Creating an Integrated Patient Navigation Model Through Hospital, Health Plan and Community Collaboration

Creating an Integrated Patient Navigation Model through Hospital, Health Plan and Community Collaboration

June 24th, 2014 Catholic Health Assembly

Presented By: • Rosemary Younts ‐ Director, Community Benefit Dignity Health Sacramento Service Area • Ashley Brand ‐ Manager, Community Benefit Dignity Health Sacramento Service Area • Kelly Bennett Wofford –Executive Director Sacramento Covered

Agenda

• Dignity Health Overview • Understanding of the Sacramento Region • Developing Need using Emergency Department Data • Creating Meaningful Collaboration • IT Integration • Patient Navigator Program Overview & Outcomes • Challenges Experienced • What’s Next • Q&A

1 Dignity Health • Founded in 1986 and headquartered in San Francisco • 5th largest hospital provider in the nation; largest in California – Over 40 hospitals and care centers serve California, Arizona and Nevada communities • Changing to meet the needs of a dynamic new health care environment • Mission, however, remains steadfast – We are committed to further the healing ministry of Jesus, dedicating resources to: • Delivering compassionate, high‐quality, affordable health services • Serving and advocating for our sisters and brothers who are poor and disenfranchised; and • Partnering with others in the community to improve the quality of life

• “Hello Humankindness” – http://www.youtube.com/watch?v=asYUiWJrfQg

Our Topic: Patient Navigation Program

• Is an expression of our mission – Responds to the health care needs of the underserved – Creates access to regular, affordable quality care – Brings hospitals, health insurers and community nonprofit partners together in a collaborative effort that is groundbreaking for our region • Is aligned with goals of the Affordable Care Act – Improve quality of care – Coordinate care – Reduce costly Emergency Department admissions – Lower health care costs

2 Concept for Patient Navigation Model Not Complex

Establish a medical home for underserved patients who admit to Emergency Departments for non‐urgent care, coordinate their care, provide other needed social support services, and follow their progress • The devil, however, is in the details … IT, legal, privacy/security, partner relations, emergency department space, process, protocols, etc… • Learning objectives we hope to accomplish: 1. Understand how to analyze Emergency Department data to demonstrate the need and basis for patient navigation 2. Develop evidence‐based system of outcomes measurement and evaluation 3. Develop implementation strategy, including process flow, cost‐benefit analysis, and template of key hospital leaders and community partners core to the project team 4. Understand the need for, and value in, building collaborations between multidisciplinary partners, including providers/provider networks, health plans and community‐based partners

To Understand Need, Must Understand Community • Our community is Sacramento, California • Home to 4 Dignity Health Hospitals

Mercy Hospital Folsom Methodist Hospital of Sacramento

Mercy General Hospital Mercy San Juan Medical Center

3 Snapshot of Sacramento County

• Sprawling urban/suburban area; 995 square miles • 7 incorporated, 29 unincorporated cities • 1.4 million residents • 17% of all residents live below FPL Sacramento • 1 in 4 residents are uninsured or Region Medi‐Cal‐insured • Only now beginning to recover from recession • Population is ethnically diverse

Caucasian ‐ 46.7% Hispanic ‐ 21.2% Asian / Pacific Islander ‐ 15.2% African American ‐ 11.5% American Indian ‐ 2.2% Multi‐Racial ‐ 3.3%

The State of Sacramento County’s Safety Net

• Sacramento County’s safety net characterized as weak and fragmented – Only 5 Federally Qualified Health Centers and Look‐Alikes – All are young, financially fragile, and have historically operated in silos with minimal outreach in the community • County’s public health programs/services have been decimated • One of 2 counties in state with Medi‐Cal Geographic Managed Care – Short list of providers and no system of care coordination • California has one of lowest Medi‐Cal reimbursement rates, making it hard to attract providers • Without change, region’s safety net will reach full capacity before 2016

