St. Johns River Rural Health Network Serving: Baker Bradford Clay Nassau Union Serving: Comprehensive Diabetes Management and Education Program.

St. Johns RiverSt. Johns RiverRural Health NetworkRural Health Network

St. Johns RiverSt. Johns RiverRural Health NetworkRural Health Network

Serving:Serving:

Baker Baker Bradford Bradford Clay Clay Nassau Nassau Union Union Serving:Serving:

Baker Baker Bradford Bradford Clay Clay Nassau Nassau Union Union

Comprehensive Diabetes Managementand Education Program

Comprehensive Diabetes Managementand Education Program

St Johns River Rural Health Network, Inc.

Brief Background onBrief Background onRural Health NetworksRural Health Networks

(RHN’s) In Florida (RHN’s) In Florida

Brief Background onBrief Background onRural Health NetworksRural Health Networks

(RHN’s) In Florida (RHN’s) In Florida

• 9 Rural Health Networks in Florida 28/33 rural counties and parts of 13 non-rural counties

• Established by State Statute 381.0406 in 1993

• Intended to address 3 fundamental problems: Inadequate Funding for healthcare in rural areas Recruitment and retention of health professionals Migration of patients from rural to urban providers

• Core function to integrate public and private health resources; and to emphasize cooperation over competition.

St Johns River Rural Health Network, Inc.

Overall GoalOverall Goalof RHN’sof RHN’s

Overall GoalOverall Goalof RHN’sof RHN’s

“The ultimate goal of rural health networks shall be to ensure that quality health care is available and efficiently

delivered to all persons in rural areas.”

St Johns River Rural Health Network, Inc.

St Johns RiverSt Johns RiverRural Health NetworkRural Health Network

St Johns RiverSt Johns RiverRural Health NetworkRural Health Network

Incorporated in 1994; Certified by the AHCA in 1995

Baker, Clay, Flagler, Nassau, Putnam, St. Johns, and Volusia (also services in Union, Bradford)

Active membership: CHD’s, AHEC, medical providers, rural hospitals, FQHC’s, RHC’s, behavioral health providers, Universities, others…

Health Planning Council of Northeast Florida provides staff support and administrative services under contract from FDOH, Office of Rural Health

St Johns River Rural Health Network, Inc.

Mission of SJRRHNMission of SJRRHNMission of SJRRHNMission of SJRRHN

To recognize, encourage, and support partnerships that improve the health of rural communities in Baker, Clay, Flagler, Nassau

St. Johns, Putnam, and Volusia Counties.

St Johns River Rural Health Network, Inc.

Strategic PrioritiesStrategic Prioritiesfor 2009 - 2012for 2009 - 2012

Strategic PrioritiesStrategic Prioritiesfor 2009 - 2012for 2009 - 2012

Develop the SJRRHN into a relevant leader and primary information source for Health Information Technology or Informatics among rural healthcare providers.

Enhance and expand the RHN’s existing Chronic Disease Management and Education program (LIP Program), and related Care Coordination activities.

Become a prime resource among rural health providers for information and technical support related to rural healthcare funding, reimbursement issues, and overall Sustainability.

Coordinate a mechanism to foster and facilitate comprehensive real-time health status, healthcare services/resources, and outcomes information sharing among rural providers in Northeast Florida.

St Johns River Rural Health Network, Inc.

Regional AssessmentRegional AssessmentRegional AssessmentRegional Assessment

MUA/MUP’s and HPSA’s in Rural NEFLAll of Baker, Bradford and Union

Low-Income groups in Clay, Nassau

Socio-Economically Disadvantaged

Per capita income as much as 55% below avg. for FL

Population below FPL as high as 23.6% (Union)

Higher rates of Medicaid enrollment and un-insured

Health Indicators

Leading Mortality: Cancer, Heart Disease/CVD, Respiratory Disease, Injuries, Diabetes

High/Very High rates of overweight and obesity (BRFSS)

Very high rates of hospitalization and lower-limb amputations (Hosp. utilization data)

St Johns River Rural Health Network, Inc.

