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Outreach Programs:


Develop a chronic disease management and preventive services strategy ... Hypercholesterolemia. COPD / Emphysema. Outreach Protocols that were. Declined or Delayed ... – PowerPoint PPT presentation

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Title: Outreach Programs:

  • Outreach Programs
  • Strengthening Patient-Physician Medical Home
    Relationship for Enhanced Chronic Care Management

David R Smith, MD, MPH Medical Director Care
Presentation Learning Objectives
  • Develop a chronic disease management and
    preventive services strategy appropriate for
    their practices.
  • Assess the potential value of introducing an
    ongoing care management program to the patient
    population, as well as the clinical and financial
    impact on the practice.
  • Identify and prepare for the most pressing
    challenges likely to arise when launching a
    proactive patient outreach initiative for care

  • Opportunity
  • The PCMH Model
  • Activating Patients for Necessary Care
  • Solution
  • Extending Care Management with Automated Outreach
  • Results and Lessons Learned
  • A look at Influenza
  • Aurora Experience
  • Questions

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Health Reform Built on Quality
  • "Lets invest in health information technologies,
    preventive care, and mechanisms that look at
    whos doing a better job controlling costs while
    producing good-quality outcomes in various
    states, and lets reimburse on the basis of
    improved quality as opposed to simply how many
    procedures youre doing."

Source Second Prime-Time News Conference,
President Obama, March 24, 2009
The Cornerstone for Change The Patient
/Physician Relationship
  • Patients that have a primary care doctor as
    their usual source of care had 33 lower annual
    health care expenditures and had a 19 lower
    mortality rate

Source Shi L, Macinko J, Starfield B, Wulu J,
Regan J, Politzer R The Relationship Between
Primary Care, Income Inequality, and Mortality in
US States, 1980-1995. J Am Board Fam Pract 2003
16(5)412-422 PMID 14645332
Health Affairs - Primary Care Solving Employers
Health Care Dilemma October 2008
The Future
Mindful of growing P4P incentives, the real need
going forward is to find and manage all of those
patients who we are not seeing and who we
therefore are not managing. Paul J. Wallace,
M.D. Former Executive Director, Care Management
Institute (CMI) Kaiser Permanente
Improving Chronic Care
Why Support the Patient Centered Medical Home?
  • A practice model that would more effectively
    support the core functions of primary care and
    the management of chronic diseases. NEJM -
    September 18, 2008
  • Endorsed by multiple primary care professional
    organizations, CMS and other payers including
    American Academy of Family Physicians (AAFP),
    American Academy of Pediatrics (AAP), American
    College of Physicians (ACP), and American
    Osteopathic Association (AOA)

Embracing the PCMH Impact on Care
Todays Care
Medical Home Care
Our patients are those who are registered in our
medical home
My patients are those who make appointments to
see me
Care is determined by todays problem and time
available today
Care is determined by a proactive plan to meet
health needs, with or without visits
Care varies by scheduled time and memory or skill
of the doctor
Care is standardized according to evidence-based
I know I deliver high quality care because Im
well trained
We measure our quality and make rapid changes to
improve it
A prepared team of professionals coordinates all
patients care
Patients are responsible for coordinating their
own care
Its up to the patient to tell us what happened
to them
We track tests and consultations, and follow-up
after ED and hospital
Clinic operations center on meeting the doctors
An interdisciplinary team works at the top of our
licenses to serve patients
Source Adapted with permission with IBM from
Daniel F. Duffy, M.D.
NCQA Physician Practice Connections-Patient-Cente
red Medical Home (PPC-PCMH)
  • Measures evaluate
  • Use of systems
  • Effectiveness in prevention
  • Management of chronic illness and patient safety
  • Measures are actionable at physician practice
  • Measures are validated by relating them to
  • Recognition is based on
  • Responses in Web-based Survey Tool
  • Supporting documentation attached to Survey Tool
  • Each element specifies type of documentation
    Reports Documented processes Records or files

