CENTRICITY HEALTHCARE USER GROUP (CHUG) 2013 SPRING CONFERENCE

Presented by: John Halfen M.D. Medical Director Lakewood Health System Staples, MN

COMMUNITY SERVED

Lakewood Health System (LHS) is located in Staples, which is near the geographic center of the state. The service area is contained in four counties that are among the poorest and the “oldest” (age of residents) in the state. The area’s growth rate is slow and the already large share of persons over 50 is expected to increase dramatically in the next 5 years. Individual patients total 61,118 with 31,827 seen in the last three years. The hospital is a “Critical Access Hospital” and the clinics are “Rural Health Clinics” The closest referral center is in St. Cloud 60 miles away.

 St. Cloud Hospital (Centracare) – 60 miles in St. Cloud – 489 beds  St. Joseph’s Hospital (Essentia) – 45 miles in Brainerd – 162 beds  University of Minnesota Hospitals – 150 miles in Minneapolis  Children’s Hospital – 150 miles in Minneapolis  St. Mary’s Hospital (Mayo) – 220 miles in Rochester  Sanford North (Sanford) – 150 miles in Fargo  Medicare  Medicaid  Blue Cross/Blue Shield  Medica  UCare  Humana  Health Partners  Preferred One  South Country Health Alliance  Other private insurances  Uninsured

 HOSPITAL: 25 bed critical access with another 10-bed senior behavioral health unit (Reflections)

 CLINICS: Staples, Motley, Pillager, Browerville, Eagle Bend, St. Cloud

 SENIOR SERVICES: Care Center, Memory Care, Lakewood Pines, Lakewood Manor, Lakewood Reflections, Home Care, Hospice, Palliative Care

 FOUNDATION: Promoting health and wellness in the communities we serve

 RETAIL: Shoppe, Medical Marketplace (DME)

 REFINE DERMATIQUE: Aesthetic medicine clinic offering laser skin care, Botox and other injections, cool and hot skin sculpting, skin care products

 SPECIALTIES (via LHS): Family Medicine, , Ob/Gyn, Pediatrics, Geriatrics, Palliative Medicine, /Hematology, , , Psychology, Dermatology, , , Medical Review Officer

 SPECIALTIES (onsite consults): Cardiology, Gastroenterology, Urology, ENT, Ophthalmology, Neurology, Orthopedics, Nephrology, Pulmonology, Radiology

U.S. Healthcare Expenditures (Per capita) “ I suffer no illusion that this will be an $16,000 easy process. It will be hard. But also $14,000 know that nearly a century after Teddy Roosevelt first called for $12,000 reform, the cost of our healthcare has $10,000 weighed down our economy and the $8,000 conscience of our nation long enough. So let there be no doubt: $6,000 healthcare reform cannot wait, it $4,000 must not wait, and it will not wait $2,000 another year.” Projected $0 -President Barack Obama

Source: Centers of Medicare and Medicare, Office of the Actuary Projections adjusted for impact of Patient Affordability Act of 2010  25% of expenditures incurred during the last year of life

 80% of Medicare expenditures on 12%

 22% of total health expenditures on top 1% (2009 per AHRQ)

 “Unnecessary Care” is $400 billion (of about $2.6 trillion)

 Decrease of 12% of “unnecessary” stops growth of healthcare over GDP! (Gwande)

Healthcare is inefficient with duplications, inappropriate applications, delayed presentations, non-focused diagnostics, and frequent use of unproven treatments

Medical Homes provide a means of efficient health care using 21st Century communication, information technology and coordination “Medicine’s place is fixed by its services to Medical Homes result in: mankind; if we fail to measure up to our opportunity, it means state medicine,  Better care political control, mediocrity, and loss of

 Reduced expenses professional ideals. The members of the medical fraternity must cooperate in this  Improved satisfaction work and they can do so without interfering

 Maintained revenue with private professional practice.” -William Mayo M.D., 1921

 JULY 2006: American Academy of Family Physicians (AAFP), American College of Physicians (ACP): Joint Principles of the Patient-Centered Medical Home

 MARCH 2007: American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA): Joint Principles of the Patient-Centered Medical Home

• Personal physician – all contacts

• Physician led team

• Whole-person orientation

• Coordinated, integrated care

• Quality and safety assurance

• Enhanced access

• Revolutionized payment system Geisinger Health System – ProvenHealth Navigator (700 MDs at 41 sites)  Admissions: 18% reduction (12% decrease vs.. 6% increase in control group)  Readmissions (30-day): 36% reduction  Diabetic quality scores: 22% better  CAD quality scores: 45% better  Costs: 7% less  Other:  Improved medication adherence and generic use  Increased compliance with evidenced-based care

