CLARION Interprofessional Case Competition “The Heart of the Matter”

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INTRO THE CASE RCA RECOMMENDATIONS IMPLEMENTATION BUDGET BARRIERS & OUTLOOKINTRO THE CASE RCA RECOMMENDATIONS IMPLEMENTATION BUDGET BARRIERS & OUTLOOK

CLARION Interprofessional Case Competition

“The Heart of the Matter”

INTRO THE CASE RCA RECOMMENDATIONS IMPLEMENTATION BUDGET OUTLOOK & TAKEAWAYS

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Nathaniel ArnoldMedical Director

of the Heart Failure Clinic at Central Hospital

Natalie NguyenHead of

WestPlan’s health plan

Disease and Case Management

Program

Darshan PandyaHead of

WestPlan’s Home Care and

Hospice

Andrew RockNurse Manager

from Central Hospital

Our Team


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The Heart of the Matter:Chronic Heart Failure (CHF)

Demands improvements in quality of care and patient safety for CHF

Hospital Readmissions

Reduction Program

50% CHF patients are readmitted

50% mortality within 5

years

5.1 million


To recognize and eliminate the gaps and failure points that prevent optimal heart failure care at WestPlan

Our Purpose

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Chronic Heart Failure & WestPlan

• 1,817 WestPlan members have CHF• 184 (10.2%) members participate in our Disease and Case

Management Program

Central Hospital treated 2,346 patients with CHF in 2013

Inpatient Admissions: 1,644 Outpatient Visits: 1,105 (87 ER Visits)

Visits per patient Visits per patient

1 to 2 1,513 (92%) 1 to 2 984 (89%)

3 to 5 125 (7.6%) 3 to 5 111 (10%)

More than 5 7 (0.4%) More than 5 15 (1.3%)


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69 Years Old

Insured by Medicare

Robert & Lisa

Reeves

Retired Mechanic

Smoking &

Drinking

Margie Reeves

Stressors

Sedentary Lifestyle& Poor

Diet

Family History

Harlan Reeves


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INTRO THE CASE RCA RECOMMENDATIONS IMPLEMENTATION BUDGET BARRIERS & OUTLOOKINTRO THE CASE RCA RECOMMENDATIONS IMPLEMENTATION BUDGET BARRIERS & OUTLOOKINTRO THE CASE RCA RECOMMENDATIONS IMPLEMENTATION BUDGET OUTLOOK &

TAKEAWAYS

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TAKEAWAYS

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INTRO THE CASE RCA RECOMMENDATIONS IMPLEMENTATION BUDGET BARRIERS & OUTLOOK

Fragmented health records

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Development/dx of DM II (12 years ago)

Unhealthy Lifestyle

Low health literacy

Smoking/drinking to deal with

stressors

No regular medical checkups

Diabetic and Cardiac Events in the 7 months following MI/Rushed to the ER (3 weeks ago)

Hospitalization for deteriorating condition and admitted as an

inpatient to the transitional care unit (2 weeks ago)

MI at home/placementof stent/pacemakerat Central Hospital

(7months ago)

Development/dx of Grade III CHF (14 months ago)

Unmanaged DM II

FH of heart disease

Continued smoking and sedentary lifestyle

Rejected palliativecare 7 months ago

Inadequate home care

Never referred to HeartClinic or transferred to

Transitional Care

High BMI due to poor lifestyle

Family History of DM II

Poor handling of CHF dx 14 mos. ago

Poor coordination of care for DM II and CHF

Non-adherence tocardiac medication regimen

Admitted only for observation 3 weeks ago

…no Transitional Care

Margie and Lisa now physically unable to

care for Harlan

Age/gender: 69 y/o M


The system failed Harlan Reeves

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Harlan’s Health Care

Access to Needed Care

Optimal Evidence-based

Disease Management

Prevention of Disease State

Interdisciplinary Coordination


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TAKEAWAYS

Our Recommendations 1. Achieve Advanced

Certification in Heart Failure by The Joint Commission

2. Partner with the Dunnelly community to implement population health management

Images retrieved from: http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx Institute of Healthcare Improvement

http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx


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Recommendation 1

Advanced Certification in Heart Failure


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Recommendation StrategyCardiac Care Checklist

