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UPMC Health Plan Partners in Excellence ™ Patient-Centered Medical Home: An Integrated Approach with Results. Cynthia Napier Rosenberg, M.D. Senior Medical Director Network Management and Provider Relations UPMC Health Plan. Three Things. Who we are UPMC Health Plan - PowerPoint PPT Presentation
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UPMC Health PlanPartners in Excellence™
Patient-Centered Medical Home: An Integrated Approach with Results
Cynthia Napier Rosenberg, M.D.Senior Medical Director
Network Management and Provider RelationsUPMC Health Plan
Three Things Who we are
UPMC Health Plan Patient-Centered Medical Home Initiative:
Overview
Results Quality Cost Satisfaction
How we got there What Matters Access2 Copying, citing, quoting, or distributing without written permission of UPMC Health Plan is prohibited.
Where We Are
3 Copying, citing, quoting, or distributing without written permission of UPMC Health Plan is prohibited.
Who We AreUPMC
Hospital and Community
ServicesPhysician Services
Insurance Services
International and Commercial
Services
4 Copying, citing, quoting, or distributing without written permission of UPMC Health Plan is prohibited.
Network Map
Copying, citing, quoting, or distributing without written permission of UPMC Health Plan is prohibited.5
UPMC Health Plan Overview More than 1.4 million members Integrated products, including:
Group Health Commercial Medicare (including SNP) Medicaid CHIP Wellness only Community Care
Employee Assistance Program (EAP) Claims Management Services
Workers’ Compensation Short-term Disability
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Integrated Care and Business Solutions
MyHealthLifestyleWellness
Askesis
UPMC Insurance Services Division
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UPMC Health PlanPatient-Centered Medical Home
Overview Made a strategic decision to organize
entire network operations and approach around principles of Patient-Centered Medical Home (PCMH)
Met with over 450 primary care practices serving adult members to assess each practice based on PCMH principles
Engaged a pilot group of four practices (approximately 8,300 members and 20 physicians) to work on an intensive, integrated PCMH approach.
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Spring, 2008 - Present Phase I PCMH
Six practice sites with 8300 members Phase II PCMH
Six additional practice sites with 14,600 members Phase III PCMH
105 additional practice sites with 62,000 members
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Spring, 2008 - Present
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Results: Quality Partners in Excellence: PCMH Phase 1
Other Network
Baseline Year 1 % ∆ Baseline Year 1 % ∆
Diabetes Denominator 877 796 -9.2% 9875 10,942 6.2%
LDL Test 49.9% 70.4% 40.9% 42.3% 46.9% 10.9%
A1C 79.7% 84.9% 6.6% 78.7% 79.3% 0.8%
Nephropathy 73.2% 82.5% 12.8% 76.0% 75.4% -0.7%
Eye Exam 75.6% 80.2% 6.0% 69.8% 71.7% 2.7%
Diabetes Completeness
33.2% 58.8% 77.2% 26.5% 30.3% 14.1%** NOTE: Baseline date is 6/2008. Year One date is 6/2009
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Results: Cost
Time Period Total Med and Pharm
Pharmacy Total
Total Medical
All Other Medical
Partners in Excellence: PCMH Phase 1
5.73% 7.60% 5.24% 0.53%
Other Network 9.83% 9.41% 9.93% 8.58%
Pre-Post Comparison (Baseline Year to Year One)
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Results: Efficiencies (Cost meets Quality) Middle-aged male with multiple chronic medical
conditions, including Diabetes, CAD, CHF, HTN, Peptic Ulcer Disease, Stroke, BPH, Urinary Retention, Neurogenic Bladder, Liver Disease, Hyperlipidemia, Sleep Apnea
Seven admissions in seven months ($30,000.00) PCMH Care Manager met with member, facilitated
appointments for durable medical equipment and home health services, engages mobile outreach representative, maintained frequent telephone contact with home health services and with member
No hospitalizations or ED visits in following two months Member compliant with outpatient office visits and
medications
Results: Satisfaction Physician
Independent and employed physicians, University of Pittsburgh School of Medicine faculty, residents
Over 80% would personally recommend program to another physician
Member Testimonials Member with newly-diagnosed symptomatic
hypertension. Placed on medication by PCMH physician.
Educational materials, contacted by PCMH office-based care manager. Follow-up both by phone and in-person over next several months.
“I would encourage anyone with health concerns to take advantage of the programs the Health Plan offers. The services are priceless.”
How We Got There Culture Change within and without organization:
An Integrated Systemic Payer-Provider Team Approach
Clear Mission: Work in an Integrated Fashion to put the tools and services of the Health Plan in the hands of the PCMH Provider
Expectation: Payer-Provider Team (two-way street)
Clear Goals: To Improve Health care, enhance patient and provider satisfaction, and control cost
Leadership Engagement of Everyone Involved in the
Program Engagement of Physician Community
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ACCESSRole of UPMC Health Plan: Supportive Services, Data,
Infrastructure
Infrastructure Lining up Health Plan Functions and Services
with the Practice
Placing the Tools and Services of the Health Plan in the Hands of the Provider
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Process Improvement
Sunday Monday Tuesday Wednesday Thursday Friday Saturday0
10
20
30
40
50
3436
33
25 24
35
49
Practice Site “R”: ED Visits by Day of the Week
Sept 2008 - Mar 2009 (n = 236)Data Source: EDW
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Process Improvement
1 am - 6 am 7 am - 11 am 12 noon - 3 pm 4 pm - 7 pm 8 pm - 12 mn0%
10%
20%
30%
8.9%
22.9%25.8%
23.3%
19.1%
Practice Site “R”: ED Visits by Time of DaySept 2008 - Mar 2009 (n = 236)
Data Source: EDW72% of ED Visits oc-
cur 7am - 7 pm
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Process Improvement
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Process Improvement
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Access E-visits
Acute Chronic
Remote Monitoring Interdisciplinary Team Meeting Supportive Services Transition Services Mobile Community-based Care Managers Pharmacy Consultation Behavioral Health Consultation Physician Rx for Lifestyle Health
Coaching
Hospita
l Admiss
ions
Readmiss
ions w
ithin
7 day
s
Readm
ission
s with
in 30
days
Readmiss
ions w
ithin
60 day
s
ED visit
s0
0.2
0.4
0.6
0.8
1
1.2
1.4
0.36
0.04000000000000010.14
0.25
1.07
0.190000000000001
0 0.05000000000000010.0800000000000002
1.33
Before Monitor Placement After Monitor Placement
*Readmissions within 60 days*
Adm
issi
ons/
Vis
its P
er M
onth
* Denote a statistically significant difference
Results: Admissions and ED Utilization Per Month Before and After Monitor Placement
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Conclusions: What Matters Culture Strategy Leadership Team Management Delivery Results
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