Redesigning the Safety Net

Presented ByPete Delgado, CEO, LAC+USC Medical Center &

Allen Miller, CEO, COPE Health Solutions June 2009

Redesigning the Safety Net Creative Restructuring of an Un-System into Regional

Integrated Delivery Networks

TopicsBackground – Use Case ScenarioOpportunities for ChangeIntegrated Delivery Network Components– Medical Home Assignment and Patient Flow Redesign

– Provider Practice Redesign– Care Management of Frequent Users

– Information Technology & Patient Information Sharing

– Financing of Care & Network Sustainability– Workforce Development

– Performance Management & Quality Improvement

A New Paradigm of Care – Use Case RevisitedValue

5/11/2009 www.COPEHealthSolutions.org; www.lacusc.org 2


Background – Use Case ScenarioPatient ProfileLisa D.Black femaleAge: 64Resides in South Los Angeles, works part-time at local grocery store, lives with husband

Health Care Access and Utilization History•No primary care provider or established medical home•Patient is overweight, smokes, and has a history of high blood pressure•Treated 5 years ago for repair of right heart valve•Visited emergency department (ED) 3 times in the past 6 months, complaining of shortness of breath and abdominal discomfort; admitted twice, with an average length of stay of four days-------•Was last taken to emergency department (ED) 3 months ago for extreme shortness of breath and edema•Diagnosed with right heart failure and undergoes treatment•Repeated admissions in the past for same condition suggests failure to adhere to medication regimen and diet restrictions


Use Case Scenario – Lisa D.

Lisa visits an urgent care center. Complains of

shortness of breath and occasional abdominal

discomfort. Examined by Dr. T

Lisa informs Dr. T of her recent hospitalization; Dr.

T cannot access ED discharge report; continues w/exam

Dr. T diagnoses heart failure, but lacks

information to gauge severity and properly

manage Lisa

Determines that Lisa needs further work-up

and treatment. However, knowing the wait for a specialty appointment averages 6 months,

sends Lisa to ED

After 8 hour wait, Lisa is examined by ED doctor.

Lisa is admitted for further treatment and diagnostic

work-up

Lisa is discharged after 4 days and sent home with

orders to remain on a fluid and salt restricted diet, and is given a complex

medication regimen


Use Case Scenario – Lisa D.

Lisa continues to have difficulty taking

her meds and adhering to her diet

2 months later, she experiences

recurring symptomsHer husband takes her back to the ED

Cycle Perpetuates

Opportunities for Change

Shift towards primary and preventive model of care

Maximize inpatient capacity

Align financial incentives and ensure parity in health care access and outcomes

Connect public and private sectors

Build and sustain a strong workforce



Integrated Delivery Network Components

Medical Home Assignment & Patient Flow RedesignObjective

Ensure patients have local and easily accessible primary careCoordinate and streamline care between hospital and clinic partners to enable continuity of care

ProcessAssign all patients to Medical HomeIntegrate Medical Home model into clinical operations


Provider Practice Redesign


ObjectiveExpand capacity of primary care providers to manage more complex patientsEnhance patients’ Medical HomeIncrease access to specialty care services

ProcessImplement Community Grand Rounds to build collegial relationships b/w Specialists and Primary Care ProvidersEstablish Consensus Care Guidelines and flow processesImplement Mini-Fellowships and phone and chart consultationsDecentralize diagnostics

Over 9,000 patient Medical Homes documented

865 Visits Managed at Community Clinic vs. Medical Center

Over 530 hours of specialty care time avoided

Guidelines completed: Rheumatoid arthritis, chest pain, congestive heart failure (CHF), colorectal cancer screening

630 mobile echocardiograms performed for CDSN clinics


LAC+USC Camino de Salud Network – Provider Practice Redesign

Care Management of Frequent Users


ObjectiveReduce disparities in care and drive effective use of resourcesDecrease avoidable, costly Emergency Department and Inpatient utilization

ProcessBilingual-bicultural bachelor-level care managers enroll patients into Care Management Program:– Medical Home Assignment– Systems navigation and advocacy– Patient-centered care plans– Patient empowerment and education

LAC+USC Camino de Salud Network Care Management

Care Management through the Camino de Salud Network– 42 actively managed patients– 56 transitioned/graduated– Program has demonstrated a $5.1 million cost avoidance– Model replicated at Kaiser, LBMMC and Kern County


Emergency Service Outcomes57.54% Decrease in ED use after 1

year of care management

Inpatient Service Outcomes 54.05% Decrease in Inpatient Bed

Stay after 1 year of care management

ObjectiveEnable secure access to health care information at the point of care Reduce health care costsProvide IT health management tools

ProcessHealth information exchange portalClinic ConnectHealthATM KiosksNaviLinx Care Management Software


