Implementing Brenner’s Collaborative Super-Utilizer Model

Barry J. Jacobs, Psy.D., William Warning, MD, Steven Sluck, DO, Stephanie Maruca Watkins,

DO

Crozer-Keystone Family Medicine Residency Program—Springfield, PA

Collaborative Family Healthcare Association 14th Annual ConferenceOctober 4-6, 2012 Austin, Texas U.S.A.

Session #D4aOctober 6, 2012

Faculty Disclosure

We have not had any relevant financial relationships during the past 12 months.

Objectives

Describe the Brenner Collaborative Super-Utilizer Model using research data to demonstrate its efficacy for improving clinical outcomes and reduce healthcare costs

Illustrate a successful implementation through presentations of two case studies

Identify key operational and training components for effective collaborative super-utilizer teams

Learning Assessment

A learning assessment is required for CE credit.

Attention Presenters:

Please incorporate audience interaction through a brief Question & Answer period during or at the

conclusion of your presentation.

This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy

accreditation requirements.

Today’s Talk

The crucial issue of utilization in today’s healthcare

What is a “super-utilizer”? What are the elements of an SU program

using collaborative team interventions? Case of SD, a hospital SU Case of CB, an ER SU SU Fellowship Keys to SU operations and funding

High Utilization Driving Healthcare Costs Premise: Our most medically and

psychosocially complex patients use disproportionate amounts of healthcare resources

Drive up total healthcare costs

1%5%

10%

50%

22%

50%

65%

97%

$26,767

$90,061

$40,682

U.S. Population Health Expenditures

$7,978

Distribution of Health Care Expenditures for the U.S. Population, According to Magnitude of Expenditure, 2009

The sickest 10% of patients account for 65% of the health care expenses. Dollar amounts are annual mean expenditures per patient. Data from the 2009 Medical Expenditure Panel Survey, adapted from the Commonwealth Fund.

What is a “High-” or “Super-Utilizer”? Well researched, well defined problem with a

few successes. 4 Major Studies were reviewed

2010 Mount Sinai School of Medicine 2009 Midwestern Urban Hospital 2009 Camden Coalition of Healthcare Providers 2006 IOM Report

Characteristics of High-Utilizers Most are insured, 60% public insurance Only 15% uninsured Over 80% have identifiable PCPs More utilization of health services in general Diagnoses vary greatly Ages 25-44 and over 65 Addiction and mental health issues make it more

difficult for patients to navigate system

Usage Patterns

High utilizers use the ED >3x per year 5-8% of ED patients account for 21-28% of

visits Over 50% sought care at 2 or more EDs 70% of frequent visits were on evening or

night shift

Who is Jeff Brenner, MD

Frustrated family MD Closed solo practice in

Camden, NJ Began looking at data

about city’s healthcare trends

Brenner (cont.)

The Camden Study-An ED Alternative 5 year study of 380,000 visits at 3 EDs 1% of patients 40,000 visits, $46 million

cost Top 35 utilizers generated $1.2 million in

charges each month

Brenner (cont.)

Formed Camden Coalition of Healthcare Providers in 2002

Developed Camden Healthcare Database Formed relationships with outpatient and

inpatient providers, as well as social service agencies, throughout city and state

Promulgated “hot-spotting” or “super-utilizer” model of collaborative intervention

Components of SU Interventions Data mining (sometimes across health systems and

agencies) to create SU list Creation of collaborative multi-disciplinary teams:

physicians/nurses practitioners, case managers, social workers, mental health consultants, health educators

Assessment procedures and outcome measures Relationship-building with other healthcare and

social service providers to improve care transitions and marshal community resources

The Camden Study

35 highest utilizers were put into Camden Coalition Project

Social Worker, CRNP, Case Managers, Health Educators, cost $300,000/yr

35 patients received individualized case management services via the Coalition

Monthly charges reduced from $1.2 million to $531,000

For every $1 spent $1.44 was saved in hospital costs

Who are we?