Hospital Stay

Hospital Discharge

Post-Acute Care

Outpatient

Home Care & Hospice

[ ] Joint Commission Core Measures in Heart Failure

[ ] Joint Commission requirements for Advanced Certification in Heart Failure: INPATIENT and OUTPATIENT

[ ] WestPlan considerations for Standards of Care

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Pathway to Advanced Certification for CHF

• Integrate and improve Health Information Technology

Tactic 1

• Coordinated Transitions of CareTactic 2

• Medication ManagementTactic 3

• Optimize Home Care and Hospice services for CHF patients

Tactic 4


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Tactic 1 : Information Technology• Existing EHR Clinical Decision Support Tool– Cardiac Care Checklist– CHF Risk Assessment Checklist

• Oregon’s Health Information Exchange program (Care Accord)– Integrating health records from WestPlan and

outside of WestPlan networks


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Tactic 2: Transition Coordinators• Transform discharge planners into Transition Coordinators • Ensures smooth transition from hospital to next care setting• Follow-up by post-discharge day 7 & connect with Home

Care and Hospice services• Goals to achieve:– 80% patient follow-up with PCP, cardiologist, or Heart

Failure Clinic or other WestPlan Service– 100% of medications prescribed are filled at discharge

with medication instructions understood by the patient

Reduce CHF readmissions by 15% within year 1


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Tactic 3: Medication Management• Medication Reconciliation– Obtaining medication histories – Reconciling patient’s home medications with updated

medication action plans

– Interdisciplinary effort– Improving medication safety across the continuum of care• Inpatient stays• Outpatient appointments• Updated personal patient medication lists


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Tactic 3: Medication Management• Medication Regimen Dose Optimization– Adding a clinical pharmacist to the WestPlan Heart

Failure Clinic to help optimize heart failure regimens in the most critical and complex patients

• Medication Therapy Management (MTM)– Adding an MTM pharmacist to the Disease and Case

Management Program to help improve medication safety for patients not regularly seen in the WestPlan Heart Failure Clinic


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P4: Home Care and HospiceWhy is Home Care and Hospice important for CHF patients?

• Quality of Life• Patient Safety• Reducing hospital re-admissions!

WestPlan’s Home Care and Hospice services are underutilized. Why?• Stigma• Access

Our current team: Geriatricians, Nurse Practitioners, Nurses, Social Workers, Assisted Living specialists (home aides), Chaplains

Which roles do we want to add or enhance?• Transition Coordinators• Dietician• Clinical pharmacist


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P4: Home Care and HospiceHow will our improved interdisciplinary team help CHF patients?

Health Professionals Roles in Patient Safety

Transition coordinators• Medicare resources• Coordination amongst the team Sharing medical information

NPs/Nurses• Medication management

• Fluid volumes Preventing medication errorsMonitoring any sudden changes

Social workers and Chaplains• Family meetings Individualized patient care

Dieticians• Menu planning Patient-specific dietary needs

Home aides• Assistance with ADLs Preventing accidents and reducing

caregiver burdenGeriatricians and Pharmacists

• Effective and personalized care and medication plans Individualized patient care


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Recommendation 2Population Health Management


http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=10PcImf3D1NixM&tbnid=r2rVz_kH8T5znM:&ved=0CAUQjRw&url=http://www.clipartbest.com/stick-people-holding-hands&ei=TMZCU8P6OKTLsQTj0IKwBA&bvm=bv.64125504,d.dmQ&psig=AFQjCNHA4J6KoaoVtx8p_xM5IbRv0Y-2kw&ust=1396971436429059

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10%Level 3

High risk

Multiple

Chronic Illnesse

s

20%Level 2

Moderate risk Single Chronic Illness or

Risk Factors70%

Level 1Low Risk

Health Risk Assessment

Intensive Case & Disease Management• Chronic disease self-management• Increased enrollment through electronic

medical records (EMR)

Health Coaching & Lifestyle Management• Coaching lifestyle choices• Programs for modifying risk factors

Health Education & Promotion• Raising health awareness• Health promotion programs

Community Partnerships• Incentives• Screening & Annual Visits • Outreach & AwarenessOUR COMMUNITY


Info

rmati

on Te

chno

logy

Population Health Management

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CHF RISK STRATIFICATIONRisk Levels Risk Criteria