Program AreaProgram AreaProgram AreaProgram Area

• 2,371 sq. miles

• 320,000 (est.) population

Target population

• Un-insured Adult (Ages 18-64)

• Low-income (≤150% FPL)

• Resident of Baker, Bradford, Clay, Nassau, or Union

• Clinical diagnoses of Diabetes

St Johns River Rural Health Network, Inc.

Program PartnersProgram PartnersProgram PartnersProgram Partners

5 County Health Departments (Baker, Bradford, Clay, Nassau, Union)

St. Johns River Rural Health Network, Inc.

Independent Eye and Foot specialists in each county

Nassau County Government (provides local match $$)

Winn-Dixie Pharmacies (and others)

Florida Academy of Family Physicians (DMCP)

Hospitals (referrals)

St Johns River Rural Health Network, Inc.

Program ComponentsProgram ComponentsProgram ComponentsProgram Components

Primary Care and Medical Home

• Labs

• Immunizations

Disease-specific Specialty Services

Prescription Medications and Supplies

Care Coordination

Individual Disease Self-Management Education and Support

Group Level Education using Accredited Programs

FAFP Diabetes Master Clinician Program and EPR

Ongoing Community Support Groups

St Johns River Rural Health Network, Inc.

Primary Care Services Primary Care Services andand Medical Home Medical Home

Primary Care Services Primary Care Services andand Medical Home Medical Home

Enrollment: • 100% of clients are screened for eligibility for Medicaid and Drug Assistance Programs.

• 100% of enrolled clients given a medical home.

Extended clinic hours in most locations

24Hr on-call service for urgent needs

Access to nutrition and other education programs

• All diabetes-related medications and supplies, plus others

Baker 40Bradford 40Clay 80Nassau 60Union 40TOTAL 260

Estimated savings to area hospitals due to reduced Emergency Room utilization and reduced Admissions/Re-Admissions is over $344,500.

OUTCOME: Self-reported ER utilization reduced by ≥50%.

St Johns River Rural Health Network, Inc.

Care Coordination and Care Coordination and Specialty ServicesSpecialty Services

Care Coordination and Care Coordination and Specialty ServicesSpecialty Services

• Referral and linkage to specialty services and other community-based resources:

Vision/Eye Care

Podiatry

Education and Support

Social Services

• Applications for drug assistance programs Receipt, distribution, tracking, and follow-up

• Follow-up to ensure services are received

St Johns River Rural Health Network, Inc.

Disease ManagementDisease Managementand Educationand Education

Disease ManagementDisease Managementand Educationand Education

• 2 FTE Disease Managers/Health Educators

– Outcome-based Disease Self-Management Education

– Community Outreach and Home Visits

– Individual and Community-based Group Education

– Ongoing Support Groups

• FAFP Diabetes Master Clinician Program

– Diabetes Registry

– Group Visits

St Johns River Rural Health Network, Inc.

Accredited and ProvenAccredited and ProvenEducation ProgramsEducation Programs

Accredited and ProvenAccredited and ProvenEducation ProgramsEducation Programs

Diabetes Conversation Maps:• Developed jointly by ADA and Merck

• 5 Total Maps (Conversations)

• 1-2 Hours each

“Take Charge of your Diabetes”

• CDC Program

• 12 Sessions (1-2 per week)

• 1.5-2 Hours each

St Johns River Rural Health Network, Inc.

FAFP Diabetes Master FAFP Diabetes Master Clinician ProgramClinician Program

FAFP Diabetes Master FAFP Diabetes Master Clinician ProgramClinician Program

• As developed by Dr. Edward Shahady, MD and FAFP in 2003

• Currently more than 80 practices participating (17,000+ patients)

• Internet based “relational” database (HIPPA Compliant)

• Based on American Diabetes Association recommended goals:– HbA1c ≤ 7%

– LDL’s ≤ 100

– BP ≤ 130/80

• Individual Client Report Cards and Aggregate Provider/Clinic Reports

• Projected cost-saving up to $1,122 per client/year (Totaling at least $291,720/yr in overall savings for all clients enrolled.)

