Frontier Extended Stay Clinic Demonstration Project

1
Frontier Extended Stay ClinicDemonstration
Project

• Report on 12 Months Data
• Presented by
• Alaska Center for Rural Health
• Alaskas AHEC
• December 2006

2
General Observations

• Data collection period for ARMC, CRMC, and IFHS
  3/15/05 3/14/06.
• Data collection period for IIMC 9/15/05-9/14/06
  (due to later start in project).
• Years data captures seasonal variations (fishing
  season, tourist season).
• Data submitted by clinics of very high quality
  required minimal data cleaning.
• Clinics reported a remarkably similar number of
  FESC encounters no need to weight/adjust the
  data.

3
Key Findings

• Each clinic is a distinct blend of geographical
  challenges, material human resources, and
  community/culture.
• Consequently, the data show that there is no
  typical participating FESC clinic.
• Overall project means/averages hide these
  distinctions.
• However, there is considerable common ground.

4
Key Differences and Common Ground

• Key differences
• Mon Ob/Transfer patient breakdown
• Patient disposition breakdown
• Length of encounters
• Percentage of Medicare-reimbursable encounters
• Key common ground
• High percentage of after hours encounters
• FESC-related staff stress (esp. after hours)
• Clinics ability to quickly diagnose, stabilize
  and
• medevac Transfer patients (weather permitting).

5
Number of FESC Encounters

• Clinics reported very similar numbers of FESC
  encounters.
• Consequently no need to weight/adjust data.

6
Type of FESC Encounter

• FESC encounter type breakdown is highly variable
  from clinic to clinic a key indicator of the
  conditions unique to that clinic.

7
Disposition of FESC Patients

• Disposition of patients is highly variable from
  clinic to clinic - closely tracks Mon Ob/Transfer
  breakdown (most Mon Obs are discharged home,
  nearly all Transfers are medevaced).

8
Disposition of Mon Ob Patients

• In all clinics, large majority of Mon Ob patients
  are discharged home.
• Similar smaller percentages are referred for
  non-urgent follow-up care.

9
Mean FESC Encounter Length

• Mean encounter length extremely variable (range
  1.42 17.07).
• Transfer encounters generally shorter than Mon
  Obs (exception IFHS, due to weather-caused
  medevac delays).

10
Median FESC Encounter Length

• Median encounter lengths also highly variable
  (range 1.25 10.25).
• Median reduces effect (statistical noise) of
  very long outliers.
• Relatively short Transfer median lengths show
  clinics ability to quickly diagnose, classify,
  and medevac Transfer patients.

11
Maximum/Minimum FESC Encounter Length

• Minimum encounters were all Transfers clinics
  can accomplish medevacs extremely rapidly under
  right conditions.
• Maximum encounters nearly all Mon Obs exception
  IFHS, due to a prolonged weather delay.

12
Maximum Encounter Length Mon Obs vs. Transfers

• Maximum encounters highly variable range 4.00
  to 99.50.
• Transfer maximums quantify longest medevac delays
  (due to bad weather, lack of daylight, waiting
  for transport, stabilizing patient).

13
Distribution of Encounter Length All Encounters

• No clinic with typical distribution matching
  overall project.
• Few encounters gt12 hours, very few gt24 hours
  exception CRMC.

14
Distribution of Encounter Length Mon Obs

• No clinic with typical Mon Ob distribution
  matching overall project.
• Few encounters gt12 hours or gt24 hours
  exception CRMC.

15
Distribution of Encounter Length Transfers

• No clinic with typical Transfer distribution
  matching overall project.
• Very few Transfer encounters gt12 hours or gt24
  hours exception IFHS, due to medevac weather
  delays.

16
After Hours Encounters

• More common ground similar percentages of
  encounters occurring outside of normal clinic
  hours (after hours) project mean 47.
• Represents FESC work and stress loads of after
  hours/on call staff.

17
Frequency of Project Top 5 Diagnoses at Discharge

• No typical clinic (IFHS close) diagnoses
  vary significantly.
• Common ground - incidence of top 2 injury and
  cardiovascular.

