Hospital-Medical Home Demonstration Weill Cornell Chiefs of Service, August 1, 2013

The Affordable Care Act is TransformingHealth Care in our Community:The Washington Heights-Inwood Regional HealthCollaborative

18th Annual NHMA Conference

J. Emilio Carrillo MD, MPH

March 29, 2014

NYP Regional Health Collaborative

Goals

Provide Better Care

Measurably Improve Health

Contain and Reduce Costs

Health Reform is transforming thecare we provide patients in theWashington Heights-InwoodCommunity

DRAFT

WHI Regional Health Collaborative WHI Regional Health Collaborative

NYPNYP

Outcomes EvaluationOutcomes Evaluation

ISABELLAISABELLA

VNSNYVNSNY

Community Health NeedsAssessmentCommunity Health NeedsAssessment

HEBREWHOMEHEBREWHOME

ColumbiaColumbia

DoctorsDoctors

ColumbiaColumbia

NYSPI(WH) NYSPI(WH)

CommunityMDsCommunityMDs

Setting the Framework:Washington Heights-Inwood Demographics

Population: 205,000

Foreign Born: >50% born outside US

Poverty Level: 31%

Education: Residents aged 25 and older havecompleted fewer years of education than NYCoverall

Race / Ethnicity:

71% Hispanic

14% Black

11% White

2% Asian

2% Other

Setting the Framework: InsuranceGaps in NYC

Map represents children in NYC communitydistricts who are “EPHINE”: “Eligiblefor Public Health Insurance but NOTEnrolled

Washington Heights / Inwood is among theworst according to this measure

Nov 24 2009

Setting the Framework: Detailed Health Needs Assessment of our Community

 Overall Health: 1/3 adults consider themselves to be in poor health

 PCP: 1/3 adults have no PCP

 Insurance: 1 in 3 adults is uninsured or had no insurance year before

 Heart Disease: hospitalization rate has increased

 Obesity: 1 in 5 adults is obese

 Diabetes: 11% of adults have diabetes

 Mental Health: more than 1 in 20 adults suffer from depression

 Asthma: hospitalization rates higher than NYC overall

Pediatric Asthma

National prevalence 8%

Local prevalence 18%-22%

Leading chronic illness in children

Health disparities in minority populations

NHLBI 2007 Guidelines –

–Control and risk

The NYP Patient Centered Medical Home: The Centerpiece of theWashington Heights Regional Health Collaborative

Targeted CareManagement

Team BasedCare

IT Tools forPatient CareandPopulationHealth

CulturalCompetencyandCommunityHealthWorkers

Diabetes, Asthma, Heart Failure, Depression, COPD, Children Special Health Needs

Care Management and Redesign

Before – Silos

After – Care Team

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Patient

Supporting the Patients after they leave the Hospital

Transitions of Care Initiative

Comprehensive Discharge

Planning and Education

Beginning on Day of Admission

Ambulatory Care begins

Engagement of the Patient

with a Medical Home

Disease Registries

Care Management

IT Enabled

Cultural Competency

Management of

Transitions of Care

Emergency Department-to-Home

Hospital-to-Home

PFA (Patient Financial Analyst– NYP Title)

- Front desk Registrar; greets andsigns- out all patients.

- Provides visit tallies ahead of time toNurses and Providers

-Participate in Pre-Visit Planning Processand discussion.

Medical Assistant (MA)

-Participates in Pre-Visit PlanningProcess and discussion

-Document Pre-Visit Planning onFlowsheet

-Execute traditional MA clinical functions

Community Health Worker(CHW)

- Peer to peer outreach, education andsupport that includes home visits

- Focused on Diabetes and Pediatric Asthma

- Subcontracted position from collaboratingCommunity Based Organizations.

Diabetes Educators

- AADE based curriculum, certification

- Dietitians, nurses, or pharmacists

- 1:1 Assessments and follow up visits

- Group classes

- Refer patients to PCMH supportingprograms

Physician

Primary Nurse

RN Care Manager

The Team

Weekly Interdisciplinary Meeting, Daily Huddles

PCMH October 2010 Cohort: 2-Year Results

•Reduced Emergency Department Utilization by 23.8%

•Reduced Inpatient Admissions by 18.0%

•Reduced 30-Day Readmission by 23.3%

•Length of Stay reduced by 13.6%

•Lowered Hemoglobin A1C Levels (0.32; 3.96%) n= 2,795

n = 5,857

Outcome Measures

2009

2012

Percent

Change

Patients withasthma

2000

3539

+77%

MS-CHONY

Admissions

- 57%

MS-CHONY

ED visits

200

156

-60%

Targeted Care Intervention - TCI

•Study is based on 580 patients (TCI=290; Control=290) who have been in caremanagement for at least 3 months. (all payers)

•Admissions reduced by 63%

•ED utilization reduced by 35%

NYS Medicaid “Health Home”

• Care management service model across a continuum of medical,behavioral care and social services.

• Health Home services are provided through a network of organizations –providers, health plans and CBOs. (26 Collaborators with MOUs)

• The care manager oversees and coordinates access to the services andpromotes communication among providers.

• Health records are shared among providers so that services are notduplicated or neglected.

• Aim to reduce ED, Admissions and improve health outcomes and patientexperience

NYP Health Home Network* Care Management Agencies for Health Home Provider Contract

Hospital-Medical Home Demonstration

•Transform outpatient continuitytraining sites to high quality PatientCentered Medical Homes

•Improve the level of integrated,coordinated, and culturallyappropriate care in the participatingoutpatient settings

•Extend/expand the continuitytraining experience for their primarycare residents

•Implement inpatient safetyimprovements

The Patient Centered Medical Home and Medical Village

21,000

120,000

240,000

PCMH Patients in Registries

(Diabetes, Asthma, CHF, Depression,Complex and High Risk)

NYP Ambulatory Carepopulation

All Washington Heights & InwoodCommunity

Targeted Care Intervention

NYP Regional Health CollaborativeNYP Regional Health Collaborative

Population Health

Infrastructure / Capability

Patient Centered Medical Homes

Transitions of Care Initiative (TCI)

Integration & Coordination of

Community-based Programs and Services

Health Information and Exchange

Medical Village

Transitions of Care Initiative (TCI)

Integration & Coordination of

Community-based Programs and Services

Health Information Exchange

Medical Village

Patient Centered Medical Homes

Targeted Care Management – Care Transitions

Collaboration Care Providers in the Region

J. Emilio Carrillo MD, MPH