St Johns River Rural Health Network, Inc.

Background on Estimated Background on Estimated Annual Cost Savings* Annual Cost Savings*

Background on Estimated Background on Estimated Annual Cost Savings* Annual Cost Savings*

• Hb A1C: Good control (<7%) = $279

• Blood pressure: <130/80 = $464

• LDL: Reduced to <100mg/dl = $369

• Total: All 3 targets met = $1,112

* Towers Perrin 2005 actuarial analysis conducted for ADA/NCQA for Diabetes Physician Recognition Program

St Johns River Rural Health Network, Inc.

Patient Report CardsPatient Report CardsPatient Report CardsPatient Report Cards

St Johns River Rural Health Network, Inc.

Provider ReportsProvider ReportsProvider ReportsProvider Reports

St Johns River Rural Health Network, Inc.

Population Population Management ToolsManagement Tools

Population Population Management ToolsManagement Tools

St Johns River Rural Health Network, Inc.

Services ProvidedServices Providedin FY 2008 - 2009in FY 2008 - 2009Services ProvidedServices Providedin FY 2008 - 2009in FY 2008 - 2009

• 3,475+ Primary Care visits

• 473+ Specialist visits (foot and eye)

• 3,288+ Prescriptions filled

• 1,905 Labs performed

• 2,504 Disease Management encounters

• 1,180 Care Coordination activities

St Johns River Rural Health Network, Inc.

Primary Care43%

Pharmaceuticals31%

Disease Management

17%

Vision/Eye Care6%

Podiatry3%

Program ExpendituresProgram ExpendituresProgram ExpendituresProgram Expenditures

More than $2.3M in services provided in FY08-09

St Johns River Rural Health Network, Inc.

Sample OutcomesSample OutcomesSample OutcomesSample Outcomes

Eye Exam 48% 70%

Foot Exam 48% 70%

% thr ough 11/ 6/ 07

% thr ough 1/ 5/ 09

Annual Exams

Average Percent of Diabetics achieving all 3 goals:

United States 7%

SJRRHN Clients 15%

St Johns River Rural Health Network, Inc.

Estimated Hospital Costs Estimated Hospital Costs from Diabetesfrom Diabetes

Estimated Hospital Costs Estimated Hospital Costs from Diabetesfrom Diabetes

Data source for all figures: AHCA hospital utilization monthly data submissions

Pt. County of Residence Average Charges # of OP visits Sum of ChargesCalculated #

Admitted from ERTotal

ER Encounters

% of ER Visits resulting in Admission

Baker 2,899$ 63 182,610$ 23 86 27%Bradford 2,183$ 25 54,566$ 21 46 46%Clay 3,791$ 137 519,421$ 163 300 54%Nassau 2,753$ 82 225,746$ 69 151 46%Union 1,938$ 15 29,066$ 8 23 35%Totals 3,141$ 322 1,011,409$ 284 606 47%

Emergency Department Outpatient visits

Based on ICD-9 code 250.xx (diabetes, unspecified)Adults ages 18-64, regardless of insurance status

Pt. County of Residence Average Charges # of Admissions % Admitted from ERCalculated #

Admitted from ERAverage LOS* Sum of Charges

Baker 48,815$ 34 67.6% 23 8.44 1,659,725$ Bradford 18,265$ 23 91.3% 21 4.61 420,102$ Clay 37,264$ 191 85.3% 163 4.85 7,117,427$ Nassau 27,911$ 86 80.2% 69 4.98 2,400,328$ Union 34,743$ 18 44.4% 8 4.78 625,375$ Totals 34,724$ 352 80.7% 284 5.21 12,222,957$ * The average Length of Stay (LOS), in days, for diabetic patients is approximately 75% longer than for the total population among this age group. This equals approximately 1 additional day per diabetic patient admission when compared to other illnesses/conditions.

Based on ICD-9 code 250.xx (diabetes, unspecified)

Hospital In-Patient/Admissions

Adults ages 18-64, regardless of insurance status

St Johns River Rural Health Network, Inc.