4 Hospitals Filling Monumental Gap

• Safety net is dependent upon Emergency Departments • Emergency Department visits by uninsured and Medi‐Cal‐insured for non‐ urgent care have more than tripled over past 5 years • Today, over 50% of all patients seen and treated in our Emergency Departments admit for basic primary care needs – Almost 70% are Medi‐Cal or uninsured – This represents nearly 47,000 patients annually – In 2013, unreimbursed Medi‐Cal expense alone for the 4 hospitals was over $103 million • Demand for care continues to grow with implementation of the Affordable Care Act in a region where access is a priority health issue

Changes with Health Care Expansion Through the ACA

5 Emergency Departments as Only Source of Care

• Research tells us Emergency Departments are suboptimal for patients in need of routine care – Designed for rapid, short‐term treatment of acute illnesses and injuries – No continuity of care – Patients with non‐urgent needs have low priority – ED physicians do not have a relationship with patients, lack complete records, face constant interruptions and distractions – No means of patient follow‐up • Emergency Department also an expensive alternative for primary care – Cost to treat primary care 3 to 5 times higher than in a physicians office or community clinic

Utilization Trends Spurred Pilot Program

• Established Community Health Referral Program through small grant award in 2011 • Despite limitations of pilot, outcomes held promise – 3,000 patients assisted over 2.5 years – 80% of those assisted received referrals and/or appointments with Primary Care Provider – 60% of those assisted attended their appointment • Felt strongly that an expanded model incorporating direct in‐person assistance in the Emergency Department would dramatically improve effectiveness – Baseline data needed to build a business case for taking the pilot full‐scale

6 How We Sold the Program: Demonstrating the Need Through Data

FY 11‐12 FY 12‐13 Number % Number % Overall ED Visits # of ED Visits 195,911 0% 202,185 0% Total ED Visits Unduplicated Patients 127,265 0% 129,851 0% Visits to ED for Primary Care # of ED Visits (D=C4) 99,658 51% 105,821 52% Unduplicated Patients (D=C5) 72,424 57% 76,700 59% ED Visits for Primary Care Visits between the hours of 8am‐5pm (D=C7) 48,827 49% 52,499 50% # of ED Visits (D=C7) 42,704 43% 45,938 43% ≥2 ED Vists for Primary Care Unduplicated Patients (D=C8) 15,470 21% 16,817 22% # of ED Visits (D=C7) 8,887 9% 9,432 9% ≥5 ED Vistis for Primary Care Unduplicated Patients (D=C8) 1,245 2% 1,362 2% Payor Mix for Visits to ED for Primary Care # of ED Visits (D=C7) 30,220 30% 34,910 33% Geographic Managed Care Unduplicated Patients (D=C8) 21,157 29% 23,979 31% (GMC) Medi‐Cal TOTAL ≥2 ED Vistis for Primary Care (D=C7) 14,295 14% 17,099 16% Unduplicated PTs w/≥2 ED Vistis (D=C8) 5,234 7% 6,168 8% # of ED Visits (D=C7) 18,030 18% 18,496 17% Self‐Pay (including Pending Unduplicated Patients (D=C8) 13,906 19% 14,917 19% Financial Aid) ≥2 ED Vistis for Primary Care (D=C7) 6,472 6% 5,920 6% Unduplicated PTs w/≥2 ED Vistis (D=C8) 2,349 3% 2,370 3% # of ED Visits (D=C7) 10,071 10% 8,502 8% Fee for Service (FFS) and Share Unduplicated Patients (D=C8) 7,515 10% 6,500 8% of Cost (SOC) Medi‐Cal ≥2 ED Vistis for Primary Care (D=C7) 4,122 4% 3,298 3% Unduplicated PTs w/≥2 ED Vistis (D=C8) 1,566 2% 1,296 2%

Capturing ED Utilization Data

• Obtaining Emergency Department utilization data to demonstrate deed – Work with Patient Registration Department and IT – Develop a report template to capture data elements

Admt Admt Dsch Dsch Dsch Dsch Diag Admt Ins Attend Name DOB Date Time Date Time ICD9 Desc Reason Name DR Phone Sex Race Acct# M/R_# Address City St Zip

• Obtain list of discharge diagnosis codes that identify non emergent diagnoses • Import codes into ED template to capture all visits for non‐ emergent needs