Group Health Cooperative - Seattle (12 month comparison to control group)  Emergency room visits: 29% reduction  Admissions: 11% reduction  Office visits: 6% reduction  Expenses: $16 per patient per year increase; $54 per patient per year less emergency room expenses  Other:  Improved patient experience ratings  Improved global quality metrics  Reduced staff burn-out

Intermountain Healthcare – Management Plus  Mortality: 16% decrease over 2 years  ER Visits: Higher

Geriatric Care Resources for Assisted Care of Elders (GRACE)  ER Visits: 19% decrease over 2 years (1785/1000 to 1445/1000)  Hospitalization: Decreased (data unreported)

Community Care of North Carolina  Savings versus control group (Mercer reported):  $240 million in 2005  $314 million in 2006

Blue Cross Blue Shield of South Carolina – Charleston Area Pilot  Admissions/1000: 14% increase in 12 months; but 11% less than control group  Days/1000: 10% decrease; 36% better than control group  ER Visits/1000: 12% decrease; 32% better than control group  Expenses: 6.5% less than control group; 15.8% less when risk adjusted

Blue Cross Blue Shield of Illinois – Patient-Centered Care Pilot  Care Gaps: 49.5% decrease within 12 months  ER Visits for Asthma: 74% decrease  ER Visits for COPD: 67% decrease  ER Visits for Migraines: 19.4% to zero  Modest improvements in Diabetes care and prevention screening Program Development:

 Predevelopment conceptions and education – late 2006

 Development and planning – Summer 2007

 Patient entry of initial trial – January 2008

 Full implementation – June 2008 Present status:

 Medical Home Patients – approximately 800

 Medical Home Providers – 14 Family Practice Physicians; 1 Pediatrician

 Care Coordinators – 5 FTE’s

 Patients

 Primary Care Physicians

 Physician Assistants and Nurse Practitioners

 Doctor of Pharmacy

 Registered Nurses

 Licensed Practical Nurses

 Registered Dieticians  Electronic Medical Record

 Internet Communications

 Web Address

 Telephone System

 Scheduling

 Publishing/Media

 Preventive Treatments

 Advance software (Sharepoint, Excel, etc)  Treat disease at home and in the clinic vs. ED and hospital  Prevent disease progression vs. dialysis, bypass, stenting, care center  Avoid excessive medications  Prevent duplicity of testing  Use the most appropriate therapies  Using appropriate providers (RN, PA, MD)  Define the patients  Enroll and maintain efficiently  Assure best practices for all  Registry usage  Maintain contact availability  Engagement of patients

CRITERIA FOR MEDICAL HOME PATIENT ADMISSION (any of these)

• Multiple diagnoses - 3 or more requiring treatment • Multiple medications - 4 or more prescriptions • Severe illness • Chronic illness - i.e. diabetes, CHF, etc. • Illness requiring frequent visits - every 2 months or less • Lack of insight into healthcare - due to age or knowledge • Physician identification as a “good candidate” • Patient request • Patient must be willing to follow-up with a single provider to routine care

 Provider initiates enrollment

 Patient, family, consultant or other healthcare provider contacts LHS and the care coordinator, who then request endorsement from the patient’s primary care provider

 LHS computer review or a third party such as pharmacy or insurer identify a patient as a candidate. The care coordinator is notified who then requests endorsement from the patient’s primary care provider.

• Personal physician

• Whole-person approach to care

• Team approach with Care Coordinator

• Heightened access

• Communication with physician

• Ongoing education

• Preventive Care Guidelines in a EMR-generated continuous registry

• Inclusion in decisions/care/responsibilities

• Electronic medical records (EMR)

• Medical Home Providers • Social Services

• Individual provider’s nurses • Physical Therapists

• Medical Home Care Coordinator • Dieticians

• Medical Home System Coordinator • Diabetic Educators

• Medical Home Physician Supervisors • Occupational Therapists

• Medical Home Pharmacist • Medical Consultants

• Independent Pharmacists • Billing/coding experts

• Medical Home Information Technologists • Communications experts

• Exercise Therapists

• By definition, must be physicians practicing primary care (at Lakewood Health System, family physicians and a pediatrician)

• Must be willing to provide care according to the Joint Principles: 1. whole person care 2. team care 3. coordinated care 4. enhanced access/communication 5. meeting established guidelines for safety and quality