PPC-PCMH Content and Scoring
Must Pass Elements
PPC-PCMH NCQA May 2007 criteria
  • Domains
  • Access and communication (9 pts)
  • Use of data systems to enhance safety and
    reliability (50 pts)
  • Care management and coordination (20 pts)
  • Support for patient self care (6 pts)
  • Effective performance reporting and quality
    improvement (15 pts)

PPC-PCMH Scoring
  • 9 standards 100 points
  • 10 Must Pass elements linked to Level 1, 2 or 3

PPC-PCMH Elements Addressed with Automated
  • STANDARD 2 Patient Tracking and Registry
  • Element F Generates lists of patients and
    reminds patients and clinicians of services
    needed (population management).
  • STANDARD 3 Care Management
  • Element A Adopts and implements evidence-based
    guidelines for three conditions
  • Element B Generates reminders about preventive
    services for clinicians.

Must Pass Elements
Telephonic Outreach Evidence
  • Behavior Change Interventions Delivered by
    Mobile Telephone Short Message Service BS
    Fjeldsoe et al AJPM Feb 2009
  • Impact of Mailed and Automated Telephone
    Reminders on Receipt of Repeat Mammograms A
    Randomized Controlled Trial AJPM April 2009
  • Effectiveness of Interventions to Improve Patient
    Compliance A Meta-Analysis DL Roter et al.
    Medical Care Aug 1998
  • Pressing the key pad trial of a novel approach
    to health promotion advice Preventive Medicine
    R. Corkrey et al. Apr 2005
  • Interactive voice response reminder effects on
    preventive service utilization Am J Med Quality
    AG Crawford et al. Nov 2005
  • Testing Reminder and Motivational Telephone
    Calls to Increase Screening Mammography a
    Randomized Study JNCI Jan 2000 SH Taplin et al

Aurora Overview
  • Aurora has an extensive program in place to
    address patients with chronic conditions.
  • We added telephonic outreach as a means of
    reducing any avoidable gaps in care.
  • Automated outbound phone calls to patients with
    treatment needs encouraging them to come back to
    the office.
  • 12 Chronic Protocols.
  • 13 Preventive Protocols.
  • No Show and seasonal Flu outreach protocols.
  • Service has delivered more than 750,000 Outreach
    Calls Delivered to Aurora Patients.

What convinced Aurora Medical Group that this was
  • Only half of patients with chronic diseases
    receive follow-up care2005 NCQA HEDIS study
  • As many as 70 percent of patients do not receive
    adequate preventive care.2006 DOQ-IT study
  • Analysis that at least 29.3 of Aurora patients
    needed recommended care.

Ready Set Go!!
  • Phase I, April August 2008
  • 24 practice locations with 164 primary care
    physicians, 139 specialists and 1,000 support
  • Patient records from the previous 24 months were
    mined to identify those who were due for care.
  • Staggered the first rounds of automated calling.
  • The number of calls per provider each week was
    carefully managed to avoid bottlenecks in the
    appointment schedule.
  • 12,500 patients who were due for care scheduled
  • Phase II, August 2008 present
  • Bringing the remaining 126 sites online, quickly
    followed (600 providers).

Selected Outreach Protocols
  • Preventive Care
  • Welcome to Medicare
  • Adult routine physical
  • Adolescent physical
  • Well child exam
  • Cervical Cancer / Pap
  • Influenza
  • Chronic Care
  • Diabetes
  • Hypertension
  • Thyroid Disease
  • Congestive Heart Failure
  • Coronary Artery Disease
  • Asthma
  • Hypercholesterolemia
  • COPD / Emphysema

Outreach Protocols that were Declined or Delayed
  • Prostate cancer / PSA
  • Colon Cancer screening
  • Osteoporosis / DEXA scanning
  • CHF / Echocardiogram testing