Patient Numerical ValueAgeAdmt_DateAdmt_TimeDsch_DateDsch_TimeDsch_ICD9Primary Care Dsch_Di ag_Desc Admt_ReasonIns_Name

1176/2562/25/12/2013 18011016/262/15/22/2013 18142001 71409946 2 N/ # AOI JGOITE NTR NOSPAI N ‐L/ LEG BITHYLAT ROI KNEED PROBL PAINEM X 7THROAT MO N T HSWE LL ING SELFMEDI PAY‐CAL

3348/4573/3342/17/7/6/20122013 20517218348/73/52/17/26/28/2012013 211850 14 379578230901060N/ # AEVER CONJFHEADUNCT INJNOS URY IVI TI UNS S NOSPECI FI ED CHBIFELLESTL,PI NKDOWHUR EYTSE N HI CHI HEAD LL S HE150 AD0 ON HUR CONRETTS HE AVYE DI CHES ZZY MEDI CA‐CALRE

4576/525/22/19/2013 16421566/285/14/29/2013 14221537 43813829 3 N/ # AATEOT L ITI EFS F ME CVD D IA‐DYS NOS ARTHRI A STROKEEAR PAI N MESELFDI CAPAYRE

6373/63711/28/1/20132012 114273/911/21/29/2013012 18104604801989 72 N/ # A HALPSYCHOSLUCINATIS IONSNOS ALCOOCNF US ED MEDI CARE

7677/7676/13/20122013 13516027/116/13/2012013 16192133990 5 UR IN TRACT INFECTION NOS MEDUTI RE FI LL MEDI CARE

9783/8179/17/7/20132012 212 1113/159/7/28/20130120830 31 55090409 8 N/ # APRAI SUNILATN INGUISHOULNAL DER/A HERNIRMA NOS HERIRNIGHTA SHOULPAI N DE R PAI N PLAYI NG F OOTBALL MESELFDI CAPAYRE

1110 3266 4/28/ 4/7/2013 134 8284/74/28/27/2013 12143253 78900233 9 ABCONTDOMIUS NALION OFPAI FI N,NGE UNS R PE CI F STOMACHINJRED U HAND PAIN FI VOMINGETI R NG MESELFDI CAPAYRE

1312 9484 5/25/ 2/1/2013 452092/85/24/25/2013 162839 5 7885009201N/ # AUBARAC ALS TERATION/HNOI CONS D HECIM OU‐NOSNES COMASDEUBDURAL SLIRIUM AND SUBAR ACHOI D S/P FALL MEDI CARE

1415 9268 12/8/20/2/2012 192105908/2 12/6/20/2012 160307V681 054 8 N/# AXSSU FI LUMBARE REPEAT VER PRETEBSCRIRA‐PTCLOSE LOWNOSE BACBLEKED/NE PAIN,EDS L2 FRACTUREFILLRE, DEMENTI A, MESELFDI CAPAYRE

15 68 8/26/ 9/6/2012 102 8589/98/26/2012 11144712 5979970092N/ # AHE ABMANORMALTURIA NOSCOAG PROF ILE NODEBRUS INGBLEE BLEDSEDI X2NG WK AROUNG S INJ ECTION AREA MEDI CARE

1617 3781 11/10/7/5/2012 948037 11/10/5/27/2012 103054 8 61171 845N/ # A CLMASOS TODY RIDI NIUMA DI FFI CI LE TOOTR SIDE H PAIBREASTN DI ARRHEPAI N A MESELFDI CAPAYRE

1817 9381 10/ 4/6/9/20132012 135 8054/9 10/6/29/2013012 16134116 7978092906N/ # A ABNORMALDOMI NAL COAGPAI N PROFEPIGASILETRI EREPICHECASTRI G K C PAI N, DI ARR EAH MEDI CARE

1819 93 3 1/27/ 8/3/20132012 19017581/228/7/23/2013012 22230132 78060804 7 FEVER DIZZINE NOSSS AND GI DDI NESS FEVERDIZZY COU GH X1DAY MESELFDI CAPAYRE