• Accept new degree of responsibility to the entirety of the patient’s healthcare

• Contribute to the Medical Home through analysis and suggestions

• Be willing to consider patient care recommendations for evidence- based practice PROCESS OF MEDICAL HOME PATIENT ADMISSION

• Provider Identifies Medical Home candidates: • If appropriate, discusses “Medical Home" with the patient • Finds out any additional information needed (such as last PSA, colonoscopy, etc.) if seeing patient in the clinic

• Updates Medical Home Summary and Care Plan:

• Gives patient an updated copy

• Sends copy to the Medical Home Care Coordinator

• Interfaces with Patient: Answers all phone and e-mail questions from Medical Home patients using own knowledge, charts and discussion with provider as needed

• Updates Medical Record: Corrects and completes records (including all preventative care categories) upon admission to Medical Home using EMR or patient telephone calls

• Enrolls Patient: • Develops lists of appropriate patients for Medical Home • Gets permission from the provider involved • Telephones patient to verify data on the record

• Welcomes Patient: • Sends “Welcome to Medical Home” Three ring binder including the welcome letter, newsletter, and calendar for new patients • Sends patient updated Medical Home Summary

• Stratifies Patients: • Compiles a list of all Medical Home patients and updates weekly. • With System Coordinator, develops lists of Medical Home patients with specific diseases for disease specific communication.

• Coordinates Care & Education: Arranges consultations and allied healthcare

• Access to personal provider and consultants • Group Visits • Clinic pharmacist – Medication Therapy Management (MTM) • Clinic diabetes educators • Monthly newsletters

• Acts as Patient Advocate: • Is innovative in concepts of preventive and therapeutic care for chronic disease, especially group-based activities and education sessions • Has a personal relationship with patients, acting in roles of educator as well as patient advocate for optimizing cares

• ENGAGES THE PATIENT IN THEIR CARE

• ENFORCES THE SYSTEM TO PROVIDE APPROPRIATELY

PATIENT ENGAGEMENT

ACCESS EDUCATION CHART SUMMARY WELCOME LETTERS LOOSELEAF BINDERS MONTHLY NEWSLETTERS ADVISORY COUNCIL

 Specific Metrics  Tools  Patient Screening Protocols  Calendar

 Periodic Medical Home Screenings

 Monthly and Annually

 LHS Preventive Care Guidelines

 Alerts/Directives

 Performance Metrics

 Surveys  Internal statistics  Payer statistics

 Centricity EMR – “Protocols”  Centricity EMR – Searches  Centricity Practice Solution  MQIC  Centricity “Care Alerts”  Centricity “Flags”  Sharepoint “Medical Home”  Sharepoint “OPPE/FPPE”

• Based upon Physician Quality Reporting System (PQRS)

• Based upon U.S. Preventative Services Task Force 2006 Guidelines

• Based upon Nursing Home Standards

• Based upon Common Practice

Monthly: • Patients with 10 or more medications without MTM in past year • Patients not seen within past 6 months • Patients turning 65 (Welcome to Medicare Exam) • Males turning 65 with history of any smoking and no abdominal ultrasound • Diabetic patients with birthdays reminded of shoe availability and documented in the chart

Annually: • “Medical Home Patient Screening Protocol” • “Medical Home Screening Calendar”

Based upon the recommendations of the U.S. Preventive Services Task Force, as well as the judgment of the Lakewood physicians, the following are guidelines which Lakewood Health System endorses. These are meant to be general guidelines only. Specific recommendations for specific patients must be made by their own physicians taking into consideration their own clinical situations as well as individual preferences. The guidelines are NOT correct for patients with specific factors which increase their risk compared to the general population. 1. Screening mammography every 1-2 years for women aged 50 to 74. 2. Screening by Pap smear for cervical cancer in women less than 65 who have been sexually active and have a cervix and every 1-3 years depending upon previous history and age. 3. PSA every 2 years for men ages 50-70.(Not a USPSTF recommendation) 4. One time screening for abdominal aortic aneurysm in men ages 65-75 who have ever smoked. 5. Aspirin use in men aged 45 to 79 and women aged 55 to 79, unless significantly contraindicated by other conditions in adults with increased risk of coronary heart disease.