LIP Program - Estimated LIP Program - Estimated Hospital Cost SavingsHospital Cost Savings

LIP Program - Estimated LIP Program - Estimated Hospital Cost SavingsHospital Cost Savings

Client self-reported ER utilizatation:

ER Utilization %Calc. # of ER visits

(Assumes 1 visit/cl/yr)

Calc. ER CostCalc. # of

AdmissionsCalculated

In-patient costsTotal

Hospital Costs

Baseline 11.5% 31.4 $ 98,611.70 14.7 $ 510,900.06 609,511.75$

Current (calculated) 5% 13.7 $ 42,874.65 6.4 $ 222,130.46 $ 265,005.11

Difference (SAVINGS) 6.5% 17.7 $ 55,737.05 8.3 $ 288,769.60 $ 344,506.64

At least 11.5% of enrolled clients indicated visiting an Emergency Room in relation to their diabetes during the 2 year period before they were enrolled in the LIP disease management program in 2006.

Within 24 months of program activity, the percentage of enrolled clients who reported visiting an emergency room within the previous 2 years had declined to 5%.

This represents a 56.5% reduction in self-reported ER utlization within 2 years.

Calculated Cost Savings (based on 273 unduplicated clients served) :

Estimated direct savings to area hospitals. Does not include primary care cost savings such as reduced need for prescription medications and fewer needed follow-ups achieved through effective disease management.

St Johns River Rural Health Network, Inc.

Return on InvestmentReturn on InvestmentReturn on InvestmentReturn on Investment

Total Program Funding: 650,000$

Cost-Limit Estimate of Services Provided: 2,315,000$

Estimated Savings to area Hospitals: 344,500$

Sub-Total 2,659,500$ 4.09

*Potential Primary Care Savings (goals met): 39,551$

TOTAL POTENTIAL RETURN ON INVESTMENT: 2,699,051$ 4.15

ROI only Match dollars 289,900.00$ 9.31

St Johns River Rural Health Network, Inc.

Success StoriesSuccess StoriesSuccess StoriesSuccess Stories

“John” enrolled July, 2008– Type II Diabetes– Stroke in May, 2008

• Weight at enrollment: 309.6lbs

• Cholesterol: 210

• Triglycerides: 309

• HbA1c: 7.9

St Johns River Rural Health Network, Inc.

Success StoriesSuccess StoriesSuccess StoriesSuccess Stories

• HbA1c reduced to 5.3 within 5 months

• John lost more than 35 lbs in 7 first months

• Learned to inject his own insulin

• Now attends all appts. and classes

• Reports feeling much more energized and is able to get around much easier!

• Total weight loss as of 6/09: 88 lbs.

• Last HbA1c: 5.1

St Johns River Rural Health Network, Inc.

Success StoriesSuccess StoriesSuccess StoriesSuccess Stories

“Mary” enrolled in July, 2007

Weight: 373 lbs

Highest HbA1c: 8.1

No daily blood glucose checks

Repeatedly no-showed for appointments

St Johns River Rural Health Network, Inc.

Success StoriesSuccess StoriesSuccess StoriesSuccess Stories

Mary in July, 2009 (2 years later)…• Testing blood glucose several times daily

• Attends all regular medical appointments

• Regularly attends education classes

• Improved diet/nutrition

• Began exercise – thanks to a new dog!

• Improved confidence

• Total weight loss: 103 lbs!!

St Johns River Rural Health Network, Inc.

Program EnhancementsProgram EnhancementsProgram EnhancementsProgram Enhancements

Behavior Change assessment and evaluation Based on proven Readiness to Change theory

Baseline assessment at enrollment

Periodic 6 month re-evaluations

Longitudinal monitoring of individual clients to better target intervention and education strategies

St Johns River Rural Health Network, Inc.

Contact InformationContact InformationContact InformationContact Information

St. Johns River Rural Health Network, Inc.Nikole Helvey, MS HSA, Program Director

(904) 723-2162 Ext. 109

[email protected]

Health Planning Council of Northeast Florida, Inc.Dawn Emerick, Ed.D., MPA, Executive Director

(904) 723-2162 Ext. 110

[email protected]