AtlantiCare- The Special Care Center SM

10/12/2015
AtlantiCare- The Special Care Center SM
Dr. Ines Digenio and Sandy Festa, LCSW
1
10/12/2015
AtlantiCare- Who We Are
• AtlantiCare Regional Medical Center’s Atlantic City
Campus was Atlantic City’s first hospital, founded in
1898. For more than a century, ARMC City has
remained a regional leader in healthcare services.
• 580-bed teaching hospital with campuses in Atlantic
City and Pomona.
• AtlantiCare became a large, multi-faceted health care
system in 1995
• Merger with Geisinger Health System October 1, 2015
AtlantiCare- Who We Are
• Southeastern New Jersey’s largest health system and
largest non-casino employer
• Dedicated to building healthy communities
• 5,000+ team members in over 70 locations
Core competencies:
• Health Delivery (acute/episodic care)
• Health Engagement (promotion, prevention, management)
• Health Information (manage information through continuum)
2
10/12/2015
AtlantiCare: Special Care Center
•
•
•
•
Faced with escalating care costs, especially for employees with chronic
conditions, AtlantiCare and the Welfare Fund adopted the AIC-U model
(Special Care Center) and opened the center July 2007 (based on the
original white paper)
Goal- Improve Care while controlling cost with focus on BENDING the
COST CURVE for patients with chronic conditions
The Special Care Center originally served only participants of the Local
54 Fund and AtlantiCare employees, but has subsequently been opened
up to other patient populations including ACO members and MSSP
participants
Changed the payment model
AtlantiCare- Special Care Center
•
AtlantiCare began planning the
Special Care Center in 2006. Adopted
from national best practice. 1
•
Purpose: To redesign primary care to
improve care while reducing costs for
patients with chronic health
conditions.
•
Opened first Special Care Center in
the heart of Atlantic City in July 2007.
•
Second site opened in Galloway NJ in
February 2010.
3
10/12/2015
Sharing The Story
• Malcolm Baldrige Quality Award Winner- 2009
• Atul Gawande- New Yorker Magazine- Hot Spotters
Article- 2011
• AHA- Quest for Quality Finalist -2011
• Premier CARES Award- 2012
• UCSF and Hitachi Foundation work on Front Line
Worker Development- 2012
• Dartmouth MBA healthcare case study- 2013
Chronic Care
• 80 % of Healthcare Spend
• The Special Care Center SM
operates as a primary care
• 20% Patients with Chronic
medical home for patients with
Conditions
chronic conditions with focus
on:
SOLUTION
• Improves the experience of
care
Care
Costs
• Improves the health of
populations
• Solution for patients with
• Reduces per capita costs of
Chronic Conditions
health care
4
10/12/2015
Special Care Center
•
•
Second site opened in Galloway
in February 2010 to provide
services on the mainland.
Pharmacy built next door to
replicate care design.
Spread learning in accordance
with IHI principles. 3
The Health Plex is the home to the first Special Care Center. Initially focused on large casino employer groups and AtlantiCare employees. The program then opened up to other payer groups.
Center became NCQA PCMH Level 3 and Diabetes Recognition 2011. 2
Special Care Principles
Give Patients what they WANT and NEED
 Relationship with their Doctor
 Health Coach support
 Care they can Access
 Provide Pharmacy Services
 Care of the highest Quality
 Controlling Costs
 Electronic care that is Connected
 Care that is Integrated
 Driven by the customer Experience
5
10/12/2015
Recruitment and Retention
•
•
•
•
Use of Predictive Modeling 4
Employee Eligibility Criteria
Invitation Only Practice Concept
Reduce barriers to care including waived
co-pays to visits and prescriptions when
allowed by health insurance plan design
• 97% retention rate
Engagement
• Make Every Patient “Feel”
Special
• Tailor care to meet their
personal needs
• One Stop Care 5
• Open Access for sick call
• Same day-next day visits for
emergency department and
hospital discharges 6
• Every patient is warmly
welcomed upon arrival. Wait
time is minimal and monitored
by CG-CAHPS. 7
• Family encouraged to
participate in care.