Information Technology & Patient Information Exchange

Data Accessed by

Clinics

NaviLinx

Network HIE

Network HIE

Financial Sustainability


ObjectiveAppropriately incentivize primary careEnsure providers comply with Network guidelines and meet performance standards as related to processes of patient care

ProcessAdapt the Disproportionate Hospital (DSH) funding scheme and apply it to primary care, reserving DSH funds for primary care providers and facilities w/in IDNsReward and reimburse providers for extra time committed to Provider Practice Redesign model

Workforce Development


ObjectiveBuild and sustain a strong health workforce pipeline that is culturally and linguistically competent

ProcessFunnel career transition professionals hit by the economic downturn into the health care field where there is job growthExpand education and training capacityPromote interest and commitment to primary care with incentive programs, e.g. practice-based research networks, scholarship and loan repayment Adapt Graduate Medical Education Health Professions reimbursement model

Workforce Development Outcomes


Nursing Pipeline Implemented since 2000 at 3-Hospital System in Los Angeles

Over 300 active interns contributing 32 FTE each year– Estimated to amount to $520,000 - $640,000 per year

40% reduction in the RN vacancy rate – Estimated cost savings of $4,101,760 on registry alone

Decrease in the new graduate RN attrition rate from 32% to 3% after the third year

Performance Management & Quality Improvement


ObjectiveEnhance measurement, management and evaluation of strategic objectives, improvement efforts, achievement, outcomes and patient experiencesIncrease transparency

ProcessImplement Balanced Scorecard to:– Transform strategic planning into integral and daily

component of operations– Continuously evaluate internal processes, adherence to

Network guidelines and outcomes– Improve performance


A New Paradigm in Care Delivery – The Case of Lisa D. Revisited

Patient ProfileLisa D.Black femaleAge: 64Resides in South Los Angeles, works part-time at local grocery store, lives with husband

Health Care Access and Utilization History•No primary care provider or established medical home•Patient is overweight, smokes, and has a history of high blood pressure•Treated 5 years ago for repair of right heart valve•Visited emergency department (ED) 3 times in the past 6 months, complaining of shortness of breath and abdominal discomfort; admitted twice, with an average length of stay of four days-------•Was last taken to emergency department (ED) 3 months ago for extreme shortness of breath and edema•Diagnosed with right heart failure and undergoes treatment•Repeated admissions in the past for same condition suggests failure to adhere to medication regimen and diet restrictions


Lisa D. Revisited

Lisa flagged as a Frequent User after her latest ED admission and assigned to a Network Care Manager (CM)

Lisa agrees to enroll in Care Management.

Before discharge, CM helps Lisa identify Clinic Y, near her home, as a

Medical Home

Lisa discharged and instructed to follow

medication and strict diet regimen; Outpatient echo

is ordered for follow up

CM helps Lisa get a follow-up appointment at Clinic Y with Cardiology Champion (CC) 10 days

after discharge

CM establishes Care Plan for Lisa, meets with

her weekly—assisting with medication and diet

management

CM goes with Lisa to her first appointment.


Lisa D. Revisited

As they wait, Care Manager teaches Lisa how to use HealthATM

Kiosk to access her health records and Care

Plan

Nurse Practitioner (NP) looks up Lisa’s medical record through Network

Health Information Exchange Portal

CC follows Consensus Care Guidelines to assist with management of Lisa

CC notes multiple ED visits for recurring heart failure symptoms; Also notes that the ordered

outpatient echo had not been performed

Per guidelines, CC orders echocardiogram through Network Mobile Echo

service

Lisa receives her echo and results are sent to CC

within 2 weeks


Lisa D. Revisited

Lisa’s echo results are abnormal. CC obtains telephone consultation from hospital specialist

With help of consult, CC establishes a

management plan for Lisa

Lisa receives continued Care Management support and obtains regular care at her

Medical Home

Lisa learns to better manage her heart

condition and transitions out of Care Management

after 6 months

ValueIntegration & StandardizationAlignment of financial incentives to encourage participation in Integrated Delivery NetworkAssurance of equitable access and quality of care


Table 1: Program Impact on PMPM Medi-Cal Costs

Contacts


Pete Delgado, CEO, LAC+USC Healthcare [email protected]

Allen Miller, CEO, COPE Health Solutionsamiller@copehealthsolutions.orgwww.copehealthsolutions.org

www.COPEHealthSolutions.org; www.lacusc.org 24

This document is proprietary and confidential to COPE Health Solutions and is protected under the copyright laws of the United States and other

countries as an unpublished work.

Any other reliance or disclosure in whole or in part of this information without the express written permission of COPE Health Solutions is

prohibited, and COPE Health Solutions does not accept any responsibility to any other party to whom it may be shown or into whose

hands it may come.

5/11/2009

Documents

Redesigning the Safety Net