Health Integration Project: Emergency Department Navigation Presented by Robin Henderson, PsyD Interim Executive Director, Central Oregon Health Council

Health Integration Project: Emergency Department

NavigationPresented by Robin Henderson, PsyDInterim Executive Director, Central Oregon Health CouncilSt Charles Health SystemSeptember 24, 2012

Presented at WSHA Safe Table – ER is for Emergencies

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Why Transform?

Unsustainable:• Health care costs are increasingly unaffordable to

individuals, businesses, the state and local governments

• Inefficient healthcare systems bring unnecessary costs to taxpayers

• When budgets are cut, services are slashed• Dollars from education, children’s services, public

safety• 2014: as many as 200,000 Oregonians will be added to

OHP

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Game is riggedWe haven’t been doing anything to solve the problem of rising costs because we were dealing with 10% of the pie

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Oregon’s Health Care Reform

• During 2011 and 2012 legislative session Governor Kitzhaber and bi-partisan lawmakers passed landmark legislation for healthcare reform

• 200 people met in Governor appointed work groups to help create the framework for CCOs

• More than 1,200 Oregonians provided input through eight community meetings that were held around the state

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The road to health care reform

• SB 1580 became law in 2012, laying the foundation for CCO development with aggressive timelines

• $1.9 billion in Federal funds over 5 years to support healthcare transformation efforts

• Agreement with federal government to reduce projected state and federal Medicaid spending by $11 billion over 10 years

• Oregon will lower the cost curve by two percent over the next two years


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CCO Definition

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Vision of Coordinated Care

Local accountability for health and resource

allocation

Standards for safe and effective care

Global budget indexed to sustainable growth

Integration and coordination of

benefits and services

Improved outcomes

Reduced costs

Healthier population

Redesigned delivery system

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Oregon Health Plan

50% of babies born in Oregon

16% of Oregonians

85% of providers

11% percent of total state budget

Fastest growing portion of state budget

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Who is Impacted in Central Oregon?

• 35,000 Medicaid (Oregon Health Plan) beneficiaries in Deschutes, Jefferson, Crook, and part of Northern Klamath and Lake counties, predicted to grow to 52,000 by 2019• 150 miles north to south

• 200,000 residents, expected to grow to 250,000 by 2019• Approximately $120m coming into the community• Oregon Health Plan (Medicaid) beneficiaries only, in 2012• Inclusion of additional State sponsored health benefits programs

in the future (Public employees)• Potential implications on non-Medicaid lines of business in

Central Oregon

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Improved Population HealthImproved Consumer Satisfaction

Shared Savings$

Resource Integration & Conservation

Care Coordination

Regional Health Policy

&Planning

Transforming Health in

Central Oregon

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Central Oregon Health Council

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VISION

STRATEGY

Resources

INITIATIVES

Care Coordinati

on

• PCMH• ED Diversion• BHC’s• PEDAL/NICU

Regional Health

• Fiscal Integration• Regional Health

Improvement Plan• Shared Savings $

TripleAim

• CO Health Council

• CO Health Board

• Advisory Committee

• Coordinated Care Organization


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Search for the low hanging fruit…

…and make a pie


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Distribution of Non-MH Claims Paid

Inpatient Hospi-tal

27%

Outpatient Hospital

22%

Physician29%

Other7%

Pharmacy16%


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Claims Distribution by Member

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Presented at WSHA Safe Table ER is for Emergencies 15

• Project focused on reducing non-emergent use of the Emergency Department in regional Emergency Department’s using Health Engagement Teams, Behavioral Health Consultants and Community Health Workers

• 274 Patients in the first cohort; over 600 identified participants to date

• 144 of these are actively identified needing intervention• Patients removed from study due to

• Death• Relocation (moved, jail, etc.)• Data issues from the original pull

Reduction of Non-Emergent ED Usage


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• Thirteen or more emergency department visits/year

•Diagnostic cluster one or more of the following:• Mental Health Diagnosis• Chronic Pain• Addiction

• Initial assumptions:• Primarily Indigent: WRONG• Lack of Primary Care Home: WRONG• Primarily Chronic Mental Health: WRONG

Who is This Population?


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• Primarily Medicaid recipients• Always enrolled in Primary Care Home

• Did not know who PCP was• Kicked out of Primary Care Home due to missed

appointments or other behavioral issues• Rarely engaged with mental health services• Complex social health issues• Often clusters of familial or socially related

individuals• Eager to engage in care

Who They Really Were?


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“Ashley” is a 34 year-old divorced mother of two enrolled in Medicaid and prescribed medication for an anxiety disorder and chronic pain due to a previous on the job injury.

Meet Ashley.


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Ashley Attempts to Negotiate the Barriers of Her Primary Care Community.

Ashley’s immediate needs are met: short-term pain and anxiety medication prescriptions

She’s referred to Community Mental Health for her anxiety disorder but she’s not acute enough to qualify for county services

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3

Ashley doesn't have access to a primary care provider so she goes to the ER when she has health needs.


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Health Engagement Team

Person

HET

Plan

CHWPCP

BHC

Health Engagement Team includes ED physician, RN Care

Manager, Social Worker, BHC and

CHW

Individualized community wide treatment plans are developed by the HET in consultation with the person, the provider and any specialty services

Community Health Workers are usually the

first contact with the person and meet with

them to present the plan

Contact is made with the primary care provider. If

none exists, Pathway established to connect to

a Person-Centered Primary Care Home.

Behavioral Health Consultants are

psychologists integrated in primary

care clinics who specialize in brief

interventional treatment.


