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HAWAI‘I ISLAND CARE COORDINATION SERVICES
OUTCOMES REPORT
September 2013
Complex Care Coordination for Private
Practicing Physicians
Executive Summary Enrolled a total of 78 patients of private Primary
Care Physicians (PCPs) Double-digit improvements in health outcomes
including HbA1c, cholesterol, triglycerides, blood pressure and weight
CONCLUSION: Care Coordination WORKS!
Patient Enrollment 78 patients with complex care needs due to
chronic diseases such as diabetes High-cost, high-risk patients identified by PCPs
and Health Plans High use of emergency departments and
inpatient care Average age 69.8 83% overall enrollment rate / 79% completion rate
Physician Participation 29 Physicians Participated
• 13 PCPs in East Hawaii• 16 PCPs in West Hawaii
Physician Role• Active participation in selecting and enrolling their
patients into the program, intro to care coordinator• Availability for care coordinator questions• Longer appointment visits if necessary• Access to PCP records by care coordinator
Care Coordinator Participation
Registered Nurse (RN) assigned to each patient to create a service plan to improve his/her health• Provided education about his/her
complex conditions • Assisted with access to specialists,
keeping track of prescriptions and appointments
• Health Coach provided support to make lifestyle changes
Use of Monitoring Technology 42 patients received, at no charge, use of
Ho‘okele’s iHealthHome® in-home monitoring technology for one year.
Enabled patients to take biometric readings at home for blood pressure, blood sugar and weight, which was submitted to the R.N.
Empowered patients to log their own food, exercise and activities and to communicate with the R.N via video calls.
HICCS HbA1c – 36% Better
IMPROVED HEALTH
Mean
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
Baseline Post Sustained
HbA1C
Baseline 7.80Post 5.04Sustained 4.99 36.0% Pct Improvement
6.63 t-value0.00 p-value
HICCS Ttl Cholesterol – 19% Better
IMPROVED HEALTH
Mean
0.00
20.00
40.00
60.00
80.00
100.00
120.00
140.00
160.00
180.00
Baseline Post Sustained
Total Cholesterol
HICCS LDL – 10% Better
IMPROVED HEALTH
Mean
70.00
72.00
74.00
76.00
78.00
80.00
82.00
84.00
Baseline Post Sustained
LDL Level
HICCS HDL – 13% Better
IMPROVED HEALTH
Mean
36.00
38.00
40.00
42.00
44.00
46.00
48.00
Baseline Post Sustained
HDL Level
HICCS Triglycerides – 37% Better
IMPROVED HEALTH
Mean
0.00
50.00
100.00
150.00
200.00
250.00
Baseline Post Sustained
Triglycerides
Baseline 193.22Post 145.52Sustained 122.00 36.9% Pct Improvement
6.75 t-value0.00 p-value
HICCS Systolic BP – 11% Better
IMPROVED HEALTH
Mean
110.00
115.00
120.00
125.00
130.00
135.00
140.00
Baseline Post Sustained
Systolic BP
HICCS Diastolic BP – 13% Better
IMPROVED HEALTH
Mean
64.00
66.00
68.00
70.00
72.00
74.00
76.00
78.00
80.00
82.00
Baseline Post Sustained
Diastolic BP
HICCS Weight – 9% Better
IMPROVED HEALTH
Mean
165.00
170.00
175.00
180.00
185.00
190.00
195.00
Baseline Post Sustained
Weight
Baseline 190.77Post 185.09Sustained 173.99 8.8% Pct Improvement
2.74 t-value0.00 p-value
IP Admits – 29% Reduction
IMPROVED HEALTH
ER Visits – 25% Reduction
IMPROVED HEALTH
Physicians See Changes
Patients who were calling or coming in to the office frequently were able to reduce their visits to
every 3-4 months.
PERSPECTIVES
“ “
Patients Feel the Difference
“It seems that healthcare is a pile of jigsaw pieces My care navigator helped to show me how the pieces fit
into a map of health. It helped to prioritize these, that allows my family and I to make better choices for me.
87% of patients agree that My RN Navigator helped me to better
understand my medical condition and what I needed to do to take care of myself.
““ “
PERSPECTIVES
MAHALOMAHALODew-Anne Langcaon, Ho‘okele Health Innovations
Ken Ono, West Hawai‘i Home Health [email protected]
Susan Hunt, Hawai‘i Island Beacon [email protected]
