Tales From the Healthcare Village: How a Team-based Collaborative Care Partnership is Uniting

Patients, Providers, and Payers to Achieve Better Care at a Greater Value

Nancy Wexler, MPHDorothy Terrazas, FNP-C

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

Session F1bOctober 16, 2015

Faculty Disclosure

The presenters of this session• have NOT had any relevant financial

relationships during the past 12 months.

Learning Objectives

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

• Identify key components of a an interdisciplinary collaborative care model for high-need, co-morbid adults

• Describe population-based strategies to patient identification and engagement

• Discuss the business case for value-based payer/provider/team-based partnership

Bibliography / Reference

1. Agency for Healthcare Research and Quality. (August 2012). Experts Call for Integrating Mental Health into Primary Care. Research Activities. Retrieved on June 3, 2014 from http://www.ahrq.gov/news/newsletters/research-activities/jan12/0112RA1.html 

2. Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Cares health, and cost. Health Affairs, 27(3), 759-769. doi:10.1377/hlthaff.273.759 

3. Flower, J. (2012). Healthcare beyond reform: Doing it right for half the cost. Boca Raton, FL.: Taylor & Francis 

4. Kathol, R. G., Perez, R., & Cohen, J. S. (2010). The integrated case management manual: Assisting complex patients regain physical and mental health. New York: Springer. 

5. Lewis, A. (2012). Why nobody believes the numbers: Distinguishing fact from fiction in population health management. Hoboken, N.J.: Wiley. 

Learning Assessment

• A learning assessment is required for CE credit.

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

University of Arizona Health Plans

Banner Health

The Tale of the ‘Garage Band’

Video

•https://www.youtube.com/watch?v=i7Gz_BAwx0o&feature=youtu.be

How Have Home-Based IntegratedPrograms Historically Been Funded?

Not very well!• Grants• Community agencies• Health centers• Foundations

The Triple Aim

• Improved population health outcomes • Person-centered health care delivery• High-value care

What is High-Value Care?

Our Triple Aim

Where to Focus Efforts?

How do Health Plans Fit Into the Picture?

• Population

• Data

• Dollars

• Clinical Expertise

About University of Arizona Health Plans (UAHP)

• Not-for Profit, Medicaid and Medicare Health Plan– University Family Care –Medicaid– Maricopa Health Plan- Medicaid– University Care Advantage-Medicare Special Needs –Dual Eligible – Maricopa Care Advantage -Maricopa Health Plan- Medicaid– Cenpatico Integrated Care

• Now Banner Health Network (March 2015)

Banner University Medical Group

• Resides in an academic medical center (University of Arizona)

• Multi-site primary care clinics• No after hours or extended day clinics• Not a comprehensive ‘medical home’

When Primary Care Alone Is Not Enough

• An 82-year-old woman was living independently and becoming very confused conducting daily activities. She stopped eating regularly and managing medication became difficult. Her only family member, a niece living in Minnesota, did not know how to care for her or assist her in obtaining a higher level of health care services.

• The Healthy Together Care Partnership (HTCP) team helped assess, treat, and manage her medications and remain safe in the home until she qualified for long-term care and hospice.

• Her niece wrote to Healthy Together, profusely thanked the team and reported, “It takes a village to transition an elder.”

Call in the Village!

Healthy Together Care PartnershipMedical Home → Medical Neighborhood → Healthcare ‘Village’

VIP Service for UAHP Members Served by BUMG Primary Care Providers

Team-based care provided at home or by remote support and in coordination with all healthcare partners

Healthy Together Care Partnership (HTCP)

• Interdisciplinary team supporting the UAHN primary care providers (PCP)

– Nurse Practitioner, RN Case Manager, Behavioral Health, Pharmacist, Community Health Partner

• Operational model that supports the Primary Care Provider

– Assists at risk patients with care transitions in the healthcare system– Conducts in home needs assessment and patient education– Performs medication reconciliation/improves medication adherence– Coordinates follow up visits and assists with pre visit preparation

• Enhances communication and coordination efforts between primary care, specialty providers, acute and post acute care, home health and health plan

“Building Bridges Between Islands of Excellence”• Desired Outcomes

– Decrease admission, readmission and ED rates– Improve quality of life– Improve provider and patient satisfaction

Healthy Together Program Population • HTCP is a clinical effort of University of Arizona Health Plans and UA Primary

Care Providers serving 3,200 Medicaid adults

• 20% of HTCP

population (600) accounts for more than 85% of all costs (needs assessments conducted)

• HTCP aims to enroll 70 % of the top utilizers (400+)

HTCP Team: Nurse Practitioner, Pharmacist, Nurse, Health Behavior Partner (BHC), Community Health Partner (CHP)

The Healthy Together Care Partnership refers to a collaboration of the interdisciplinary care team, primary and specialty care

providers, and patient and family members.

• A 46-year-old woman with numerous chronic conditions including Lupus. She suffered for more than a year with an open, bleeding wound encompassing her full lower leg.

• The Healthy Together Care Partnership team coordinated her care with rheumatology, dermatology, and primary care and helped her understand and manage her diet, disease, and wound care.

“Thank God you called me. I was so overwhelmed.”

• Bill Jones, HTCP clinical pharmacist, meets with a patient partner in her home

What are we Really Doing?• Reduce reliance on the high-cost services by improving self-care• Access to the right care at the right time• Navigation of complex healthcare system

• Support of the non-clinical aspects of care– Psychosocial

• Trauma• Poor support• Few resources• Confusing medication protocols• Poor health behaviors• Anxiety

“Now I know why my patient is having a hypertensive crisis”!