HIGH RISK

1. Any cardiac condition or hospitalization for a cardiac condition2. Valvular Heart Disease3. MI4. Cardiomyopathy5. Left Ventricular Hypertrophy6. CHF Grade II, III, IV

MODERATE RISK

Conditions:1. CHF Grade I2. Diabetes3. Hypertension4. High

cholesterol

One or more of the following:1. Smoking2. Alcohol use-due to impact on risk factor

conditions for CHF3. Poor Diet4. Stress5. Low Physical Activity6. Overweight

LOW RISK Defined by exclusion of all of the above

Community All those who have not come into contact with our healthcare system, not currently patients, or we do not have any health assessment information

Risk StratificationINTRO THE CASE RCA RECOMMENDATIONS IMPLEMENTATION BUDGET OUTLOOK &

TAKEAWAYS

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WestPlan Community Care-a-Van• Interdisciplinary Team (Allocated Part Time)

– 1 Public Health Specialist (Epidemiologist)– 2 Registered Nurses – 1 Social Worker

• Services provided– Blood Pressure and Blood Glucose Readings– BMI Assessments– Tobacco and Alcohol Use Assessments (ASSIST)– Individual Health Risk Assessments– Referrals to WestPlan providers

• Care-a-Van operations would partner with the Million Hearts Campaign


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Raising Health Awareness• WestPlan Community Care-a-Van– “Honoring Choices”– Onsite patient counseling

• Health Education and Promotion– Classes on various health topics – Specialized for inpatients, outpatients,

or the general public• Community Partnerships– Health Fairs– Engagement with community stakeholders


http://www.healthadministrationdegree.net/wp-content/uploads/2013/03/healthed-postmaster.jpg

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TAKEAWAYS

Recommendations

1. Achieve Advanced Certification in Heart Failure by The Joint Commission

2. Partner with the Dunnelly community to implement population health management

Images retrieved from: http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx Institute of Healthcare Improvement



http://www.google.com/url?sa=i&source=images&cd=&cad=rja&uact=8&docid=FOTg-Aai-50IIM&tbnid=GN5yZWHuV6ld_M&ved=0CAgQjRw&url=http://www.clker.com/clipart-transparent-green-checkmark.html&ei=FdMxU-2bHaWG0AGU1oGwBg&psig=AFQjCNGa4vWfLt8M4W1gVfkgIOs0sNmSNA&ust=1395860629559736

http://www.google.com/url?sa=i&source=images&cd=&cad=rja&uact=8&docid=FOTg-Aai-50IIM&tbnid=GN5yZWHuV6ld_M&ved=0CAgQjRw&url=http://www.clker.com/clipart-transparent-green-checkmark.html&ei=FdMxU-2bHaWG0AGU1oGwBg&psig=AFQjCNGa4vWfLt8M4W1gVfkgIOs0sNmSNA&ust=1395860629559736

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Tactic 1-4 ExpensesTable E: Salary Expense Annual Salary Monthly Salary Allocated for Central Hospital

Registered Nurse(RN)** $ 69,000.00 $ 5,750.00 $ 51,750.00 9 months

Registered Nurse(BSN)** $ 73,000.00 $ 6,083.33 $ 54,750.00 9 months

Social Worker (MSW)** $ 58,233.00 $ 4,852.75 $ 43,673.00 9 months

Epidemiologist (MPH)** $ 86,132.00 $ 7,177.67 $ 71,776.67 10 months

Dietician (RDN) $ 57,034.00 $ 4,752.83

Clinical Pharmacist (PharmD) $ 109,974.00 $ 9,164.50

Pharmacist (PharmD) $ 105,049.00 $ 8,754.08

Social Worker Manger (MSW) $ 65,000.00 $ 5,416.67 Total Salary Expense and Training and Orientation Time

$ 623,422.00 $ 31,171


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Tactic 1-4 Cost Savings


Intervention Total Savings Cardiac Rehabilitation $ 671,381.50 Guideline Directed Medical Therapy $ 161,349.60 Multidisciplinary Teams $ 3,661,981.80 Transitional Care Coordination $ 4,401,682.50 Enhanced Medication Management by Pharmacist $ 2,929,585.44 Discussions about Advanced Directives HCAPS Increase

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Care-a-Van Pro Forma Analysis

Scenario 3Care-a-Van Volume (low performance)