• Walk-in patients welcomed.
6
10/12/2015
Team-Based Care
• Team based care is essentialprovides deep understanding
of patients when other
providers are on call. 8
• Match patient preferences
based on culture, linguistic
and gender.
Three Key Aspects of Care
Health Coaches
• Highly motivated Health
Coaches (medical assistant,
LPN)
(cost effective and high performing)
Medical Providers
Specialist Network
• High performing medical
providers
• High Value Specialist
Network
(cost effective and high performing)
7
10/12/2015
•
Each patient is assigned a personal
health coach. 10
•
The health coaches (medical assistant
or LPN) support each patient during
their in-office care as well as
coordinate care for specialist, testing
and maintain contact with patient
between office visits.
•
The heath coaches provide
systematic and tailored education to
each patient and their family.
•
The health coach visit frequency is
based on each patient’s health care
needs.
Health Coach
Health Coaches
• Train medical assistants to function as
Health Coaches
• Health Coach visits ( 40% of current
visits are not with provider)
• 10% of visits are now Virtual
8
10/12/2015
Health Coaches (HC) Key to Engagement
•
•
•
•
•
•
•
Develop and train standard competencies
Utilize HCs more effectively in patient care delivery
Empower HCs as critical members of care team
Improve HC job satisfaction and retention
Impact HC quality and performance
Improve provider work-life balance and satisfaction
Improve health indicators
Question
The difference between embedded nurse
care managers and health coaches
• RN case managers- declining healthcarry until re-stabilized-episodic
• Health coaches- rising risk and restabilize patients- ongoing relationship
9
10/12/2015
Cost Efficiency
• Compare cost of health coach to LPN or
RN- average savings per hour is:
• 20-30% savings LPN vs HC
• 50-60% savings RN vs HC
Chronic Care Management (CCM) Services 99490
• At least 20 minutes of clinical staff time
• Directed by a physician or other qualified health care professional,
per calendar month, with the following required elements:
• Multiple (two or more) chronic conditions expected to last at least
12 months, or until the death of the patient,
• Chronic conditions place the patient at significant risk of death,
acute exacerbation/decompensation, or functional decline,
• Comprehensive care plan established, implemented, revised, or
monitored.
10
10/12/2015
Physician
Huddle
• Each patient is assigned their
own personal physician that
provides direct primary care.
• Care is “relationship” based.
Each physician becomes
familiar with their patient
population, is aware of the
strengths and areas needing
attention. 9
• This model improves care by
matching patients on many
indicators including language
and culture and this has
shown to improve the care
experience and motivation to
change.
• The multi-disciplinary team
meets each morning to review
ED and hospitalization reports
to determine actions and plan
of care. 11
• High risk patients are
continuously reviewed
(Homecare, hospice, ESRD).
• New patients to the practice
are reviewed.
11
10/12/2015
•
Pharmacy
•
•
•
The on-site pharmacy provides easy access to
e-prescribed medications that can be taken
home immediately following each visit. 13
Fill rate exceeds 98%. 14
Waived copay reduces financial burden for
many.
Generic utilization rate at 88%. National
average is 75%. 15
The savings from generic use accrue to both plan sponsors and
consumers. On average, a generic drug costs about $45 less than a
brand name drug and it is estimated that for each 1% increase in
generic fill rate, pharmacy spend decreases by 1%. Consumers also
pay a lower copayment for generic medications, saving on average
$10 per prescription compared to branded medications (Express Scripts).
•
•
Strategic use of test strips can save $245
PMPY.
Low cost medications are made available for
those in need.