6. Blood pressure screening for adults over 18 every two years if normal. 7. Lipid screening for men over age 35 and women over age 45 at 5 years intervals if normal, but start at age 20 if history of diabetes, coronary artery disease or family history of coronary artery disease. 8. Urine cultures in pregnant women at 12-16 weeks gestation. 9. Depression screening during routine visits. 10. Weight and height measurements along with waist circumferences when applicable to find BMI >35, or male waist>40 or female waist >35. 11. Promote physical activity with a minimum of 3X weekly with heart rate >100 for 20 minutes or more. 12. Screening for diabetes every 3 years in adults with hypertension or hyperlipidemia. 13. Bone densitometry in women starting at least by age 65 but younger with higher risk factors and repeated according to findings no sooner than every 2 years when abnormal.

14. Rh (D) blood typing and testing for all pregnant women during the first visit for prenatal care. Repeated at 24-28 weeks for Rh (D) negative women prior to receiving Rh(D) immunoglobulin. 15. Screening of children less than 5 years old for evidence of defects in vision. 16. Screening for chemical misuse such as alcohol and tobacco during routine visits. 17. Colonoscopy every 10 years starting at age 50 to 75 unless increased risk factors. 18. Chlamydia testing in all sexually active women < 24 years old at least annually and other women is any increased risk. 19. HIV screening for all adults and adolescents at increased risk due to being in correctional facilities, or homeless shelters, or being male homosexuals or parenteral drug abusers.

Physical examinations and immunizations are encouraged for children and adults according to the following schedule: • Children and adolescents: – Immunizations according to the established schedule of the American Academy of Family Physicians, American Academy of Pediatrics and the Center for Disease Control. – Annual visits for routine physical screenings • Male adults: – Annually until finished with college, every 5 years until 50, then every 2 years. – Consider meningococcal and hepatitis vaccinations when starting college. – Diphtheria/tetanus boosters every 10 years. – Influenza annually starting at age 50 but anytime earlier if desired. – Pneumococcal vaccine at age 65.

Physical examinations and immunizations are encouraged for children and adults according to the following schedule:

 Female adults:  Once sexually active, annually with pap smears, birth control and Chlamydia testing until finished with college, and annual Pap smear has been normal for 3 consecutive years, then every 3 years.  Resumption of annual visits at age 50  Consider meningococcal and hepatitis vaccines when starting college  Papilloma virus immunization preferable before sexual activity  Diphtheria/tetanus boosters every 10 years  Influenza annually starting at age 50 but anytime earlier if desired  Pneumococcal vaccine at age 65  Self examinations are recommended as follows:  Testicular examination for tumors is recommended every 3 months  Breast self-examinations are recommended monthly  Skin examinations should be done every 6 months

1. DM without urine microalbumin within last year 2. Chronic kidney disease stages I & II 3. Chronic renal disease without creatinine, calcium and lipid profile within one year 4. Chronic renal disease without BP in last year 5. Chronic use of Prednisone 6. Prescribed use of NSAIDS daily 7. BMI >35 or <22 without dietary consult 8. Chronic use of antipsychotics without psychiatric consult 9. Chronic use of Estrogens 10.Chronic Aspirin use in men < 45 y.o. 11.Chronic Aspirin use in women < 55 y.o. 12.Plavix and PPI 13.Heart failure with chronic NSAID use in patients 14.Hypertension or hyperlipidemia without blood glucose in past year 15.No lipid profile within 5 years and > 50 or < 75 16.CAD not on ASA

17. Age 50-80 and no colonoscopy within 10 years 18. Women with uterus < 65 without pap smear within last 2 years 19. Women between 50 – 75 y.o. without mammogram within last 2 years 20. Psychotropics without psychosis diagnosis and no dosage reduction in past year 21. Males 50 - 70 y.o. with no PSA within last 2 years 22. Women > 65 without bone densitometry 23. Women > 50 on PPI/H2 blocker, without bone densitometry within 2 years 24. Diabetes with thiazide 25. COPD without Pneumovax 26. CAD without HMG Co-A reductase inhibitor < 80 27. Hgb A1C > 9 28. Diabetes without Hgb A1C within 6 months 29. Diabetes with LDL > 100 30. CAD with LDL > 100 31. CHF without ARB or ACE inhibitor 32. Previous MI without beta blocker 33. CVA/TIA without ASA or Plavix