Year Patient Volume2015 4802016 5282017 5812018 6392019 703

(1day x 48weeks x 10patients) (10% annual growth)

Table E: Salary Expense Annual Salary Monthly Salary Allocated for Care-a-Van

Registered Nurse(RN) $ 69,000.00 $ 5,750.00 $ 17,250.00 3 months

Registered Nurse(BSN) $ 73,000.00 $ 6,083.33 $ 18,250.00 3 months

Social Worker (MSW) $ 58,233.00 $ 4,852.75 $ 14,558.25 3 months

Epidemiologist (MPH) $ 86,132.00 $ 7,177.67 $ 14,355.33 2 months

Total Salary Expense $ 64,413.58

Table B : Cash Savings from Heart Attack Prevention

2015 2016 2017 2018 2019

Number of M.I. prevented 5 8 10 12 15

Cost per M.I. = $14,000 14,000 14,000 14,000 14,000 14,000Annual Cost Savings $ 70,000.00 $ 112,000.00 $ 140,000.00 $ 168,000.00 $ 210,000.00


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Care-a-Van Pro Forma Analysis

Assumption of Scenario 3 - Low performance conservative estimates.

Care-a-Van Pro Forma 2014 2015 2016 2017 2018 2019 a Initial Capital Outlay $ (75,000.00) b Cash Savings ( M.I. prevention) $ 70,000 $ 112,000 $ 140,000 $ 168,000 $ 210,000 c Donations $ 1,200 $ 1,320 $ 1,452 $ 1,597 $ 1,757 d Net Revenue (earned and saved) $ 71,200 $ 113,320 $ 141,452 $ 169,597 $ 211,757 e Less: Salary Operating Expense $ 64,414 $ 65,702 $ 67,016 $ 68,356 $ 69,723 f Less: Supply Operating Expense $ 868 $ 955 $ 1,050 $ 1,155 $ 1,271

g Less: Depreciation Expense $ 14,000 $ 14,000 $ 14,000 $ 14,000 $ 14,000 h Net Operating Income $ (8,081) $ 32,664 $ 59,386 $ 86,086 $ 126,763 i Add: Depreciation Expense $ 14,000 $ 14,000 $ 14,000 $ 14,000 $ 14,000 j Net Operating Cash Flow $ 5,919 $ 46,664 $ 73,386 $ 100,086 $ 140,763 k Add: Salvage Value $ 5,000 l Project Cash Flows $ 5,919 $ 46,664 $ 73,386 $ 100,086 $ 145,763

m Cost of Capital 3% 3% 3% 3% 3% n Present Value Interest Factors 0.9709 0.9426 0.9151 0.8885 0.8626

o Annual Present Value of Cash Flows $ (75,000.00) $ 5,746.35 $ 43,985.03 $ 67,155.55 $ 88,926.32 $ 125,735.15 p Net Present Value $ 331,548.39 IRR 51%


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Harlan Reeves

Development/dx of DM II (12 years ago)

Poor lifestyle management

Lack of education

Smoking/drinking to deal with

stressors

No regular medical checkups

Diabetic and Cardiac Events in the 7 months following MI/Rushed

to the ER (3 weeks ago)

Hospitalization for deteriorating condition and admitted as an

inpatient to the transitional care unit (2 weeks ago)

MI at home/placementof stent/pacemakerat Central Hospital

Development/dx of Grade III CHF (14 months ago)

Unmanaged DM II

FH of heart disease

Continued smoking and sedentary lifestyle

Rejected palliativecare 7 months ago

Margie suffering from caregiver’s burden

Never referred to HeartClinic or transferred to

Transitional Care

High BMI due to poor lifestyle

FH of DM II

Poor handling of CHF dx 14 mos. ago

Poor coordination of care for DM II and CHF

Non-adherence tocardiac medication regimen

Admitted only for observation 3 weeks ago

…no Transitional Care

Margie and Lisa now physically unable to

care for Harlan

Age/gender: 69 y/o M

Disease & Case Management

Home Care & Hospice


Community Care Partners

Health Promotion & Education

Health Coaching & Lifestyle Management

The system failed Harlan Reeves

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Thank You


CLARION Interprofessional Case Competition “The Heart of the Matter”

Documents

Transcript of CLARION Interprofessional Case Competition “The Heart of the Matter”