Cabin creek

Craig Robinson, MPH

Amber Crist, MS Cabin Creek Health Systems

Creating a Senior Medical Home

Becoming as Complex as our Patients

Cabin Creek Health Systems

Craig Robinson, MPH

Amber Crist, MS

crobinson@cchcwv.com

acrist@cchcwv.com

Cabin Creek Health Systems An FQHC with 4 Centers in

central West Virginia.

14,000 annual users

2,259 Patients 65 and older

65 – 74 = 1,298

75 – 84 = 711

85 years and older = 250

Implemented Electronic Health

Record in 2008

Affiliated with the Central

Counties Area Health Education

Center

Implemented Senior Medical

Home in 2009

Cabin Creek Health Center -- Dawes, WV

An organization is a conversation before it is anything else: it begins with people talking together about something they would like to do that is beyond

their capacity to do as individuals. Anthony Suchman

Leading Change in Healthcare

Let’s Start-- With Some Conversations

CMS, under Don Berwick, is promoting the Triple Aim: improve the individual patient experience, improve the health of populations, and lower cost.

What are the issues in your community or organization that are barriers to meeting the triple aim for the elderly?

Group Issues

Why focus on elders?

We had…

A problem (high hospital use by seniors).

Some money (Claude Worthington Benedum Foundation, AHEC).

Some interest (medical staff struggling alone with complex elderly patients, PACE project failed)

Some expertise (consulting geriatrician, consultant researchers, AHEC leader)

Some maps. (the Medical Home model, COPC, SoC)

The Problem: Dartmouth Health Atlas

Hospital discharges per 1,000 Medicare enrollees (overall 2005)

http://www.dartmouthatlas.org/

Charleston, WV

HRR = 117.0

http://www.dartmouthatlas.org/

Medicare Discharges for ACSC per 1,000 - CY2005

What’s Behind the Numbers? Complexity

Our Patients are Complex

Elderly Patients are Complex

Multiple chronic conditions

Functional and cognitive variation

Many, many medicines – opportunities for harm/waste.

Multiple medical providers – minimal coordination.

Fat complicated medical records – error prone.

PCP not told important stuff – i.e. hospital stays, ED visit...

Behavioral health conditions not discovered, not treated.

Gaps in patient/family health knowledge

Big variation in home/family support

Ambiguity over end of life care – family disagreements

And – Primary Care Health Organizations are Complex

There is a continuous flurry of diverse demands facing the staff

AND

There is a Culture – “How we do things around here.” Culture develops through staff interactions and relationships. It is Emergent.

A common aspect of primary care culture – “We are already overloaded and you want to add what?”

BUT - Our Care Model was Simple

Problems Can be Simple, Complicated or Complex AND

“Disasters can occur when complex issues are managed or measured as if they are merely complicated or simple.” *

*Brenda Zimmerman, Getting to Maybe. 2006

Mann Gulch, on the Missouri River

(138 miles east of Missoula, MT)

History of Learning from

Mann Gulch

August 1949 – Mann Gulch Forest Fire

and Disaster

September 1993 – N. Maclean’s book,

Young Men and Fire

December 1994 – Karl Weick’s article,

The Collapse of Sensemaking at Mann

Gulch

December 1999 – Dr. Berwick’s IHI talk,

The Escape Fire.

(and now Don Berwick takes the

lessons from Mann Gulch to CMS)

Some of Weick’s Lessons from Mann Gulch --

Four Sources of Resilience for Organizations ALSO: Required for Medical Homes

1. Improvisation and Bricolage (creating with what you have).

2. Virtual Role Systems (carrying the team’s roles in your head).

3. The attitude of Wisdom - (understand we don’t fully understand what’s happening.)

4. Respectful Interaction – (showing trust, honesty and self-respect.)

Characteristics of Useful Conversations

Listening and Talking

Structure that invites input

Diversity in the group

Learning from stories

Take note of ideas and of action steps

Sources of

Resilience/

Effectiveness

Actions Promoting

Transformation to

Medical Homes at CCHS

Improvisation /

Bricolage

o Staff involved in continuous design of the set of services, the tools, the reporting

and the training.

o Diverse staff members participate in program assessment and planning meetings.