Crozer-Keystone Health System 5-hospital health system, with 6800 employees, in

western suburb of Philadelphia Delaware County: pop. of 550,000;

socioeconomically and culturally diverse; inner ring, decaying suburbs and more middle-class neighborhoods

Residency: 9-9-9 program, founded in 1994; two family health centers; one an FQHC

Two fellowship programs (SU and sports medicine) Clinical affiliation with Temple University School of

Medicine

Timeline of Our SU Project

Pilot initiated in summer of 2011 Joined FMEC SU Learning Community Feb. 2012: SU presentation to health system’s

administrators by Jeff Brenner; SU team presented two cases

Led to health system initiating High Utilizer Program At that presentation, announcement of SU

Fellowship, co-sponsored by Crozer and Cooper Health System in New Jersey

Our SU Team (with Dr. Brenner)

SU Team Activities/Outcomes Graduated one of pilot cases; other has

made gains but still underway Developed data mining and SU selection

process Selected 5 more cases (at 3 outpatient

centers) for this academic year Working on assessment procedures, team

coordination processes and outcome measures

Case Report: Meet SDCase Report: Meet SD

SD is a 64 yo male who SD is a 64 yo male who has lived in the Delaware has lived in the Delaware County community for County community for years.years.

He is a retired electrician He is a retired electrician and lives with his wife.and lives with his wife.

Wife works part time 3 Wife works part time 3 days a week.days a week.

In 2010 -2011 - 13 In 2010 -2011 - 13 Admissions for CHF.Admissions for CHF.

Past Medical HistoryPast Medical History BPHBPH CADCAD CHF (7-2010 EF = 30-35 % ) CHF (7-2010 EF = 30-35 % )

CKDIIICKDIII CVACVA Depression/Anxiety/Depression/Anxiety/

InsomniaInsomnia Diabetes Mellitus IIDiabetes Mellitus II GoutGout HypercholesterolemiaHypercholesterolemia HTNHTN HypothyroidismHypothyroidism

Past Surgical History Past Surgical History

CABG 1998CABG 1998 ICD placement x2 ICD placement x2

(11/2008 & dual (11/2008 & dual chamber 3/2010)chamber 3/2010)

L4-L5 LaminectomyL4-L5 Laminectomy MastoidectomyMastoidectomy

Date Adm/ER visit Reason2/1/10 Adm PNA/CHF2/9/10 ER Anxiety2/15/10 ER Anxiety2/18/10 ER Insomnia3/8/10 ER Ear pain3/26/10 Adm- ICU CHF4/7/10 Adm CHF/PNA4/25/10 Adm CHF7/4/10 ER Back pain7/6/10 Adm CHF/PNA7/11/10 Adm CHF7/24/10 Adm CHF7/27/10 Adm CHF8/18/10 Adm CHF10/14/10 Adm CHF10/22/10 Adm CHF11/13/10 ER SOB11/22/10 Adm CHF1/22/11 ER Left w/o being seen2/23/11 Adm CHF

1 year Charges = $520,000; Receipts: $90,000;

Inpatient Admissions: 12; ED visits: 7

Leng

th

of

Sta

y

• IP Admit • ED Visit

Comprehensive Medication Comprehensive Medication ManagementManagement

Opportunity Within the Opportunity Within the Patient-Centered Medical Patient-Centered Medical Home (PCMH)Home (PCMH)

Medication ManagementMedication Management6-20116-2011

Aggrenox one po dailyAggrenox one po daily Aspirin 81 mg po dailyAspirin 81 mg po daily Lopid 600 mg po bidLopid 600 mg po bid Lipitor 80 mg po hsLipitor 80 mg po hs Zetia 10 mg po dailyZetia 10 mg po daily Lantus sc dailyLantus sc daily Lasix 40 mg po bidLasix 40 mg po bid KCl 20 mEq po dailyKCl 20 mEq po daily Norvasc 10 mg po dailyNorvasc 10 mg po daily Enalapril 20 mg po dailyEnalapril 20 mg po daily Sotalol 80 mg take ½ po Sotalol 80 mg take ½ po

bidbid Coreg 25 mg po bidCoreg 25 mg po bid Toprol XL 100 mg po dailyToprol XL 100 mg po daily