  • Managing the Health of a Chronic Population

Study Overview
  • Purpose To investigate the impact of automated
    outreach to patients in need of treatment for
    chronic conditions.
  • Study Design Interrupted Time Series
    Retrospective Analysis
  • Control Group Timeframe 4/21/08 8/23/08
  • Outreach Group 8/23/08 4/30/09
  • Conditions included Asthma, COPD, Coronary
    Artery Disease, Diabetes, Heart Failure, High
    Cholesterol, Hypertension, Thyroid Disorder

  • Compared visit rates specific to chronic
    conditions for Aurora patients who were
    successfully called by vendor after program
  • The ICD-9 codes included in the analysis were
    only those billed specifically for a chronic

Patient Response
Of the Outreach Group patients that schedule a
first chronic visit within 90 days, 41 do so
within the within 30 days
Speed to Visit Results
47 of all chronic care visits occurred within 30
days of the first successful outreach contact
Response For Chronic Protocols
42 of patients called scheduled 2.5
appointmentswithin 30 days. 51 scheduled 3.1
appointments within 60 days of outreach.
Includes Initial Plus Ancillary Visits
Creating a Lasting Response
Significant Patient Scheduling Activity Occurs up
to 180 Days after Outreach
Creating a Lasting Response
Once re-engaged, patients schedule multiple
office and ancillary visits well into the first
What is the Impact on Non-Compliance?
Average days since last chronic visit has dropped
by 34.
Addressing No Shows
More than 43,000 patients had a visit within 30
Days of a No Show
Financial Impact
  • Assuming 80 Visit
  • Visit revenue scheduled at 60 days reached 134K x
    80 per visit 10.7M

  • Impacting Flu Vaccination Rates

Study Overview
  • Purpose To investigate the impact of Phytel
    automated phone calls to patients in need of Flu
  • Study Design Control Group
  • Timeframe 2008 Flu Season
  • Patient Populations Analyzed
  • Patients over 50 years of age.
  • Patients under 18 years of age.

A Look at Influenza
  • The estimated total direct hospitalization
    costs of a severe influenza epidemic are over
    3 billion
  • 36,000 Annual Deaths
  • 226,000 hospitalizations
  • Source Centers for Disease Control and
  • The National Committee for Quality Assurance

  • Compared clinic vaccination rates for patients
    contacted via an Flu outreach call to those not
  • The CPT billing codes included in the analysis
    were only those billed specifically for influenza
  • In order to avoid calling a household multiple
    times for several patients, only one outreach
    call occurred with each phone number.
  • All patients with the same phone number were
    considered contacted

Enhancing Immunization Response
  • 18 and Under Results
  • 50 and Over
  • Outreach Group
  • 114,412 patients
  • 22,917 (20) success rate
  • Control Group
  • 175,659 patients
  • 10,033 (5.7) success rate
  • Outreach Group
  • 139,412 patients
  • 22,801 (16) success rate
  • Control Group
  • 339,676 patients
  • 16,983 (5) success rate

Note Only measuring those visits at an Aurora
Time to Vaccination
Of the 53,538 patients who received flu
vaccination after a outreach, 56 (29,874)
received one within 30 days.
Study Summary
  • Patients in high risk population intervention
    group had a vaccination rate at an Aurora clinic
    three times that of control group.
  • Assuming an average revenue of 25 per
    vaccination, the value of the additional
    vaccinations was over 800,000.
  • Staff time was freed up for other tasks while
    vendor delivered more than 250,000 automated
    calls to high risk flu patients.

Outreach Lessons Learned
  • Clean database removing patients who are
    deceased or known to have left the practice, for
  • Respond to internal problems that are revealed
    for example, some providers may not be coding
    every service provided (such as preventive
    services provided during a problem-oriented
  • Gain support from providers
  • reassure them that they will be the key person in
    directing individual patients care .
  • modify protocols to fit ones culture practice
  • Inform patients about higher level of service,
  • reassure them that they will continue to receive
    personal care.
  • Support front desk staff when increased numbers
    of appointment requests are generated.

  • Questions
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