1920 31 30/ 18/10/15/2012 2002117198/10/10/25/2012 20232227 78659652 4 PA ACUTINFU E URIL RES NOSPIATI R ON HEFEVERART PAL PI TATI ONS SELF PAY

2120 1831 8/16/ 1/3/20132012 14116211/28/13/26/2013012 16182713 78826 6650N/ # ACE CHLLESTULTI IPA SIN OF NOS LEG PAINFIN ECTI ON IN LUNGS ,C P SELF PAY

22 2 5/4/12/30/2013 22315425/124/32/20/2013 23164612 37200829 3 ACOTUTITI ES CONJME D IUNCTA NOS VI I TI S NOS FEVEREARACHE SORE FEVER THROA T MEDI ‐CAL

232524 5382 1 1/20/ 7/9/7/6/20122013 115123 5107/91/299/7/20/26/2012013 1314570111 78650659221 49 N/ # AAC CHCONTESTUT EUS PAURIIN ION NOS NOSOF CHES T WALL FEVERMVCHEST A /BACKPACOUINGH PA IN SELFMEDI CAPAYRE

2627 2730 4/3/7/3/2013 17111354/03/7/23/2013 17154539 78906900 AB DOMI NAL PAI N,N UNSEPIGAS PETRICI F ABPHYSCD AIP ME N N ALT IS SUE S MESELFDI ‐CALPAY

2829 8830 4/1/19/26/2013 10211124/131/29/26/2013 14162300 78359903 4 N/ # ARANS TABDOMI CER NALEB ISPAICHEMI N RT ALW NOS QUA SLURRRQ L PAIEDN SPE ECH SELFMEDI PAY CARE

30 81 3/17/ 9/4/20122013 12413199/93/19/2012013 10213045 41071359 4 N/ # AUBERANS ST NDO CER AMIEB/1S ISCHEMIT EPISODEA NOS L GAUPPERSTRO EXINTTER EMI STINALTY WE BLE AEDNE K WI S S HT CHE S T PAI N MEDI CARE

3231 20 1 9/20/ 7/6/2012 20416519/297/0/26/2012 21201640 7753989081PESOPHAGE ERINAT AL ALCON REDIFLUX TION NE C CIABRCDOMIUM NALISCED 6PAI DAYS N AG O, DOE SNT LOOK RIGHT SELF PAY

33 38 4/5/12/20/2013 10013334/155/22/20/2013 10163821 71100946 7 N/ # AYSTJOI S NT LUPUSPAI N ER‐L/YTHELEG MA TOSISLUPUSL KNE E FLPAIAREN SL IP PED OF F STEP SELF PAY

3435 24492/ 128/ 6/5/20132012 22120066/712/26/28/2013012 210632 1 291 7539 HE MYALRPESGI AZOS AND T E R MY NOSOS I T IS NOS WEAKBACK PAINEN S S WICHITHLS L RAS NAUSH EA VOMIT ING DIARRHEAMEELF SDI CAPAYRE

3736 44 1 1/2/25/22/2013 153 9281/292/25/22/2013 19122038V872 78060 #N/ AFEVER HAZARD NOS CHE M CONT ACT NE C CHFEVEREMIC ALSICK EXP OS URE SELF PAY

3837 62 12/ 15/30/11/20132012 16522465/3812/10/21/2013012 19230541 71946531 5 N/ # AJOI UMBI NT LIPAICAL N‐L/HERNILEG A KNBEEELLY PAIBUTTN RION GHTNOT HEALE D MESELFDI ‐CALPAY

3940 21100/ 13/10/15/20122013 1021613173/10/10/25/2013012 20110152 78650906N/ # A ABCHESTDOMI PA NALIN NOSPAI N EP IGASTRI STOMACHCHEST HURTS IS HURT VOMI ITINGNG BIT OF PAIN SELF PAY