34. CVA/TIA without carotid Doppler 35. Osteoporosis without bone resorption inhibitor 36. Hip/Spine fracture without bone densitometry 37. Breast cancer without Selective Estrogen Receptor Modulators (SERM) 38. PPI/H2 block without GERD/PUD Dx 39. PPI/H2 block with osteoporosis 40. Hepatitis C without viral studies 41. >50 y.o. without influenza vaccine 42. >65 y.o. without Pneumovax 43. CAD with DM without ARB or Ace inhibitor 44. CAD > 140/90 45. Chronic Kidney Disease Stage 4/5 and no renal consult in 1 year 46. COPD and no PFT in 2 years 47. Asthma, Emphysema without PFT Testing 48. Ischemic Vascular Disease and no ASA/Plavix

MEDICAL HOME CALENDAR MEDICAL HOME HEALTH CARE HOME  Better care: Provides optimal care to patients with complex medical conditions through improved access to care, greater adherence to proven treatment protocols, and achievement of optimal clinical outcomes

 Lower cost: Reduces overall medical costs by shifting care to less cost-intensive modes of delivery

 Higher Satisfaction: Improves patient and provider satisfaction rates, and assists in physician recruiting efforts

 Enhanced Access: Promptly getting the most appropriate help when it is needed, with 24/7 access to a dedicated team of clinicians

 Optimal Treatment: Assuring that the best treatment practices are utilized across the entire continuum of care

 Improved Outcomes: Achieving the best clinical outcomes Enhanced Access:

 Personal physician

 Direct access to Care Coordinator via phone, email and web

 Interdisciplinary team, whole-person approach to care

 Heightened access to designated and expanded clinic hours

 Ongoing education and newsletters

 Inclusion in decisions, care and responsibilities

 Electronic medical records (EMR) Optimal Treatment:

 Preventive Care Guidelines and Screening Protocols

 Driven by a EMR-generated continuous registry

 Based upon accepted standards of care  Physician Quality Reporting System (PQRS)  U.S. Preventive Services Task Force 2006 Guidelines  Nursing Home Standards  Common Practice

 Assures accountability of practice Optimal Treatment (continued)

 Routine Monthly Screening Protocols  Patients with 10 or more medications without MTM in past year  Patients not seen within past 6 months  Patients turning 65 (Welcome to Medicare Exam)  Males turning 65 with history of any smoking and no abdominal ultrasound  Diabetic patients reminded of shoe availability upon birthdays

 Routine Annual Screening Protocols  “Medical Home Patient Screening Protocol”  “Medical Home Screening Calendar”

 Application of Clinical Alert Audits UCARE REPORTS VALUE-CARE REFORMS OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT

HCH CREDENTIALING REQUIREMENTS Care coordination according to need Participation in collaborative learning groups Holistic approach to medical, mental and social Registries for diseases and follow-up Focus on preventive cares Quality reporting participation “Top of license” care teams IMPROVED OUTCOMES Measure Baseline Most Recent Time Period Percent Improvement N N Improvement Rating Chronic NSAID use in 1.44% 1.3% 2 year 10 % patients with heart 418 707 failure (13)

MI without Plavix & PPI (12) 4.5% 0.5% 2 year 89% 444 657 CVA /TIA without carotid 0.6% 0.9% 2 years 50% Doppler (34) 469 664 Chronic use 0.26% 0.23% 4 months 11.5% Antipsychotics without 383 443 Psychiatric Consult (8) DM without micro- 20.9% 13.8% 3 year 34% albumin within last year 359 506 (1) Chronic Renal Disease 0.82% 0% 2 year 100% without BP in last year (4) 367 714 CHF without ARB or Ace 5.5% 4.6% 2 year 16% Inhibitors (31) 469 656 PROGRAM VALUE: Improved Outcomes Measure Baseline Most Recent Time Period Percent Improvement N N Improvement Rating DM with HgbA1C > 9.0% 1.7% 3.4% 3 year 7.0 % (27) 459 668 DM without HgbA1C IN 6 1.67% 0.87% 1 year 48% 180 460 MONTHS (28)

DM with LDL > 100 (29) 1.1% 3.7% 3 year 236% 380 672

DM with Thiazides (24) 4.2% 6.4% 2 years 52% 451 654

Breast Adenocarcinoma 3.3% 0.6% 2 years 82% without SERM (37) 486 649 ASA in men <45; in 2.5% 2.5% 1.5 months 0% women < 55 y.o. (10) 646 678 Hip Fracture without 1.0% 0.6% 2 years 40% Dexascan (36) 482 649 Chronic use of 6.2% 1.8% 3 year 71% Prednisone (5) 466 668 PROGRAM VALUE: Improved Outcomes

Measure Baseline Most Time Period Percent Improvement N Recent Improvement Rating N