Virtual Roles o New roles are defined by planning groups for MAs/nurses, pharmacist, behavioral

health, care coordinator, patients.

o Medical providers/leaders respect new (expanded) roles.

Attitude of

Wisdom

o Staff determine their gaps in knowledge and skills and help to decide content of

training.

o Regular staff meetings at the clinics to review progress (data) and problems.

o Outside experts invited to give different perspectives.

Respectful

Interaction

o Enlarged the team boundary and created processes for sharing patient care

information among team members.

o Referrals and requests flow back and forth among all team members.

o Leaders model norms of effective communication and cooperation.

o Rules for meetings: Listen and talk; agendas and minutes, everybody invited to

talk/share.

Rather than planning a long series of steps in advance and getting anxious when things start to go off course, we can just plan one step at a time and pause after each

one to notice what’s happened and only then plan the next step. The plan emerges as we go.

Anthony Suchman

Leading Change in Healthcare

When we got going, the conversations

focused on: PORT3 AL

Population (who are we working with)

Objectives (what are our aims)

Relationships (With patients/staff/resources)

Tasks (how do we do it)

Training (how do we do it)

Tools (how do we do it)

Administrative (what support is needed)

Logic (why will it work?)

Developed by C. Robinson, Cabin Creek Health Systems

Senior Medical Home – 2 Populations - Frail Elders = 100

- Risk of Falls and Meet 3 of the 5 criteria

- Low physical activity

- Exhaustion

- Unintentional Weight Loss

- Failed Time Walk Test

- Failed grip strength

- Multiple Chronic Conditions = 540

- Patients with diabetes and at least one other chronic condition

Senior Medical Home - Objectives

Describe the population in terms of health issues and health status.

Patients and caregivers are highly satisfied with their care.

Minimize re-hospitalizations.

Improve adherence to clinical standards for chronic conditions and preventive measures.

Minimize adverse drug events.

Improve the experience for the medical staff.

Who’s on the Team - Relationships Medical Provider

Medical Assistant Administers screenings, tests, and preventive care review

Behavioral Health Consultant Address behavior change issues related to health risks to serious

mental illness, arrange for the next level of care if needed

Care Coordinator Patients main point of contact

Pharmacist Conducts drug utilization reviews for patients at risk for adverse

drug events

Tools Teams create, apply, and redesign the tools. This is

achieved by experience and conversation

The GCT reviews and endorses tools.

The Clinical teams actually apply the tools and give feedback about their usefulness and feasibility

POV and Assessment forms

Electronic Surveys

Patient Registry and templates in the EMR

Computer Notification of Hospitalization –“real time”

Training

Topics covered included:

Common geriatric medical conditions and preventive measures.

Communicating

Medication Review/Falls Prevention

In home risk assessments

Connecting with community resources

Partnered with a local Community College to design a 15

week college credit course

References – Logic Journal Articles

Anderson, R. & McDaniel, R. Managing health care organizations: where professionalism meets

complexity science. Health Care Management Review. 2000; 25(1): 83 – 92.

Boult, C., Counsell, S., Leipzig, R., & Berenson, R. The urgency of preparing primary care physicians

to care for older people with chronic illnesses. Health Affairs. 2010; 29(5): 811 – 818.

Fried, L., Tangen, C., Walston, J., Newman, A., Hirsch, C., Gottdiener, J., Seeman, T., Tracy, R., Kop,

W., Burke, G., & McBurnie, M.A. Frailty in older adults: evidence for a phenotype. Journal of

Gerontology. 2001; 56A(3): M146 – M156.

Jordan, M., Lanham, H., Crabtree, B., Nutting, P., Miller, W., Stange, K. & McDaniel, R. The role of

conversation in health care interventions: enabling sensemaking and learning. Implementation

Science. 2009; 4 (15): 25 – 38.

