Models of Care: House Call Program Components for Clinical Efficiency and Cost Effectiveness

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Models of CareHouse Call Program Components for
Clinical Efficiency andCost Effectiveness

• George Taler, MD
• Director, Long Term Care
• Washington Hospital Center

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Components

• NPs and PAs as clinical partners
• An innovative program for SW support
• The Practice Nurse
• Urgent Care Program
• The Hospital Interface
• Proposal for a Chronic Care Coordination Payment
  for Interdisciplinary Teams

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My Reality

• Primary Care for 150 patients _at_ 0.5 FTE
• 17 home visits/pt/yr (2/3 NP1/3 MD)
• Multiple, concurrent chronic illnesses
• High prevalence of functional and mental
  disability
• Interdisciplinary team and manage hospital care
• Other admin, educ and clinical duties
• On-call 24/7 on rotation with partners
• Salaried position, but need to earn my keep
• EMR in development with hospital IT system

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NPs and PAs as Clinical Partners

• Clinical Efficiency
• Complementary and often substitutive care
• Greater availability and flexibility
• Cost Effectiveness
• 150pt x 17visits/pt/yr 240d/yr 10visits/d
• _at_ 4 visits/d x 105/visit x 240 days 100,800
• _at_ 6 visits/d x 90/visit x 240days 129,600

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An Innovative Program for SW Support Medicaid
EPD Waiver

• EPD Waiver
• Every state Community-based care
• Serves those with moderately advanced chronic
  illness and functional disabilities
• Clinical Efficiency Priceless
• Cost Effectiveness
• Case management fees 1800/pt/yr
• Case load at 35 63,000/yr

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The Practice Nurse

• Processes all prescription refills
• Tracks labs, imaging and consultations
• Triages clinical calls
• Intermediary with physician/NP
• Overrides schedule
• Monitors CPG
• Drug level (Dilantin)/ Effect monitors (INR/TSH)
• Disease Management care coordination
• Special Patient liaison

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The Practice Nurse

• Clinical Efficiency
• Shores-up home-base capabilities
• Supports overall QI initiatives
• Unburdens the support staff
• Cost Effectiveness
• Through greater MD/NP efficiency
• Potential for DM sub-contracting and P4P
  incentives

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Urgent Care Program

• Target issue
• Avoidable ED transfers
• Unnecessary hospitalizations
• Extends capabilities of On-Call system
• Develops a formal linkage with HHA
• Increases potential referrals
• Increases staff capabilities

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Urgent Care Program

• Clinical Efficiency
• More appropriate services in least setting
• Cost Effectiveness
• At the patient level
• At the societal level
• Potential for DM sub-contracting and P4P
  incentives

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Hospitals Are a Big Part of the US Economy
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The Hospital Interface

• A major economic engine
• Start-up funding
• Referral base clinics, discharges, ED,
  consultants
• Human Resources capabilities
• Legitimizing change agent
• Patient base
• Community organizations
• Philanthropic organizations

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The Hospital Interface

• Clinical Efficiency (for you)
• More timely use of acute care resources
• Better integration with specialty services
• Specialist colleagues
• Advanced diagnostics
• Cost Effectiveness (for them)
• New to the System Admissions
• Less costly admissions ? LOS and Palliative Care

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The Hospital Interface

• Cost Effectiveness (for both)
• Better contracting position for alternative
  revenues sources
• Disease Management
• Pay-for-Performance
• More global source of clinical data
• Subjects
• Controls Case-based and Community-based

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Proposal for a Chronic Care Coordination Payment
for Interdisciplinary Teams

• Premise 1 As 1 Care shrinks nationally, it
  will increase in value locally.
• Diminishing support for E/M services
• 5 / year reductions in Medicare 2006-2013
• Surgical v Medical internecine fighting over
  spoils
• CMS support of corporate medical models
• Decreasing supply of 1 specialists

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Proposal for a CCCP for Interdisciplinary Teams

• Premise 2 The value added will be in care
  coordination and personal services, rather than a
  consultative model.

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What Patients Want(From Donald Berwick MD, IHI)

• Relationship(s)
• Doctor/Patient mutual caring and respect
• Doctor/Team communication and integration
• Continuity
• Time
• Settings
• Natural history of the illness

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What Patients Want(From Donald Berwick MD, IHI)

• Science
• Knowledge
• Judgment and Perspective
• Technology

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What Patients Want(From Donald Berwick MD, IHI)

• Access and Availability
• When they want you
• Where they want you
• For however long it takes

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Proposal for a CCCP for Interdisciplinary Teams

• Premise 3 Payment structures will shift from
  FFS to contractual PPM models with P4P
• More efficient use of high-cost institutional
  resources and decentralizing high-tech care
• Meeting Quality Standards in chronic disease
  management
• Personalizing care to the patients prognosis,
  values and goals

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Proposal for a CCCP for Interdisciplinary Teams

• Premise 4 There will be new sources of funding
  for chronic care coordination
• Concierge Models/Health Savings Accounts/Long
  Term Care Insurance
• Sub-contracting through HMO, DM
• Medicaid Waiver Programs

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Proposal for a CCCP for Interdisciplinary Teams

• Premise 5 Home-based health care delivery
  organizations are in the best position to address
  future challenges.
• Create systems that are highly integrated across
  a broad spectrum of services
• Define our true costs for services and
  coordination of care
• Assure accurate and complete data collection

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We are the physicians of the future, not only
through our spirit of innovation, but because we
also remember what was good about the past.
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