-HTCP Nurse Practitioner at a home visit

Healthy University• Primary purpose of Healthy U is to support sustainable health behavior change

through integrated, patient-centered approaches• Healthy U establishes a patient empowerment ‘curriculum’ focused on the

psychosocial and environmental barriers to care• Utilizes evidence-based community health and peer support practices

• Establishes core expectations for HTCP program participation/engagement• Builds upon patient goals and unites them with the clinical goals of the care team• Identifies action steps and a timeline within which to achieve them• Clarifies the role of the Behavioral and Community Health Partners in self-care support• Provides basic health management supplies and tele-health monitoring • Reinforces positive health behaviors and intrinsic rewards received through accomplishment of

goals (completion of Healthy U)

• Aim is for Healthy U ‘graduates’ to complete program in 90-180 days

Healthy U Core Components Core components (learning objectives) of Healthy U:

Patient can articulate medical conditions and how to recognize and manage red flags

Patient can articulate medications, what they are for, and how to use them

Patient has set at least one health management goal

Patient has had a visit with designated PCP and knows how to access care

Patient can articulate relevant preventive health measures and advance care planning

Patient can articulate support systems (family, health, community)

Patient Perception of Care and Health Status

94% -Very Satisfied

94%- Likely to Recommend

87%-Improved understanding of condition

94% -Better able to manage heath

87%- Health improved

Additional Benefits• Team satisfaction and productivity increases

• Team members work at the top of their licenses• Greater team support and professional satisfaction• Cost effective and greater number can be served

• Provider satisfaction increases• Patients more accountable for their own care• Clear goals addressed in care plan • May be a provider retention function

• Patient satisfaction/ Marketing and market share increases• Patients are more involved in their own care• Patients experience reward of managing own care and completion of ‘courses’• Improved patient and member retention in Banner University Medical Group• Model can be exported to other UAHP populations

• “Since I started my new insulin I have stopped having high highs and low lows. My sugars are level. I feel better with my diabetes. Thank you for all of the support. I feel better just knowing people are looking out for me.”-

Patient Partner, Mr. K in March 2014 (30 year old with 4 hospitalizations in prior 6 months No hospitalizations in 4 months since HTCP)

How Do We Pay For This?

• Many hospital-based services are preventable

• These services average $5,000 per hospital admission and $400 per emergency visit

• The top high-cost group’s costs are two-three times higher

• A reduction of 10%-15% in utilization of the total population can cover the cost of the program

HTCP Metrics –Enrollment

Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 -

1,000

2,000

3,000

4,000

5,000

6,000

3,053

2,981 2,883

2,851 2,830 2,790 2,748 2,697

2,491 2,422 2,385 2,311 2,256

3,280

3,822 4,079

4,310 4,520 4,634 4,710 4,608 4,529

4,740 4,899 5,019

HTCP - Enrollment21yo+

Original Cohort Total HTCPMonth

Enro

llmen

t

HTCP Metrics –Admissions

Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 150.0

160.0

170.0

180.0

190.0

200.0

210.0

220.0

230.0

240.0

250.0

204.4

231.0 239.5

233.4 234.8

216.9 222.2

228.1 230.3 234.1

226.6

219.8

209.7

193.0

HTCP - Admissions per 1,00021yo+

Original Cohort Target (10% Reduction) Total HTCP

Stretch Target (15% Reduction)

Month

Adm

issio

ns p

er 1

,000

HTCP Metrics–Readmission Rate

Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-156.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

14.2%

14.8%14.6% 14.5%

14.4%15.3%

15.7% 15.7%16.5%

17.6% 17.7% 17.5%16.9%

13.4%

HTCP - Readmission Rates21yo+

Original Cohort Target (10% Reduction) Total HTCP

Stretch Target (15% Reduction)

Month

Read

miss

ion

Rate

s

HTCP Metrics –ED Visits

Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 400.00

450.00

500.00

550.00

600.00

650.00

618.37

HTCP - ED Visits per 1,00021yo+

Original Cohort Target (10% Reduction) Total HTCP

Stretch Target (15% Reduction)

Month

ED V

isits

per

1,0

00

Length of Hospital Stay

Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 400.0

500.0

600.0

700.0

800.0

900.0

1,000.0

1,100.0

1,200.0

817.1

880.4 928.3 929.8

988.3

928.4 953.3

984.1 1,020.0

1,087.4

1,016.5

1,001.7 943.7

771.7

HTCP - Bed Days per 1,00021yo+

Original Cohort Target (10% Reduction) Total HTCP

Stretch Target (15% Reduction)Month

Bed

Days

per

1,0

00

Meeting Tanya’s needs with HTCP

Meet Tanya…

42 year old woman with hospital admission for bowel obstruction. She has multiple conditions including hypertension, anxiety, depression, morbid obesity, chronic pain, and history of falls.

With the help of her Healthy Together care partners she:

• Established care with a trusted PCP• Made medication changes to prevent loss of balance• Managed her hypertension with weekly monitoring• Lost significant weight with daily exercise, and dietary changes• Enrolled in COPE for behavioral health services• Developed advanced care directives• Obtained service dogs

Key Lessons Learned

• Integrate into the medical record• Engage the medical providers and spend time in their

clinics and meetings• Clarify roles and functions of the team members • Partner with one payer and one clinical group• Develop a tracking database! • Ensure populations of need can be identified • Develop a solid evaluation plan and resources

Questions? Ideas? Contact Us!

Nancy Wexler, MPHProgram Manager, Healthcare Innovation University of Arizona Health PlansBanner Health Network2701 E Elvira Tucson, Arizona 85756nancy.wexler@bannerhealth.com(520) 874-2428

Dorothy Terrazas, FNP-CHealthy Together Nurse PractitionerBanner University Medical GroupDorothy.terrazas@bannerhealth.com(520) 626-5813

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!