monitor her vital signs, inform physician.”
Physician viewed progress from offsite
If hospitalization were indicated, it could have immediately been carried out.
Mrs. S.’ temperature became normal over 24 hours and she began to eat, drink.
Treatment plan appropriate
No hospitalization.”
Enabling Success with Care of Complex Patients
Role of Clinical IT – Patient Vignette
http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2010/Apr/1380_Klinger_lessons
_HIT_New_York_nursing_homes_case_study.pdf, Commonwealth Fund, 2010
11. Transitions of Care
Clinical IT Challenges for Long-Term Post-Acute Care (LTPAC) 1 of 3
Health IT adoption spectrum for long-term post-acute care
(LTPAC): systems for federally required assessments for payment
and quality >> systems for care
Health IT-enabled facilities: Data feeds to an exchange, secure
messaging
Low/no IT-adopted facilities
Web-based portals for secure messaging, information query with hospitals and other care
partners
Simple clinical documentation tools to facilitate electronic capture of LTPAC data shared at
transitions
EHRs: integrated connectivity is evolving; CCHIT modular
certification growing
Standards: 5 Transition of Care data sets to meet needs of most
types of transitions
12. Transitions of Care
Clinical IT Challenges for Long-Term Post-Acute Care (LTPAC) 2 of 3
Clinical Workflow: paper/fax electronic solutions
To assess patient acuity, service needs and staffing levels, on-
site administrator and nursing leader and off-site medical
director all need access to information
Better identify and ensure services for patients with high
medical complexity and resource utilization patterns with data
from multiple episodes of care and settings
Urgent ED evaluations: via DIRECT
Secure message and change in condition documentation earlier in the care episode,
detailing symptoms and events leading up to the transfer
Communicate assessments performed in the ED to both the nursing facility and the
attending medical provider, for safe transition to sending facility
13. Transitions of Care
Clinical IT Challenges for Long-Term Post-Acute Care (LTPAC) 3 of 3
Staffing and User Access
Core team: administrator, director of nursing, assistant director of
nursing, compliance leader and senior charge nurse vs. Care managers
or Nursing coordinators
High staff turnover: train multiple staff, work with very small user
groups in well-defined phases
Value Proposition: Too early in adoption phase for ROI
Avoid penalties for readmissions, improve staff efficiency and reduce
staff time, reduce burden on patients and families
More accurate and timely medication reconciliation, better access to
all anticoagulation results, fewer missed wound/therapy treatments
http://www.healthit.gov/sites/default/files/challengegrantslessonslearnedltpac_paper.pdf 2013
14. Supporting Collaborative, Coordinated Care
Socially Disadvantaged Clinically Vulnerable
Clinical
Documentation
Care Planning
Practice Technology
EHR
• Software /
database
• Functionality
• Configuration
tools
http://www.nationalehealth.org/ckfinder/userfiles/files/Improving%20Care%20Coordination%20Slide%20Deck.pdf
Content
• Evidence-based
• Intentional
automation
• Integrated
interprofessional
care
Workflow Design
Culture
Change
16. References
Newhouse JP, et al. (2013). Variation in health care Spending: Target Decision Making, Not
Geography: http://www.nap.edu/catalog.php?record_id=18393
Berwick DM, Hackbarth AD. Eliminating Waste in US Health Care. JAMA. 2012;307(14):1513-1516.
doi:10.1001/jama.2012.362
Zilberberg MD, Tjia J. Growth in Dementia-Associated Hospitalizations Among the Oldest Old in the
United States: Implications for Ethical Health Services Planning. Arch Int Med 2011; 171; 1850-1851.
Boult C, et al. (2009), Successful Models of Comprehensive Care for Older Adults with Chronic
Conditions: Evidence for the Institute of Medicine's “Retooling for an Aging America” Report. Journal
of the American Geriatrics Society, 57: 2328–2337. doi: 10.1111/j.1532-5415.2009.02571.x
Kane RL (2009), What Can Improve Chronic Disease Care? Journal of the American Geriatrics Society,
57: 2338–2345. doi: 10.1111/j.1532-5415.2009.02569.x
Reuben DB (2009), Better Ways to Care for Older Persons: Is Anybody Listening?. Journal of the
American Geriatrics Society, 57: 2348–2349. doi: 10.1111/j.1532-5415.2009.02574.x
Reuben DB (2011). Physicians in Supporting Roles in Chronic Disease Care: The CareMore Model.
Journal of the American Geriatrics Society 59:158–160
Dzau VJ, et al. Transforming Academic Health Centers for an Uncertain Future. N Engl J Med 2013
369;991-992.
CareMore, 2012:
http://www.wellpoint.com/prodcontrib/groups/wellpoint/@wp_news_main/documents/wlp_assets
/pw_e181475.pdf
Center for Aging Service Technologies, 2013:
http://www.leadingage.org/uploadedFiles/Content/About/CAST/Resources/2013_CAST_EHR_For_LT
PAC_A_Primer_on_Planning_and_Vendor_Selection.pdf