Lanham, H., McDaniel, R., Crabtree, B., Miller, W., Stange, K., Tallia, A., Nutting, P. How improving

practice relationships among clinicians and non-clinicians can improve quality in primary care. The

Joint Commission Journal on Quality and Patient Safety. 2009; 35(9): 457 – 466.

Nelson, K., Pitaro, M., Tzellas, A., & Lum, A. Transforming the role of medical assistants in chronic

disease management. Health Affairs. 2010; 29(5): 963 – 965.

Nutting, P., Miller, W., Crabtree, B., Jaen, C., Stewart, E., & Stange, K. Initial lessons from the first

national demonstration project on practice transformation to a patient –centered medical home.

Annals of Family Medicine. 2009; 7(3): 254 – 260.

Pham, C. & Dickman, R. Minimizing adverse drug events in older patients. American Academy of

Family Physicians. 2007; 76: 1837 – 1844.

Tallia, A., Lanham, H., McDaniel, R., & Crabtree, B. Seven characteristics of successful work

relationships. Family Practice Management. 2006: 47 – 50.

Parkerson, G., Broadhead, W., & Tse, C. The duke health profile: a 17 – item measure of health and dysfunction. Med Care . 1990; 28(11): 1056 – 1072.

References – Logic Websites The Plexus Institute – http://www.plexusinstitute.org

An organization that is dedicated to fostering the health of individuals, families, communities,

organizations, and our natural environment by helping people use concepts emerging from the new

science of complexity.

The Dartmouth Atlas of Health Care - http://www.dartmouthatlas.org/

The project uses Medicare data to provide information and analysis about national, regional, and local

markets, as well as hospitals and their affiliated physicians.

Books Weick, K. + Sutcliffe,K. (2001). Managing the unexpected: assuring high performance in an age of

complexity. San Francisco, CA: John Wiley & Sons.

ROI for the Health Center

Job enhancement for Medical Assistants. Opportunity for more learning and independence.

Increase job satisfaction for primary care provider.

Builds community support for the health center.

Team members learn a systems approach to understanding problems and solutions – carries over to other problems.

Preparation for Health Reform - Medical Homes and Accountable Care Organizations

The Money is Coming…… Affordable Care Act Initiatives that Provide Resources

for Care Coordination

Accountable Care Organizations

Medicaid Health Home Initiative with enhanced federal match

FQHC Advance Primary Care Demonstration Project

CMS Healthcare Innovation Challenge Programs

Community Care Transition Programs

Closing Conversation

What resources do you have in

place that could be used to improve

the care of your elderly patients?

What can you build upon?

QUESTIONS

Senior Medical Home – Numbers

Currently 640 patients enrolled

Avg age 82, 74% female 87% Diabetic 90% Hypertension 68% Heart Disease 42% Chronic Pain 56% Psychiatric Diagnosis

Drug Utilization Reviews Completed Avg # meds in the

beginning = 10.3 Avg # of meds today = 8.1

263 home visits 3,120 care coordinator

contacts 10 ramps built 84 grab bars installed 30 trips to visit patients in

the hospital Linking patients with

outside resources Educating all about health

care reform

Limiting Our Focus – Frailty Patients identified as frail have a significantly higher

health service and hospital use compared to those adults the same age who are not considered frail.

Presence of three or more of the following components Weight loss

Weakness

Poor endurance and energy

Slowness

Low physical activity

Fried, L., et al. Frailty in older adults: evidence for a phenotype. Journal of

Gerontology. 2001; 56A(3): M146 – M156.

Our Team’s Definition of Frailty Risk of falls – determined by the provider

AND

Patient meets 3 of the 5 following criteria:

Low physical activity

Exhaustion

Unintentional weight loss (≥ 10 pounds in last years)

Failed timed walk test (≥ 7 seconds to walk 15 feet)

Failed grip strength (based on BMI)

Enrolled first frail patient April 2009

Two kinds of Teams—First Team

Geriatric Project Development Team (reps from the 4 clinics):

Providers

Medical Assistants

Pharmacist

AHEC facilitator

Consulting Geriatrician

Care Coordinator

Behavioral Health Consultant

Two kinds of Teams – Second Team Care teams at each of 4 clinic sites.