Colchicine po prn gout Colchicine po prn gout attacks attacks

Vit D 50000 units po q Vit D 50000 units po q other monthother month

Flomax 0.4 mg po dailyFlomax 0.4 mg po daily Levothyroxine 50 mcg Levothyroxine 50 mcg

po dailypo daily Celexa 20 mg po dailyCelexa 20 mg po daily Ativan 0.5 mg po hsAtivan 0.5 mg po hs Melatonin 3 mg po hsMelatonin 3 mg po hs Diphenhydramine 25 Diphenhydramine 25

mg capsmg caps Omeprazole 40 mg po Omeprazole 40 mg po

dailydaily

Identify, Resolve and Prevent Drug Identify, Resolve and Prevent Drug Therapy ProblemsTherapy Problems

Adherence

Effectiveness

Safety

Indication

4 Areas

Cipolle, R., Strand, L., Morley, P-Pharmaceutical Care Practice-The Clinicians Guide-2004-2nd edition-McGaw Hill

AdherenceAdherenceProvider Provider NoteNote

CommentsComments

Jan & June 2010Jan & June 2010

CardiologistCardiologist

““Called Rx. Not on beta blocker. Rxist Called Rx. Not on beta blocker. Rxist doesn’t think pt understands doesn’t think pt understands medications. Instructed to take all meds medications. Instructed to take all meds in bag to PCP to review.”in bag to PCP to review.”

““did not bring med list, does not know did not bring med list, does not know what he is taking.”what he is taking.”

Inpatient Inpatient Progress notesProgress notes

Frequently noted as non-compliant.Frequently noted as non-compliant.

Retrospective Medical Record Chart Review Jan 2012

Adm Date

ER Med History

Med Admin Record

Chart Discharge Note

Patient Discharge Instr.

2/1/2010 Toprol XL ??Toprol XL 25 mg 0900

Coreg 3.125 mg bid Coreg 3.125 mg bid

3/26/2010

Toprol XL 50 mg hs

Metoprolol 50 mg bid 50 mg twice daily

transfer to Bryn Mawr

4/7/2010Toprol XL 50 mg hs

Toprol XL 50 mg 0900

Toprol XL 50 mg hs

Toprol XL 50 mg daily

8/18/2010

No recorded medications

No beta blocker administered

"dc on home meds"

No Beta Blocker on Patient discharge instructions

10/14/2010

Coreg 25 mg q12hrs Coreg 25 mg bid not noted Coreg 25 mg bid

11/22/2010

Toprol XL 50 mg daily and Sotalol 40 mg bid Coreg 25 mg bid

Coreg 25 mg 2x/day

Sotalol 40 mg bid (checked to not continue) Coreg 25 mg bid

1/22/2011

Sotalol 40 mg bid and Toprol XL 50 mg daily N/A N/A N/A

2/23/2011 None recorded

Sotalol 40 mg bid and Coreg 25 mg bid

Sotalol 40 mg bid and ToprolXL 50 mg daily

Toprol XL 50 mg daily and Sotalol 40 mg bid

3/23/2011

Toprol XL 100 mg daily

Toprol XL 100 mg daily

Retrospective medical record review 2-2012

SD’s Medication ManagementSD’s Medication Management

Resolve Drug Therapy ProblemsResolve Drug Therapy Problems Discontinue Sotalol and Toprol XLDiscontinue Sotalol and Toprol XL Continue Coreg 25 mg twice dailyContinue Coreg 25 mg twice daily Communicate with cardiologistCommunicate with cardiologist Communicate with pharmacyCommunicate with pharmacy Wife educated about medicationsWife educated about medications

Assumes responsibility to assure medications set up Assumes responsibility to assure medications set up and taken correctly by patient.and taken correctly by patient.