SCC Diabetic Bundle Measure
cohort 1054
A1c measurement
Every six months
100%
A1c control
<7%
48%
LDL measurement
Yearly
84%
LDL measurement
<100 mg/dl
63%
Blood Pressure control
<130/80 mmHg
60%
Urine Protein testing
Yearly
91%
Influenza immunization
Yearly
72%
Pneumococcal immunization Once before 65,once after age 65
65%
Smoking status
Nonsmoker
86%
% who achieve all of above
Diabetes bundle percentage
12%
12
10/12/2015
Special Care Center- Impact on
Health Disparities
•
•
•
•
•
The SCC design includes multiple features to reduce such disparities including
culturally and linguistically matched physicians and health coaches, in depth and
culturally appropriate educational materials, improved access, and team training
on cultural competency.
The SCC has resulted in improved outcomes for SBP, LDL, A1c and smoking
status for all racial groups when looking at initial and most recent measures for
patients enrolled over 6 months.
Pre SCC, all measures showed disparities similar to those reported in the
literature, with worse performance for Black and Hispanic patients compared to
White English speakers.
When looking at all patients, disparities for all measures were cut in half after
enrollment in the SCC.
When looking at patients who started in the SCC out of control, disparities were
virtually eliminated in Black and Hispanic patients compared to Whites after being
in SCC 6 months.
Special Care Center
•
•
•
•
•
•
Operational for 8 years in Atlantic City
Reduction in ED and hospital admission by 40%-50%
Re-admission rate averages 5%
Significantly reduces PMPM to self-insured partners
Continues to bend the cost curve
Payer partners refer patients for care- disease and
cost
13
10/12/2015
Savings
• $200 average savings PMPMlarge union group
• $170 average savings PMPMself insured employer group
• 40-45% reduction in ER and
hospitalization rates
• 3%-5% re-admission rates
• 20% reduction in pharmacy
spend
• Each diverted Emergency
Department visits has
accountable savings.
• Each diverted hospitalization
has accountable savings.
• Focus is on reducing
unnecessary and repetitive
testing.
• Drug costs are reduced.
Clinical Affiliations
ATLANTICARE HEALTH SERVICES
Service Area Map
STAFFORD
STAFFORD
Harvey
Harvey
Cedars
Cedars
BURLINGTON
BURLINGTON
COUNTY
COUNTY
LITTLE
LITTLE
EGG
EGG
HARBOR
HARBOR
c
Hammonton
7
8
Folsom
Folsom
Boro
Boro
10
11
Upper
Upper
Deerfield
Deerfield
Twp
Twp
MULLICA
MULLICA
a
Egg
Egg
Harbor
Harbor
City
City
GALLOWAY
GALLOWAY
Buena
Buena Boro
Boro
5
EAGLESWOOD
EAGLESWOOD
Tuckerton
Tuckerton
SOUTHERN
OCEAN
COUNTY
AtlantiCare Urgent Care Network
a – Tuckerton
b – Health Park
c – Hammonton
d – Marmora
Surf
Surf City
City
Ship
Ship Bottom
Bottom
LONG
LONG
BEACH
BEACH
Little
Little
Egg
Egg
Harbor
Harbor
Beach
Beach Haven
Haven
Port
Port Republic
Republic
HAMILTON
HAMILTON
OH
OH
Bridgeton
Bridgeton
10
Deerfield
Deerfield
Twp
Twp
BUENA
BUENA VISTA
VISTA
9
8
3
b
VINELAND
VINELAND
Hopewell
Hopewell Twp.
Twp.
EGG
EGG
HARBOR
HARBOR
ESTELL
ESTELL
MANOR
MANOR
MILLVILLE
MILLVILLE
Corbin
Corbin City
City
Lawrence
Lawrence Twp.
Twp.
Downe
Downe Twp.
Twp.