CAD not on ASA (16) 3.7% 3.8% 3 years 3% 432 707

Males 50 – 70 with no PSA 5.0% 2.8% 2 years 44% within last two years (21) 597 714

CAD without HMG Co-A 4.8% 2.3% 2 years 52% reductase Inhibitor < 80 (26) 459 660

Previous MI without beta 1.3% 1.2% 1 year 8% blocker (32) 603 665 CVA/TIA without ASA or 0.6% 0.9% 2 years 50% Plavix (33) 469 664 PPI or H2 blocker without 19.41% 8.2% 2 years 58% GERD/PUD (38) 338 714 PPI or H2 blocker without 10.7% 11.3% 3 year 6% bone densitometry within 2 476 654 years (23) PROGRAM VALUE: Improved Outcomes

Measure Baseline Most Recent Time Period Percent Improvement N N Improvement Rating > 50 y.o. without Influenza 14,68% 16.5% 3 years 50% vaccination (41) 620 714 > 65 y.o. without 22.10% 19% 2 years 14% Pneumococcal vaccination 620 714 (42)

PPI/H2 with diagnosis of 3.5% 8.1% 3 year 131% osteoporosis (39) 487 714 Hypertension or 7.1% 1.1% 3 years 85% Hyperlipidemia without blood 420 696 glucose in past year (14) BMI > 35 or < 22 without 23.3% 19.9% 1 year 15% dietary consultation (7) 636 668 COPD without Pneumovax 5.5% 4.1% 1 year 26% (25) 597 659

Chronic kidney disease 0.82% 0.40% 1 year 51% stages I & II not on ARB or 367 506 ACE inhibitor (2)

Average Number of Clinic Visits (6 month periods):

700

600

500

400

300

200

100 Average Clinic Visits per 100per Visits Clinic Average 0 Period: -4 -3 -2 -1 +1 +2 +3 +4 +5 +6 +7 Number: 797 797 797 797 709 35 566 490 383 313 229 Average Charge per Clinic Visit (6 month periods):

$200 $180 $160 $140 $120 $100 $80 $60 $40 $20 $0 Period: -4 -3 -2 -1 +1 +2 +3 +4 +5 +6 +7 Number: 797 797 797 797 709 635 566 490 383 313 229 Average Total Charge for Clinic Visits (6 month periods):

$1,000 $900 $800 $700 $600 $500 $400 $300 $200 $100 $0 Period: -4 -3 -2 -1 +1 +2 +3 +4 +5 +6 +7 Number: 797 797 797 797 709 635 566 490 383 313 229

Average Inpatient Admissions (6 month periods):

25

20

15

10

5 Inpatient Admissions per 100per Admissions Inpatient 0 Period: -4 -3 -2 -1 +1 +2 +3 +4 +5 +6 +7 Number: 797 797 797 797 709 635 566 490 383 313 229 Note: 2007 CDC NHSR Reported Average Inpatient Admission Rate/100 = 11.44 Average Charge per Inpatient Admission (6 month periods):

$18,000 $16,000 $14,000 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $0 Period: -4 -3 -2 -1 +1 +2 +3 +4 +5 +6 +7 Number: 797 797 797 797 709 635 566 490 383 313 229 Average Inpatient Charge (6 month periods):

$3,500

$3,000

$2,500

$2,000

$1,500

$1,000

$500

$0 Period: -4 -3 -2 -1 +1 +2 +3 +4 +5 +6 +7 Number: 797 797 797 797 709 635 566 490 383 313 229

Average Emergency Room Visits (6 month periods):

60

50

40

30

20

10

Emergency Room Visits per 100per Visits Room Emergency 0 Period: -4 -3 -2 -1 +1 +2 +3 +4 +5 +6 +7 Number: 797 797 797 797 709 635 566 490 383 313 229 Note: 2008 CDC NHSR Reported Average ER Visits/100 = 41.4 Average Charge per Emergency Room Visit (6 month periods):

$2,500

$2,000

$1,500

$1,000

$500

$0 Period: -4 -3 -2 -1 +1 +2 +3 +4 +5 +6 +7 Number: 797 797 797 797 709 635 566 490 383 313 229

Average Total Emergency Room Charge (6 month periods):

$1,400

$1,200

$1,000

$800

$600

$400

$200

$0 Emergency Room Capita per CostsRoom Emergency Period: -4 -3 -2 -1 +1 +2 +3 +4 +5 +6 +7 Number: 797 797 797 797 709 635 566 490 383 313 229

Average Admissions (6 month periods):