18
Frequency of Project Top 5 Mon Ob Diagnoses

• Again, no typical clinic ARMC is close
  diagnoses vary.
• IFHS substance abuse most common IIMC injury
  most common CRMC renal-urinary high incidence.
• Common ground high incidence of
  gastrointestinal (esp. CRMC).

19
Frequency of Project Top 5 Transfer Diagnoses

• Highly variable only IIMC approaches overall
  project pattern.
• Common ground injury and cardiovascular top 2
  for all clinics.

20
Top 10 Diagnoses at Discharge for Each Clinic

• Highly variable only IFHS approaches overall
  project pattern.
• Common ground injury, cardiovascular,
  gastrointestinal.

21
Medicare/aid Eligibility for Reimbursement

• Medicare/aid-eligible FESC patients range from 7
  (IFHS) to 55 (IIMC).
• High percentage filtered out by 4 hour
  encounter length criteria (esp. IIMC).
• Net Medicare reimbursable encounters range from
  4 (IFHS) to 19 (CRMC).
• Most clinics will receive minimal financial boost
  from CMS reimbursements.

22
Time Distribution Medicare/aid-Eligible Encounters

• Time distribution of Medicare/aid eligible FESC
  encounters highly variable
• Total numbers of eligible patients also highly
  variable
• Potential reimbursements thus variable, from high
  (CRMC) to very low (IIMC)

23
Time Distribution Medicare-Eligible Encounters

• Time distribution of Medicare eligible FESC
  encounters highly variable
• Total numbers of eligible patients also highly
  variable
• Potential reimbursements thus variable, from high
  (CRMC) to very low (IIMC)

24
Clinic Thumbnails

• ARMC Short encounters (all types) rapid
  medevacs low percentage medevaced high
  percentage discharged home many Medicare
  eligible patients but few Medicare-reimbursable
  encounters.
• CRMC Very long Mon Ob encounters rapid
  medevacs low percentage medevaced high
  percentage discharged home many
  Medicare-eligible patients and many Medicare
  reimbursable encounters.

25
Clinic Thumbnails

• IFHS Long encounters otherwise rapid medevacs
  prolonged by distance/bad weather median
  percentages medevaced and discharged home very
  few Medicare eligible patients and very few
  reimbursable encounters.
• IIMC Very short encounters (all types) very
  rapid medevacs high percentage medevaced few
  discharged home many Medicare-eligible patients
  but very few Medicare-eligible encounters.

26
Key Variables
ARMC CRMC IFHS IIMC
Medevaced 32 31 49 74
Transfer mean length (hrs) 4.00 4.00 8.64 1.42
Mon Obs 66 67 50 22
Mon Ob mean length (hrs) 4.19 17.07 5.83 3.14
After hours 40 55 42 54
Top 3 Diagnoses at Discharge Injury Gastro Cardio Gastro Pneum/bronch Cardio Cardio Injury Gastro Injury Cardio Gastro
Medicare reimbursable 7 19 5 5
27
Key Qualitative Findings

• Staff cite stress and turnover due to both
  FESC-related and unrelated causes (or causes
  beyond clinic control).
• Main FESC-related causes cited
• - Stress of after hours/on-call FESC
  encounters
• - Disruption of daytime routine
• - Lack of space for FESC patients
• - Demands on skills (urgent care)
• - Sporadic nature of encounters
  (anticipatory stress)
• - Community expectations for after
  hours/urgent care

28
Key Qualitative Findings

• Unrelated/uncontrollable causes cited
• - Medevac weather delays
• - Personal/family/spousal issues
• - Professional isolation/lack of educational
  opportunities
• - Call schedule/sleep loss/call remuneration
• - Administrative issues
• - Staff issues staff turnover/poor hires
• Clinics that added after hours staff/providers
  reduced staff stress. New/additional equipment
  also helped.
• Most staff positive and optimistic about FESC
  project, and recommend project participation.