ATLANTIC
ATLANTIC COUNTY
COUNTY
Linwood
Linwood
6
Woodbine
Woodbine
Boro
Boro
Sussex
Atlantic
Atlantic City
City
Ventnor
Ventnor
Margate
Margate
Marmora
Marmora d
Bergen
Morris
Hunterdon
Somerset
Ocean
Ocean
City
City
4
Mercer
Sea
Sea Isle
Isle
City
City
Philadelphia
•
Camden
MIDDLE
MIDDLE
Hudson
Union
RSA Market Area
1
AtlantiCare Regional Medical Center Mainland (Pomona)
2
Burlington
Monmouth
AtlantiCare Regional Medical Center (Atlantic City)
AtlantiCare Health Plex
3
AtlantiCare Health Park
4
AtlantiCare MOB
5
Southern Ocean County Hospital (Manahawkin)
6
Shore Memorial Hospital (Somers Point)
7
Burdette Tomlin Memorial Hospital (Cape May Courthouse)
8
William B. Kessler Memorial Hospital (Hammonton)
South Jersey Health System:
9
SJHS Regional Medical Center
10
Elmer
Ocean
Gloucester
7
Avalon
Avalon
Salem
Atlantic
Stone
Stone Harbor
Harbor
Cumberland
LOWER
LOWER
North
North Wildwood
Wildwood
Wildwood
Wildwood
Wildwood
Wildwood Crest
Crest
West
West Cape
Cape May
May
Cape
Cape May
May
Point
Point
Essex
Middlesex
DENNIS
DENNIS
CAPE
CAPE
MAY
MAY
COUNTY
COUNTY
PSA Market Area
Pass
Passiac
Warren
Longport
Longport
UPPER
UPPER
Commercial
Commercial
Twp.
Twp.
Brigantine
Brigantine
Northfield
Northfield
Somers
Somers Point
Point
Maurice
Maurice River
River Twp.
Twp.
CUMBERLAND
COUNTY
Absecon
Absecon
Pleasantville
Pleasantville
WEYMOUTH
WEYMOUTH
9
Fairfield
Fairfield Twp.
Twp.
Cape
Cape May
May
Cape
May
14
10/12/2015
Spread for MSSP PMPM
AtlantiCare ACO
AtlantiCare SCC
Average Risk Index
24.39
25.90
Medical Plan Paid $914.27
$486.95
Office Plan Paid
$206.39
$99.54
Outpatient Hospital Plan Paid
$118.50
$103.17
Inpatient Hospital Plan Paid
$369.87
$43.15
Review
• In a large health system- you have to make the decision if you
want your health system to care for your patients or have some
other health system care for them
• Why not improve care while controlling or reducing costs in the
most effective manner
• This is only the beginning of health care reform
• Try small tests of change
• Develop relationships with your patients- they will become loyal
• Many to most will get better with better care
15
10/12/2015
References
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
1 A-ICU White Paper- Available upon request
2 NCQA PCMH - http://www.maga.com/blog/patient-centered-initiative-improves-health-reduces-costs/
3 IHI Spread Model -http://ahca.myflorida.com/Medicaid/quality
management/workgroups/hospital/the_science_of_spread.pdf
4 Predictive Modeling -http://www.healthguideinfo.com/health-apps/p18151/
5 One Stop Care Benefits - http://www.www.caller.com/2013/apr/21/cst-of-diabetes-atlantic-city-hospitalsystem/
6 Same day appointments-http://pweb1.rwjf.org/reports/grr/056351.htm
7 CG-CAHPS-http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2012/rwjf72673
8 Team-based Care Benefits - http://www.ahaphysicianforum.org/files/pdf/team-delivery-report.pdf
9 Physician Relationships Benefits -http://www.medicalhomenews.com/issues/MHNNews0110page1.pdf
10 Use of Health Coach Model-http://www.innovations.ahrq.gov/content.aspx?id=2941
11 Use of Huddle-http://www.stfm.org/fmhub/fm2013/July/Anne501.pdf
12 Individualized Care Plans -http://www.ehcca.com/presentations/acocongress1/schneider_pcl.pdf
13 Benefits of On-site Pharmacy- http://www.behavioral.net/article/four-key-benefits-site-pharmacy-services
14 Fill Rate-http://www.reducedrugprices.org/av.asp?na=128
15 Generic Utilization -http://aspe.hhs.gov/sp/reports/2010/GenericDrugs/ib.shtml
Discussion
16
10/12/2015
17