1600

1400

1200

1000

800

600

400

200

0

Average Admissions per 100per Admissions Average Period: -4 -3 -2 -1 +1 +2 +3 +4 +5 +6 +7 Number: 797 797 797 797 709 635 566 490 383 313 229 Note: 2007 CDC NHSR Reported Average Inpatient Admission Rate/100 = 11.44 Average Charge per Admissions (6 month periods):

$12,000

$10,000

$8,000

$6,000

$4,000

$2,000

$0 Period: -4 -3 -2 -1 +1 +2 +3 +4 +5 +6 +7 Number: 797 797 797 797 709 635 566 490 383 313 229 Average Total Admissions Charge (6 month periods):

$900 $800 $700 $600 $500 $400 $300 $200 $100 $0 Period: -4 -3 -2 -1 +1 +2 +3 +4 +5 +6 +7 Number: 797 797 797 797 709 635 566 490 383 313 229 Inpatient Admission Measures: Data Perimeters: • Inpatient Admissions per 100 • Average Cost per Inpatient Admission • Lakewood Health System Pre- & • Average Inpatient Costs Post-enrollment in Medical Home • Inpatient Re-admissions within 30 days (in 6 month Coherts)

Emergency Room Measures: • “Outside” Pre- & Post-enrollment in • Emergency Room Visits per 100 Medical Home (in 6 month • Average Cost per Emergency Room Visit Coherts) • Average Total Emergency Room Costs • Control Group of Non-Medical Outpatient Clinic Measures: Home Patients with similar • Average Clinic Visits per 100 characteristics/severity (in 6 month • Average Cost per Clinic Visit Coherts) • Average Total Costs for Clinic Visits • 50 to 80 years of age, with:  CHF, COPD, Diabetes Pharmaceutical Cost Measures:  Greater than 10 medications • Average Number of Medications

• Pharmacy Costs per Patient

Patient Satisfaction Survey: One of Medical Home’s key elements is the active involvement of the patient and their family. Thank you for your input regarding this program. Please return your completed survey during your next appointment, drop them off at any clinic desk or send them back in the enclosed envelope.

When you need to see your doctor, do you feel you are able to get in when needed? Always Usually Sometimes Rarely When you have questions, do you get a timely response? Always Usually Sometimes Rarely Do your visits with your Medical Home provider address all of your medical needs? Always Usually Sometimes Rarely Does the Medical Home Care Coordinator (Niki, Connie) adequately answer your questions when you call? Always Usually Sometimes Rarely Do you feel that your provider addresses all of your health problems to your satisfaction? Always Usually Sometimes Rarely Are consultations with other physicians and ancillary personnel made as you feel necessary? Always Usually Sometimes Rarely Do you like the “Medical Home News” that is mailed to you monthly? Always Usually Sometimes Rarely Do you understand your health problems and needs? Always Usually Sometimes Rarely Patient Satisfaction Survey (cont’d): Are you interested in more educational offerings such as classes or literature about your disease problems? Always Usually Sometimes Rarely

Is your health better this year than last? Much improved Some Improvement Same Worse

Are you able to take care of yourself better this year? Much A little Same Worse

Do you understand what Medical Home means for you? Always Usually Sometimes Rarely

Do you know what to do to care for yourself? Always Usually Sometimes Rarely

Do you feel that you are included in the planning of your medical care? Always Usually Sometimes Rarely

How would you compare your healthcare at Lakewood Health System prior to joining Medical Home to now? What are the biggest differences? Your comments:

Would you be interested in helping to direct the efforts of our Medical Home by serving on an advisory board which would meet quarterly? If yes, please provide your name and telephone number below. Your input is critical for us as the Medical Home continues to evolve. Thank You! When you need to see your doctor, do you feel you are able to get in when needed? Always 2011 Usually

When you have questions, do you get a timely response? Sometimes Rarely 2011 Missing Do your visits with you Medical Home provider address all of your medical needs? 2011 Does the Medical Home Care Coordinator adequately answer your questions when you call? 2011 Do you feel that your provider addresses all of your health problems to your satisfaction? 2011 Are consultations with other physicians and ancillary personnel made as you feel necessary? 2011 Do you like the "Medical Home News" that is mailed to you monthly? 2011

0% 20% 40% 60% 80% 100% Do you understand your health problems and needs? Always

2011 Usually Are you interested in more educational offerings such as classes Sometimes or literature about your disease problems? Rarely 2011 Missing How would you describe your ability to take care of yourself this year compared to last year? 2011 How would you compare your health this year compared to last year? 2011

Do you understand what Medical Home means for you?

