Beyond PCMH Walls : Wedding Community-based, High-Utilizer approaches to Integrated Primary Care Macaran A. Baird, MD, MS Barry J. Jacobs, Psy.D. Collaborative.

Beyond PCMH Walls: Wedding Community-based, High-Utilizer approaches to

Integrated Primary Care

Macaran A. Baird, MD, MS

Barry J. Jacobs, Psy.D.

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session # D5b in Period 5October 17, 2015

Faculty Disclosure

The presenters of this session

• currently have the following relevant financial relationships (in any amount) during the past 12 months:

• 20% of Barry Jacobs’ salary is covered by a proof-of-concept grant from Independence Blue Cross of Philadelphia for his work on the Crozer-IBC Medicare Advantage Super-Utilizer Program

Learning Objectives

At the conclusion of this session, the participant will be able to:

• 1. Describe the 3 major shifts required to get past habits of thinking of the PCMH as a location

• 2. Describe actions and options already being implemented outside the walls of the PCMH for the “high-utilizer” population.

• 3. Reflect on what it takes to restore a sense of satisfaction and professionalism in working with complex, high-utilizing portion of our primary care population—and in teaching young clinicians to value this as part of their jobs.

Bibliography / References--Baird MA. (2014). Primary Care in the Age of Reform – Not a Time for Complacency. Family Medicine, 46(1)7-10.

--Baird M, Peek CJ, Gunn W & Valeras A. (2013). Approaches to complexity care. Chapter in The Landscape of Collaborative Healthcare: Evaluating the Evidence, Identifying the Essentials. M Talen & AB Valeras (Eds), Springer Science & Business Media

--Coburn, K. et al. (2012). Effects of a community-based nursing intervention on chronically ill older adults: a randomized control trial. PLoS Medicine , 9(7)

--Gawande, A. (2011). The hot-spotters—can we lower medical costs by give the neediest patients better care?, The New Yorker, January 24.

--Pratt R, Hibberd C, Cameron IM, Maxwell M. The Patient Centered Assessment Method (PCAM): integrating the social dimensions of health into primary care. Journal of Comorbidity. 2015;5:110-119.

--”Working with the Super-Utilizer Population: The Experience and Recommendations of Five Pennsylvania Programs,” 2015, available at http://www.aligning4healthpa.org/pdf/High_Utilizer_Report.pdf

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Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

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Goals

1. Review why clinical care systems are concerned about a small group of very complex patients who fail to improve.

2. Understand what we can do to help these patients more effectively?

3. Learn from current clinics designed specifically for “High-Utilizer” patients

Why Transform?

• New delivery/payment systems

• Population health• Capacity (team-based

care)• Triple Aim (Quad Aim)

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The market for medical services is shifting

• Clinical practices are becoming responsible for reaching the “Triple Aim” & must achieve a 4th “Quadruple Aim”-an improved clinical team experience

• “Total cost of care” savings depend upon reaching those who use many resources, or “high utilizer” / “Priority Patients”

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The fulcrum is moving

Your leverage and net value to the system is larger through managing a panel

If you don’t address the expense and misery accompanying patient complexity, someone else will.

Fee for service

Total cost of care contracts

Bundled care mgmt fees

Pay for performance

Global budgets

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Avoiding complacency with PCMH: 4 steps

• Improve assessment & interventions for social and health system complexity

• Regard primary care as a way of operating, not as a geographic place

• Incorporate/integrate with “hot spotters” and other mobile providers

• Improve leadership competence– Baird, Family Medicine, 2013.

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Who becomes a “high utilizer” and therefore, a “high priority” patient?

Whom do we see most often but not really help?

Do some just demonstrate the “reversion to the mean” concept?

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High-Priority patients?

• Comprise from 1% – 3% of most primary care populations

• May use 10-20% of population budget• Usually have complex medical, psycho-

social and behavioral health problems• Often fail to respond to routine care plans

delivered within clinics & hospitals• Some improve and become near normal

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What types of issues do High Utilizer patients face?

• Serious medical and end-of-life illness• Acute injuries and serious illnesses from

which they will eventually recover• Co-morbid and entangled medical and

psychiatric problems• Medically unexplained symptoms (MUS)• Social determinants of health- barriers

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Alternative definitions• Clinician reaction: “difficult,” “not responsive,” “I don’t

have anything else to offer”

• Patterns of healthcare use: Overuse, misuse, cost, ineffective use – “high utilizer,” abusing the system

• Mental health: Distress vs. disease; code-able vs. meaningful diagnoses

Cumulative complexity: Imbalance between patient workload and patient capacity (Schipee et al, 2012)• Workload: All everyday tasks plus demands of patient-hood• Capacity: All abilities, resources, readiness to address demands—physical,

mental, socioeconomic, support, literacy, attitudes, beliefs

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Commonplace “wishful thinking” in the face of unnamed and unmanaged complexity

Clinician Payer / health plan?Maybe the next dxThe next consultant Maybe a different provider group?