Composed of those doing the work at each site.

Medical Provider

Medical Assistant (trained in geriatric care)

Care Coordinator (shared)

Pharmacist (shared)

Medical Assistants Tasks

Administer screenings, tests, and preventive care review – at routine PCP visits.

Conducted quarterly home visits – ck risk for falls, med reviews, education

Regular phone call check-ins with enrolled patients.

Made referrals to Care Coord.

Completed notes in the Electronic Health Record

Geriatric Care Coordinator Tasks Develop working relationships with outside

resources.

Telephone resource for care givers – for benefits, legal issues, medications, access to medical care.

Link patients with health center services

Contact hospitalized patients - in person or by phone and arranges follow-up PCP visit.

Enter notes and data in the EMR.

Pharmacist Tasks Review patient medication list against standard criteria:

1. Reviewed accuracy of medication list

2. Beers Criteria: i.e. to identify drugs with potential for adverse outcomes in older patients.

3. Hamdy Review: Still indicated?

Duplication?

Prescribed for adverse reactions?

Is Dosage subtherapeutic or toxic due to age or renal status?

Possible Drug-Drug interactions?

4. Lower Cost options available?

Assessing for Frailty Patient assessed during

regular primary care visit

Duke Health Profile

Vulnerable Elders Survey

Timed walk test

Grip strength assessed with a dynameter

Duke Health Profile Clinically valid instrument Reference values for

primary care patients 66 – 92

User friendly, self administered

Questions relate to events of the past week – easy to remember

Responsive to real change in health related quality of life

Items are generic, not disease specific

Duke Health Profile – Data

Variables Baseline 8 Months CCHS Norm

National Norm

*Physical Health

19.7 26.8 42.5 49.9

**Anxiety-Depression

51.5 61.3 33.8 26.3

*Higher the score the better

**Lower the score the better

73 patients enrolled over 8 months

Average Age = 79.7

80% Female

Average number of medications = 9.1

63% need assistance with ambulation

60% hospitalized or visited the ER in the previous year

17% have had a fall in the previous year

70% depression/anxiety

52% chronic pain

45% diabetes

20% dementia

85% hypertension

Avg # prescriptions = 9.5

TT

Senior Medical Home

Cost Projection

Total project participants= 200

Personnel Costs

Cost

PMPM

Cost

PMPY

Annual

Cost

SMH Care Coordinator $24.00 $288.00 $57,600

Med Assist (service/training) $17.07 $204.78 $40,960

Pharmacist $7.11 $85.33 $17,070

Medical Director - (physician) $3.56 $42.67 $ 8,533

Total Personnel Costs $51.73 $620.78

Other Expenses

Travel $3.33 $40.00 $8,000

Home safety equipment $4.17 $50.00 $10,000

Administrative overhead

20% $10.35 $124.16 $24,831

Total Other Expenses $17.85 $214.16 $42,831

Total All Expenses $69.58 $834.94 $166,988

PMPM PMPY Project

Annual

Utilization Data Primary Care Visits = 4.6 per patient per year

Medical Home Visits = 2.5 per patient per year

Care Coordinator Contacts = 4.7 per patient per year

Hospital Admission Rate = 719 per 1,000 per year

(Compared to 433.5, Medicare rate for our HRR)

NO patients were re-hospitalized within 30 days of discharge

Emergency Room Visit Rate = 68 per 100 per year

Avg # prescription meds = 9.5 at start, 8.5 after 8 months

ROI – Lessons for Change

Step by step. Build on what we did and what we learned.

Stay with it. Keep talking and listening.

Models are helpful but must customize.

Be mindful of everything else going on in the primary care setting.

“Bricolage” – taking advantage of what we had.