4142 6153 2/9/10/30/20132012 132 5212/199/31/20/2013012 13183052 25950000 5 DM2/ ACUT ENOS CYSTI UNCOMPTIS NS U LETHABLOODRGY SUGAR RECENT HIGH STEMI DM2 HY POT HY ROI DISM SMEELFDI CAPAYRE • Sort data to demonstrate need 43 5 1118/0/221 8//2 0 12 18047 8/10/218// 20 12 19032 28 72 45 B ACKACHE NOS LOWHA UPERP BE ACKR B AC PAIK N ECK PAI N MEDICAR E

7 Bringing the Partners Together

Represents groundbreaking collaboration for Sacramento region

About Sacramento Covered

Sacramento Covered is a community based non‐profit organization getting people covered and connected to health care services throughout the Sacramento region.

8 Organizational History

• Founded in 1998 as a collaborative initiative between four local health systems • Program was launched to expand local participation in Medicaid and SCHIP, among children and pregnant women • Cover the Kids reached over 50,000 children with coverage and access to care • In 2012, expands to serve adults and is re‐branded as Sacramento Covered

Comprehensive Services • Outreach • Education • Enrollment • Utilization • Retention

9 Program Overview

• New ED Patient Navigator Program builds on successful pilot demonstration • Includes 6 navigators • Purpose is to assist underserved patients who admit to the EDs for primary care in connecting/reconnecting with PCPs, community clinics, and other social support services • Goals are to: 1. Ensure patients can access appropriate primary care 2. Decrease dependence on EDs for primary care 3. Reduce uncompensated care expense

Information Technology Integration

• MS4 ‐ Electronic Health Records (EHR) used by Patient Registration in the Emergency Department to capture demographics of patients utilizing the ED. • Cerner –EHR used by ED clinical staff to capture medical activities that occur in the hospital. The system houses all hospital medical records • MobileMD ‐ Health Information Exchange (HIE) system used to communicate with providers outside of the hospital. It is a secure web‐based system that allows for sharing of medical records that meet HIPAA standards. • Health Plan Provider Portals – Access to obtain information regarding with whom patient is assigned to for primary care

10 Identification of Target Population • Focuses on Medi‐Cal insured and uninsured as target population • Majority of patients are identified by Patient Registration prior to discharge and directed to navigators – All patients sign a consent form prior to receiving assistance – During registration, uninsured and underinsured patients are asked if they need assistance with establishing a Primary Care Provider or reconnecting with their assigned if Medi‐Cal‐insured managed Medi‐Cal. • Answering yes triggers Patient Registration to connect patient with navigator

Role of the Patient Navigator

Patient Navigators:

• Establishes immediate rapport with patients in ER

• Provides follow up to ensure that patients connect to primary care physician

• Build collaborative relationships with clinics contacts

• Support patients in mitigating access barriers (i.e. transportation, health coverage, language)

11 Case Model

Program Services • Navigators provide direct patient assistance, which includes: – Determining patient’s assigned Medi‐Cal PCP – Making timely follow up appointments with PCP – Helping uninsured get established at a community clinic – Connecting patients to additional community resources – Educating patients on current health plan coverage – Enrolling patients in Dignity Health’s no‐cost chronic disease programs • Navigators conduct reminder calls prior to scheduled appointments • Transportation is arranged on a case by case if needed – Navigators schedule taxi pickups for patients • Navigators follow up after appointment to confirm attendance and ensure patient is pleased with their care.

12 Meet our Navigators

From left to right: Adriana Sandoval, Eva De La Cruz, Gabriela Fredrickson, Silvia Dominguez, Joseph Garcia • Experienced with with target populations • Come to us from community‐based nonprofits, clinics and health plans • Culturally competent/ bilingual • Tenacious and patient

Management Oversight • Management and analysis of all data elements • Organize quarterly meetings with all partners at management level • Develop audit process of systems utilized by PN’s to meet Dignity Health compliance requirements • Ensure all new employee hospital requirements are met for all PN’s • Develop orientation for PN’s that encompasses all partner organizations • Facilitate hospital core team meetings quarterly • Constant internal communication with hospital senior leadership