The next test or scanThe next medication / txA new Dr. (better than me) Remote disease management ?

Maybe P.T. or otherMental Health (if all else fails)

Maybe they will N.S.

(Your own wish here)

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Two Axes of Patient Complexity

Medical Complexity• How many diseases• How chronic• How severe• How challenging

Social or Care Complexity: Interference with usual care and decision-making

Definitional: Co-morbidity vs. interference with care

• Distress and distraction• Lack of social safety and support• Disorganization of care• Lack of resources for care

Part II: Complex patients -risk becoming high utilizers?

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Medical Complexity

Social / Care Complexity

Axes of patient complexityHypothesis: Total care challenge = size of shaded area

Patient A•High medical complexity •Low social/care complexity

Patient B•Low medical complexity •High social/care complexity

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Medical Complexity

Social or Care Complexity

Patient C•High medical complexity •High social/care complexity

Total care challenge = size of shaded area

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Complexity: A Property of what exactly?

A property of….. • ….The patient as a person or partner in care?

(patient complexity)• ….The patient’s diagnoses?

(medical complexity)• ….The patient’s situation?

(social complexity)• ….The organization of care and team? (care

complexity)Most or all of these?

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Complex patients need….

• Clinician and system willingness to accept social and care complexity as part of the job—a culture shift

• Respectful clinicians & teams using a systematic and non-pejorative vocabulary for “complexity”

• Care plans connecting the dots among relevant “outside” factors—that often lead outside the clinic

• Acceptance that “non-adherence” may be more a property of the intervention than of the patient

Part III: What do they need?

Example: Tool with questionsPatient-Centered Assessment Method (PCAM)

1. Health and well-being• Physical symptoms to investigate further?• Physical symptoms affecting mental well-being?• Lifestyle affecting physical or mental well-being?• Other concerns about mental well-being?

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Maxwell, Hibberd, Pratt, Mercer, & Cameron (2013); Scotlandwww.pcamonline.org

3. Health literacy & communication• Present understanding of health & well-being?• Capability to engage in discussions regarding health and care?

2. Social environment• Home safety & stability?• Daily activities & well-being?• Participation in social network?• Financial resources?

4. Service coordination• Other services needed?• Are services well coordinated?

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The product is action: In common across 3 complexity checklists:

Any question that lights up requires action within the care plan (not just a threshold sum across questions)

MCAM: Peek, Baird, & Coleman (2009)PCAM: Maxwell, Hibberd, Mercer, & Cameron (2013--Scotland)INTERMED: deJong, Huyse, & Stiefel (2006-The Netherlands)

Choose level of action needed on complexity:• Routine care (little or no complexity detected)• Active monitoring (potentially need to act on complexity) • Plan action for complexity (commence planning) • Act immediately (urgent action on complexity is needed today)

Plan of action—written & shared by team in record:• Goals for care–both medical and social complexity• Specific actions to accomplish goals—who does what (incl pt. and family)• What the clinician / team will do today—how urgent such action is

Complexity items & action areasItem Action areas

Impairment--sx severity Mitigate functional limitations; self-regulation

Diagnostic uncertainty

Review, 2nd opinion, find out patient’s theory, motivational interviewing, build trust

Distress & distraction Identify & help mitigate social / personal stress with peer support, groups, self-care

Social isolation, risk Build social connections and safety, connect with social services

Disorganization of care

Clarify roles & plan, engage patient, build trust

No common language Professional interpreters, cultural bridging

Un- or under-insured Financial counseling, seek public health plan

Adapted from Peek, Baird, & Coleman, 2009

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Medical Complexity (MN HCH tiers*)• How many conditions in what dx groups?• Chronic?• How severe?• If chronic & severe—need a major team?

Social or Care Complexity: Interference

• Distress and distraction• Lack of social safety and support• Disorganization of care• Lack of resources for care

Example: Care coordinator assessing medical and care complexity in a MN Health Care Home

*Based on MN Health Care Home complexity tiering V. 1.0

www.health.state.mn.us/healthreform/homes/payment/HCHComplexityTierTool_March2010.pdf

Coordinated plan—who does what

• Findings and goals on each axis

• What matters to pt & family

• Team roles, incl patient / family

• What level of urgency to act

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New methods of approaching High Priority patients

• Assess for social and behavioral complexity• Reach out beyond the clinic with specific

staff- “Hot Spotters” • Connect to other community resources• Continue to survey patients in clinic for

becoming “high-utilizers” and engage them with the new outreach efforts

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References• Baird MA. Primary Care in the Age of Reform – Not a Time for Complacency. Family Medicine.

