I N T E G R A T I N G P O P U L A T I O N H E A LT H I N Q U I R Y T R A N S F O R M S ( I P H I T ) FA M I LY M E D I C I N E

COMPLEXITY AT NORTHEAST

Northeast Education AfternoonMarch 27, 2014

Jennifer Edgoose

DO YOU FEEL LIKE THIS?

Email on 1/21/4 to Lou and Jennifer

We deal with complexity

TRYING TO QUANTIFY THE WORK WE DO:

THE ARNDT SCALE

WHY?

• Fair distribution of patients• Appropriate scheduling of patients• Appropriate distribution of staff• Quality measures could include attention to effort

as well as outcome• Burnout

TRYING TO QUANTIFY COMPLEXITY

• Current measures• Face-to-face workload• E.g. work relative value units (wRVUs) based on the Centers

for Medicare and Medicaid Services Resource Based Relative Value Scale

• Insurance claims data try to predict future utilization, cost, mortality and quality of life• Chronic Disease Score, Charleston Index, etc.

• What about non face-to-face work?• E.g. Telephone calls, electronic communication, supervision of

nurse visits, medication refills• Increased work associated with poverty• Patient characteristics

Perceived Overall Encounter Workload

Encounter Type WeightStandard Deviation

95% Confidence

IntervalHospital 1.81 0.43 (1.78, 1.90)Emergence room 1.48 0.56 (1.36, 1.60)Off-site facility (home or nursing home)

1.19 0.58 (1.07, 1.32)

Office visit (serving as baseline) 1.00 - -Urgent care 0.89 0.35 (0.81, 0.96)OB visit 0.68 0.38 (0.60, 0.76)Telephone 0.45 0.28 (0.39, 0.51)Online communication 0.39 0.32 (0.32, 0.46)Laboratory test ordered 0.30 0.26 (0.25, 0.36)Medication refill 0.26 0.24 (0.21, 0.32)Patient letters 0.24 0.25 (0.19, 0.29)

DescriptionAverageRanking

Standard Deviatio

n

95% Confidence

Interval WeightUnspecified psychiatric condition 8.64 3.76 (7.83, 9.46) 1.33Uninsured 8.14 4.04 (7.27, 9.01) 1.25Having more than 10 types of medication

7.53 3.93 (6.68, 8.38) 1.16

Five or more no-show or cancelled appointments*

*** 

*** 

*** 

1.14 

Schizophrenia 7.36 3.63 (6.58, 8.15) 1.13Interpreter services needed 7.19 3.43 (6.45, 7.93) 1.11Medicare patient whose age is less than 65 (e.g., disability or end-stage renal disease)

6.89 3.17 (6.21, 7.58) 1.06

Diabetes 6.75 3.22 (6.06, 7.45) 1.04Dementia/cognitive impairment 6.74 3.17 (6.06, 7.43) 1.04Chronic kidney disease 6.71 3.41 (5.97, 7.44) 1.03Depression/anxiety/bipolar 6.51 3.06 (5.84, 7.17) 1.00Chronic opioid/stimulant use 6.25 4.46 (5.28, 7.21) 0.96Chronic heart failure 6.19 3.53 (5.43, 6.95) 0.95Asthma/COPD 6.05 4.65 (5.07, 7.05) 0.93

Ranking of Challenging Patient Characteristics

How to Calculate Arndt Scale (Step 1)

• The encounter workload score for a patient is equal to the sum of all individual encounter scores computed during a time period.

Example:

A patient had 1 emergency department visit, 4 office visits, 6 phone calls, 10 medication refills, 2 lab orders, and 2 lab results letters

Encounter Score:

(11.48 + 41.00 + 60.45 + 100.26 + 20.30 + 20.24) = 11.86

* Look up weights in the “Overall Encounter Workload” table

How to Calculate Arndt Scale (Step 2)

• The challenging characteristics score for a patient is equal to the sum of all chronic conditions, medications burden, and socioeconomic characteristics computed during a time period.

Example:

An uninsured patient with diabetes and chronic kidney disease who has no-showed or cancelled five or more appointments.

Challenging Characteristics Score:

(1.25 + 1.05 + 1.03 + 1.14) = 4.47

* Look up weights in the “Ranking of Challenging Patient Characteristics” table

How to Calculate Arndt Scale (Step 3)

• The overall complexity score for a patient is determined by adding the encounter workload score to the total patient characteristics score.

In this example, the patient would have a total complexity score of 16.33 (=11.86 + 4.47).

The 30 most complex patient panels in the entire statewide DFM• Northeast has 33

%• Wingra has 13%

NORTHEAST

WHAT DOES THIS MEAN?

• Systematic QI processes are important• We could ask further questions of the data. What

primarily drives our high complexity?• Examples:• Number of ED visits?• % of patient under 65 who are disabled?• The mental health comorbidity of our patients?

• Should we use this to leverage more support• E.g. more staff?