2011

Do you know what to do to care for yourself?

2011 Do you feel that you are included in the planning of your medical care? 2011

0% 20% 40% 60% 80% 100%

MQIC: • Consortium of ambulatory provider groups using GE Healthcare’s Centricity EMR • Provides HIPPA compliant data repository for medical information • Information is used for research in support of the Institute of Medicine’s quality goal of achieving measureable improvements in quality and the reduction of errors and inconsistencies

Recent Status: • 20,000 providers, with over 70% primary care physicians • 300 institutions in 46 states across the country • 20 million patient records, representative of the U.S. population

Condition Measures: • Diabetes • Congestive Heart Failure • Coronary Heart Disease • Hypertension • Preventive Care • Bridges to Excellence • Cardiology Performance • Direct PQRS reporting

 Built-in Tools EMR CPS

 External Data Processing CRYSTAL REPORTS

 Custom Data Procession – finding and combining any available data

 Manual Searches

 CMS - Direction

 PRIMARY CARE PROVIDERS - Coordination

 CONSULTANTS – Cooperation; Value-care

 PRIMARY HOSPITALS - Utilization

 REFERRAL CENTERS – Value-care

 TERTIARY CENTERS – Value-care

 PAYORS – Sharing in savings; Direction

 BUYERS – Understanding and Promotion

• System works: • Enables primary care provider time and contact for patients

• Patients like it: • Able to get answers and help • Reassured they are being taken care of

• Physicians like it: • Able to spend effective amount of time with complicated patients • Care coordinator able to effectively answer questions and triage • Urgent care has allowed primary care provider base time to do medical home

• Primary care base

• “Devoted”, confined population

• Urgent Care

• Progressive administration

• Care coordinator role successfully developed • Loyal patients

• Adequate comprehensive visits

• Feeling of giving GOOD, COMPREHENSIVE CARE

• Avoidance of tasks equally suited for other levels of health care providers

• Less inappropriate visits

• Better educated patients

• Feeling of inadequacy eased by role of care coordinator, medical home team, and computer systems registries (vs... memory alone)

• Reimbursement for physician assistant/nurse practitioner supervision

• Reliable medical records including preventive care history PROVIDERS:

• Increased coding due to increased time and attention

• Quality reporting – PQRS for now (not Rural Health Clinics)

• Marketing of services resulting in more reliable and engaged patients

• Increased efficiency of Urgent Care with a “Medical Home” follow up

• Increased efficiency of hospitalization and consultation requests

• Primary care providers seeing known patients with reliable follow-ups, known payment history, and not having to see unreliable, unknown patients as often

• Health Care Home reimbursement for care management

• Competitive advantage over other area providers

• Shared savings arrangements 1. Adopt the philosophies

2. Designate/hire the personnel

3. Acquire the tools (EMR, phones, etc)

4. Define the practice (who, when, where, how)

5. Develop strict guidelines and uniformity

6. Start small with a pilot program

7. Be open to changes and react quickly to problems

8. Listen to patients (advisory council and directly)

9. Expand when the pilot has demonstrated an effective program  Joint Principles • Care coordinator duty list  Definition of patients • Care coordinators  Duties of providers • System coordinator duty list  EMR • Physician supervisor duty list  Welcome to Medical Home • Routine of screenings/alerts letter • Patient advisory council routine  Care Plans • Medical home committee  Tiering forms membership and meeting  Preventive care guidelines routine  Alerts/Directives • Devoted e-mail sites  Medical Home Summary sheets • Web site  Provider explanatory loose-leaf • Definition of provider roles for  Patient explanatory loose-leaf triage/urgent care/office visits  Consultation request form • Tracking system for consultations

 Interoperability and portability – HITECH completion

 PHR consistency

 Financial support for non-face-to-face work and care coordination

 Outcomes-based financial support and other incentives in a Rural Health Clinic setting

 Healthcare system basic changes In order to aid in successful implementation of medical home programs at other facilities, Lakewood Health System has developed a Medical Home Comprehensive Training Package available for purchase. Package includes:  Full-day meeting with Clinical, Informatics, and Billing Team  PDF’s of Patient Welcome Kit and Monthly Medical Home Newsletters  Copy of Medical Home: Putting the Principles into Practice

For more information, please contact: Lois Walters at (218) 894-8311 or [email protected]

CONTACT INFORMATION

EMAIL: DrJohnHalfen@ LakewoodHealthSystem.com PHONE: 218-894-8597