2014;46(1)7-10.• Baird M, Peek CJ, Gunn W & Valeras A. (2013). Approaches to complexity care. Chapter in The

Landscape of Collaborative Healthcare: Evaluating the Evidence, Identifying the Essentials. M Talen & AB Valeras (Eds), Springer Science & Business Media.

• Browning D. Listening to elderly cuts use of costly medications. Star Tribune. Dec 20, 2013.• Brownlee S. Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer, New York:

Bloomsbury USA 2007.• de Jonge, P., Huyse, F., & Stiefel, F. (2006). Case and care complexity in the medically ill.

Medical Clinics of North America, Volume 90, #4. Elsevier• Horwitz AV, Wakefield JC. The loss of sadness: how psychiatry transformed normal sorrow

into depressive disorder. New York, Oxford University Press, 2007.• Kuehn BM. Health Reform, Research Pave Way for Collaborative Care for Mental Illness.

JAMA. 2013; 309(23):2425-2426.• Kuehn BM. Studies shed light on risks and trends in pediatric antipsychotic prescribing. JAMA.

2009; 303:1901-1903.• Maxwell M, Hibberd C, Pratt R, Cameron I, Mercer S. (2011). Development and initial

validation of the Minnesota Edinburgh Complexity Assessment Method (MECAM) for use within the Keep Well Health Check. Scotland National Health Service. Available at: www.pcamonline.org

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References (con’t)• Peek, CJ. (2010). Building the medical home around the patient: What does it mean for behavior?

Families, Systems and Health Vol. 28, No. 4, 322-333• Peek CJ, Baird MA & Coleman E. Primary Care for Patient Complexity, not only disease. Families,

Systems, & Health, Dec 2009• Peek, CJ. (2008). Integrating care for persons, not only diseases. Journal of Clinical Psychology in

Medical Settings. Vol 16, No. 1. Springer, New York.• Peek CJ, and Heinrich RL (1995) Building a collaborative healthcare organization: From idea to

invention to innovation. Family Systems Medicine, Vol. 13, No. 3/4, pp. 327-342.• Pratt R, Hibberd C, Cameron IM, Maxwell M. The Patient Centered Assessment Method (PCAM):

integrating the social dimensions of health into primary care. Journal of Comorbidity. 2015;5:110-119.

• Rasmussen NH1, Furst JW, Swenson-Dravis DM, Agerter DC, Smith AJ, Baird MA, Cha SS. Innovative reflecting interview: effect on high-utilizing patients with medically unexplained symptoms. Disease Management. 2006 Dec;9(6):349-59

• Salazar-Fraile J et al. “Doctor, I just can’t go on.’ Cultural constructions of depression and the prescription of antidepressants to users who are not clinically depressed. International Journal of Mental Health, 2010, 39:29-67.

• Schwarz A. Report Says Medication Use Is Rising for Adults With Attention Disorder. New York Times. March 12, 2014.

References (con’t)• Singer N. Selling That New-Man Feeling. New York Times. November 23, 2013.• Stipp D. Trouble in Prozac Nation. Fortune. November 28, 2005.• Tracy L. Johnson, Deborah J. Rinehart, Josh Durfee, Daniel Brewer, Holly Batal, Joshua Blum,

Carlos I. Oronce, Paul Melinkovich and Patricia Gabow. For Many Patients Who Use Large Amounts Of Health Care Services, The Need Is Intense Yet Temporary. Health Affairs. Aug 2015; No. 8: Tracy L. Johnson, Deborah J. Rinehart, Josh Durfee, Daniel Brewer, Holly Batal, Joshua Blum, Carlos I. Oronce, Paul Melinkovich and Patricia Gabow. For Many Patients Who Use Large Amounts Of Health Care Services, The Need Is Intense Yet Temporary. Health Affairs. Aug 2015; No. 8: 1312-1319.

• Tiefer L and Witczak K. A call to challenge the “Selling of Sickness.” BMJ 2013:346-12809.• Watters E. The Americanization of mental illness. New York Times. January 8, 2010.• Weiss, K. (2007); Managing Complexity in Chronic Care: An overview of the VA State-of-the-Art

Conference, GJIM 22 (Suppl 3): 374-8, 12/07

Extending Beyond PCMH Walls

• There are many examples of interventions for high-complexity patients, including telephonic case management

• But high-complexity pts require more intensive interventions and, what Dr. Baird has termed, “mobile health teams”

• “Super-Utilizer” care, originally developed by Jeff Brenner, MD

Who is Jeff Brenner, MD?

• Frustrated family MD• Closed solo practice in Camden, NJ • Began looking at data about city’s healthcare trends

Brenner (cont.)

