CENTRICITY HEALTHCARE USER GROUP (CHUG) 2013 SPRING CONFERENCE Presented By: John Halfen M.D. Medical Director Lakewood Health

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, Minnesota 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, Surgery, Ob/Gyn, Pediatrics, Geriatrics, Palliative Medicine, Oncology/Hematology, Rheumatology, Psychiatry, Psychology, Dermatology, Podiatry, Anesthesiology, 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

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