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• Primary Focus: the 90%• Social Disparities of Health

• Poverty• Food insufficiency• Transportation

• Healthcare Navigators• Walk alongside the patient

• Based in ER and in PCPCH• Voluntary program

• Under Supervision of RN Care Coordinator or Behavioral Health Consultant

Community Health Workers


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• Psychologists work with medical providers in shared system• Focus on behavioral interventions for medical

conditions

• Always available for consultation and interventions with patients• Primarily unscheduled• Some targeted appointments

• One integrated treatment plan covers full spectrum of patient’s needs

• Shared medical record

Behavioral Health Consultants


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• Medically Unexplained Physical Symptoms• Cyclical Vomiting

• Plan of Care Attached to ED Record• Interventions• Plan for Discharge

• Behavioral Health Plan• Plan for care from Community Mental Health

• Children• Elders

• Increased Provider satisfaction

Primary Care Practitioners


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• Medication Seeking Behaviors• Regional Pain Contract• Pain School to obtain medication

• Chronic Mental Health Conditions• Alternative plan with Community Mental Health

• Illegal Behavior• Seeking drugs for others

• Generational• ED as Primary Care

• Urgent Care intervention

Decline to Participate


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Total (144) PCS (83) PCS/Self Pay (18) Self Pay (18)0

200

400

600

800

1000

1200

1094

582

140170

553

296

92 80

Emergency Department VisitsQ1 Q2 2010 vs 2011

49%

49%

34%54%

541visits


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PCS ED SCHS ED ED Pro Fees TOTAL $-

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

54 % 49%77 %

62%

Average Cost/Patient Medicaid and Medi/Medi Q1 Q2 2010 vs 2011

Presented at WSHA Safe Table ER is for Emergencies 27

Qtr. 1, 2010

Qtr. 2, 2010

Qtr. 3, 2010

Qtr. 4, 2010

Qtr. 1, 2011

Qtr. 2, 2011

Qtr. 3, 2011

Qtr. 4, 2011

ED Vis-its

598 496 460 372 276 277 244 210

50

150

250

350

450

550

650

598

460

276210

ED V

isits

65%Reduction in visits per person

Emergency Department Visits Per Quarter 2010-2011


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Qtr. 1, 2010 Qtr. 2, 2010 Qtr. 3, 2010 Qtr. 4, 2010 Qtr. 1, 2011 Qtr. 2, 2011 Qtr. 3, 2011 Qtr. 4, 2011

$-

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

$350,000

$400,000

$253,679

$72,404

$362,399

$103,434

Reimbursement Loss Total Cost

71%

Cost Avoidance

Reduction in Emergency Department Costs (excluding ancillaries)


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Shared Savings

100 people

$200,000 investment

$325,000 RETURN


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ED Diversion: Cohort #2 Visits (205 patients)

QT 3 2010 QT 4 2010 QT 1 2011 QT 2 20110

200

400

600

800

1000

1200

1130 1084

329203


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Cohort #1 (144 patients): Behavior is cyclicalOutliers are normal and need different interventionsSavings are difficult to quantifyWhat constitutes a cohort?

Cohort #2 (205 patients):Better initial intervention

Cohort #3 (195 patients):Strategies for other hospitals within the region

ED Diversion: Lessons Learned


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Complex Persons across the Lifespan

Birth/Early Childhood

•Early Childhood/ Nurse Family Partnership

•NICU Clinic/ CaCoon RN

•PEDAL Clinic

Complex Care

Strategies•ED Navigation PCPCH Focus

•Complex Care Center

•Severely and Persistently Mentally Ill

Aging and End of Life

•Long Term Care/Care Transitions

•Advanced Illness Management

Community Wide Plan of Care

HIT--Clara

Health Engagement Team

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Presented at WSHA Safe Table – ER is for Emergencies 33

Complex Care: the 12% of patients who are 72% of cost

Complex Care Center Development Continuation of the Emergency Department Navigation Project Develop and Implement Comprehensive Hospital Discharge

Follow-up Program Develop and Implement a Comprehensive Chronic Pain Program Expansion/Integration of Integrated Care Management & Health

Engagement Teams Expand RN Care Coordination with High Utilizers and Physician

Directed/At-Risk Patients

Year One Strategic Initiatives*

*Initiatives in dark teal are existing projects. Light blue are new/expanding.

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Integration of Behavioral Health and Physical Health: Psychopharmacology Utilization Initiative

Modification of OAR requirements to increase access to care Expansion of Integrated Behavioral Health Consultants in Primary

Care including Pediatrics

Pediatrics: Largest Service Population Program for the Evaluation of Development and Learning Neonatal Intensive Care Unit Follow Up clinic Expansion of Title V $$ to all Children with Special

Healthcare Needs (enabling increased care coordination and support services)

Year One Strategic Initiatives, Cont.


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Synergy and Systems: Global Strategies for the Community Maintain Policy and Planning Objectives

One four-year Regional Health Improvement Plan One ongoing Regional Community Health Needs Assessment Healthy Communities Institute website

Timely information for care coordination, patient care and outcomes measurement with a pilot project goal

Expansion of Health Information Exchange Database/Communication Solution for Social Health needs

Aligned Payment Reform Global Budget Initiatives

Year One Strategic Initiatives, Cont.


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Never doubt that a small group of thoughtful people

can change the world. Indeed, it's the only thing that ever has.—Margaret Mead


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Central Oregon Health Council

www.cohealthcouncil.org

www.stcharleshealthcare.org


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http://www.cohealthcouncil.org/

http://www.stcharleshealthcare.org/

Documents

Health Integration Project: Emergency Department Navigation Presented by Robin Henderson, PsyD Interim Executive Director, Central Oregon Health Council