• Formed Camden Coalition of Healthcare Providers in 2002

• Developed Camden Healthcare Database• Formed relationships with outpatient and

inpatient providers, as well as social service agencies, throughout city and state

• Promulgated “hot-spotting” or “super-utilizer” model of collaborative intervention

Key SU Components

• Continuous, real-time utilization data across health systems to identify high-utilizers

• Assessment procedures and outcome measures• Intensive, community-based care coordination (as

overlay to PCMH), conducted by interprofessional teams (nurses, social services, community health workers)

• Home visits; medical visit accompaniments• Relationship-based, trauma-informed care

Crozer-Keystone SU Program

• Part of 5-hospital system in Philly suburb

• 10-10-10 family medicine residency

• PCMH III (since 2009)• Launched first SU pilot

in 2011• Started Crozer-Camden

Super-Utilizer Fellowship in 2012

Initial PCMH-Based SU Program

• 14 hospital- and ER-SU pts from our PCMH practice

• Dxs: CHF, CVA, anxiety, SA• Close coordination between

primary physician and SU team (fellow, psychology, pharmacy, social work, volunteer)

• Spectacular successes and failures

• Overall decreased costs

A Frail Elderly SU Program

• In spring of 2013, the SU team at the Crozer-Keystone Family Medicine Residency Program was approached by a physician executive at Independence Blue Cross, the largest Philadelphia area insurer, to create a proof of concept SU intensive care coordination program for 10 IBC Medicare Advantage patients with PCPs in the Crozer Keystone Health System

• Launched January 2014; renewed for 2nd year

• As of 8/15, team saw 20 patients; avg age=80

• Dxs: CHF, COPD, DM, dementia

• 50% decrease in inpt admissions, 80% decrease in OBS

Crozer-IBC Model

• Based on work of Drs. Ken Coburn (“warm spotting”; nurse as point person), Dave Moen (home visit), and Dan Hoefer (palliative care)

• Hired nurse case manager as point person—weekly home visits, medical accompaniment, family meetings

• Interprofessional team of advisors/interveners—family medicine, psychology, social work, pharmacy, volunteer

• Weekly huddles; EMR

Camden-inspired SU vs. Elderly SU

• Greater numbers of chronic medical morbidities (e.g., CHF, COPD)

• Fewer social problems; many behavioral problems

• Patients more dependent on family and community services; creates greater need for intervening with family caregivers, local agencies

• More frequent involvement with PCPs

Carmella, IBC PT• 89 year old widow who

lives in a multi-generational rowhome.

• Co-morbidities include: DM, CHF, HTN, CAD, Obesity, Peripheral Neuropathy & edema

• Chaotic home environment; boisterous Italian-American family

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LOS

9/4/13 11/4/13 1/4/14 3/4/14 5/4/14

Baseline utilization x 6 mos for CO

INPT

OBS

ER

Engagement

10/4/13 – Admitted for bilateral lower extremities cellulitis 11/20/13 – ER for Edema 11/24/13 – OBS for arm cellulitis 1/7/14 - Admitted pneumonia and CHF 2/5/14 – Admitted for change in mental status/Anemia/UTI Enrolled in Crozer Connections to Health Team program 2/12/14

Challenges

• Busy household with diffusion of responsibility among family members for C’s healthcare

• C’s insisted on sleeping in recliner in living room that didn’t recline because she was afraid to be alone (unsure of her place in afterlife); chronic leg edema, cellulitis, UTIs

• C defied children by going up and down rowhome steps on her own to sit on patio; falls risk

Interventions

• Weekly RN visits (and frequent phone calls with family members)

• Weekly Psy.D. student behavioral health visits• Coordination of home PCP visit (through residency

program) and home lab draw• Home medication reconciliation• RN accompaniment to medical visits• Team worked toward decreased family caregiver

burden/increased family organization

Outcomes

• Since 2/14, only 1 hospitalization for possible CVA (later diagnosed Bell’s Palsy)

• More frequently sleeps upstairs• Decreased edema• Decreased blood sugars• Ongoing psychological and spiritual counseling

still addressing fear to change sleep behaviors• Family better coordinated and hopeful

Outcome Studies

• South Central Pennsylvania High-Utilizer Learning Collaborative (Crozer-Keystone, Lancaster, Neighborhood Health Centers of the Lehigh Valley, Pinnacle, WellSpan):

• 2012-14: 446 pts, 21% decrease in ER admits; 52% decrease in hospital admits; 63% decrease in patient-days in hospital

• Camden: In midst of RCT of 800 pts (run by MIT’s Poverty Action Lab); results due 2017

Final Comments

• In conversations with Marci Nielsen, director of the Patient Centered Primary Care Collaborative at last year’s CFHA conference, she said SU programs as part of the PCMH

• Not a question of either/or• Mobile health teams extend the PCMH’s reach

and lower overall utilization and costs

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