13 Program Data • Emergency Department utilization analyzed bi‐annually using data compiled through Patient Registration System o Provides ability to track large trends o Navigators are able to see high utilizers through MS4 and are tailoring their conversations accordingly • Through MobileMD, able to track readmission rates for all patients assisted by navigator at all 4 hospitals o Data analyzed quarterly o Navigators notified of patients readmitting , allowing them to provide additional follow‐up services as needed • Navigators have limited access in EHR system, allowing them to document when follow‐up appointments are scheduled • All data is shared with hospitals

Quantitative Program Outcomes

• Persons Served (8/6/2013‐4/30/2014) ‐ 2999

Insurance Type Count of Patients % of Total Appts Scheduled Blank 90.3% 2 Blue Cross GMCP 219 7.3% 156 CMISP 11 0.4% 3 Emergency Medi‐Cal 79 2.6% 72 Health Net GMCP 402 13.4% 270 Medi‐Cal 437 14.6% 373 Medi‐Cal Share of Cost 19 0.6% 14 Molina GMCP 120 4.0% 94 Molina LIHP 50 1.7% 39 Other 63 2.1% 36 Pending Financial Assistance 1147 38.3% 935 Self‐Pay 443 14.8% 377 Grand Total 2999 100.0% 2371 • 2371 Appointments scheduled with Primary Care Providers – 79% of patients have a follow up appointment scheduled

14 Quantitative Program Outcomes

• Appointment Show Rate – 62% (669/1075) of all patients contacted attended their appointments and 10% (112/1075) rescheduled. – Identify challenges with show rate for target population • Readmissions

Sacramento Service Area Patient Navigation # of Hospital # of Unique Patients Unique Patients (YTD: (FY12‐13) 8/6/13‐4/30/14) ED Visits for Primary Care 76,700 2,999 ≥2 ED Vists for Primary Care 45,938 497 Readmission Rate for Primary Care 60% 17%

Qualitative Program Outcomes • True collaboration established with sharing of data and engagement from all partners • Establishment and/or strengthening of relationships with local Community Health Centers • Ability to articulate barrier trends experienced by patients • Development of collaborative meetings between health plans, hospitals, and Individual Provider Associations (IPA’s) • Continuous feedback loop to improve program • Hospital staff engagement – Ongoing education and communication of program outcomes – Quarterly meetings with hospital core team – Support from all hospital senior level management

15 Challenges During Implementation • Sharing of information through multiple systems – Working with health system IT to provision navigators • Engaging hospitals • Establishing reporting mechanisms and appropriate data elements to capture desired outcomes • Orientation and training of patient navigators • Challenges with non‐clinical contract employees being placed inside ED – Available space in Emergency Departments • Ensuring target population is being served • Accessibility of patients to obtain information following services

What’s Next

• Working with IT to implement a Population Health Management System – Moving from spreadsheets to management of data through one system • Replication of program across other Dignity Health Hospitals • Creating awareness within county level and across managed care health plans • Establishment of goals and expectations for Navigators – Development of priorities – Analyze case loads

16 Patient Feedback

“…Patient Navigator Silvia Dominguez was very kind, helpful and professional. Since I am unemployed and without insurance, she offered all kinds of information and resources for help.”

“ …We had spent two weeks attempting to locate a doctor in this area (with no success). After approximately 30 minutes, she had accommodated all our needs for our 3 year old to our 30 year old. I cannot express the relief and assurance I felt after leaving her office. She was polite, concerned and very authentic in her line of work. It felt as if she was providing services for her own family…”

“…Mr. Garcia is awesome with the work he does to help any patient who needs his guidance. Mr. Garcia is always found to very respectful, caring and understanding, always the professional, always ready to help. In fact, our family could have not asked for more from Mr. Garcia, and he left our family with us feeling a greater sense of ease, and that is something that we needed very much!...”

17 Thank You Contact Information:

• Rosemary Younts Dignity Health Community Benefit Director [email protected] (916) 851‐2731

• Ashley Brand Dignity Health Community Benefit Manager [email protected] (916) 851‐2005

• Kelly Bennett‐Wofford Sacramento Covered Executive Director [email protected] (916) 414‐8336