1 year pre-enrollment Charges= $520,000; Receipts= $90,000;

Inpatient:12; ED visits:7

Post-enrollmentCharges = $11,686 ; Receipts= $0.

Inpatient: 0; ED visits:3

Leng

th

of

Sta

y

• IP Admit • ED Visit

Family Perspective Family Perspective

SD is not aware of the SD is not aware of the difference.difference.

Wife is both proud of her Wife is both proud of her accomplishment as a accomplishment as a caretaker and grateful caretaker and grateful that he is not in the that he is not in the hospital and ER so much.hospital and ER so much.

Hospital EncountersHospital EncountersReadmissions within 30 daysReadmissions within 30 days1/2010 – 1/20111/2010 – 1/2011

SMS Dsch Date SMS Entity Sum of SMS Total Charges

Sum of SMS Total Payments

2/2/10 DCMH 25558 9298 3/29/10 DCMH 49112 2322 4/10/10 DCMH 56778.6 9292 4/26/10 DCMH 29808 9298 7/9/10 DCMH 49979 6227

7/12/10 DCMH 24094 4014 7/24/10 DCMH 21744 5800 7/29/10 DCMH 25032 7843 8/18/10 DCMH 17756.8 2900

10/17/10 DCMH 43201 7840 10/23/10 DCMH 21691 10743 11/24/10 DCMH 37534 7843

TOTAL Admissions in 2010 12 402,287 83,460

TOTAL Readmissions within 30 days

6

Now and FutureNow and Future

Prepared Office Visits Team approach

SD and his wife Physician seeing SD RN reviews diabetes Pharmacist med review

Case of CB: “Why is she here so much?”

CB seemed to be in office waiting room every week—well dressed, friendly, no apparent distress

We reviewed the chart—multiple ER visits and brain CTs over past 2 years

Who is she?

Meet CB

Meet CB

60yo AAF Youngest of 5 children; identical twin Grew up in Philadelphia home with marital discord,

high levels of family conflict Physically abusive first marriage; strong second

marriage for past 24 years Has 3 adult children, many grandchildren On Social Security disability for chronic pain Works part-time as a hospital chaplain Currently working on second MA in theology

Family History

Mother - died at 53 y/o from DM complications

Father - died at 62 y/o from CAD, h/o stomach cancer with mets

Twin sister – BRCA gene positive

2 brothers - one died from suicide, other brother died from drug and etoh abuse

PMH

Anxiety/depression Fibromyalgia HTN CVA-1995 TIA Nephrolithiasis- 2009 PUD, GERD Diverticulosis MVA -2011

PSH

Hysterectomy, oopherectomy ('89) Bilateral Mastectomy with breast

reconstruction ('00) - precancerous lesion in nodes and twin sister with BRCA

Cholecystectomy

CB as a Super-Utilizer

5/5/2009: patient first presents to CFH for primary care

Patient with multiple ER visits prior to presentation to CFH for care for various complaints

Patient first identified as a super-utilizer on 8/22/11 Around this time patient was in ER/admitted multiple times

for syncope/gait imbalance and was complaining of memory issues, often forgetting her CFH appointments

CB as a Super-Utilizer

Methods: Electronic medical records from 1996-present reviewed Date of ER visit, Diagnosis, Disposition recorded

-Radiology files in net-access reviewed for type and number of CT scans

How many ER Visits has CB had since 1996?

Answer- 102 ER visits!

Let’s break it down…

Year Number of ER visits

1996 2

1997 2

1998 0

1999 0

2000 0

2001 13

2002 6

2003 7

2004 1

2005 1

2007 9

2008 21

2009 21

2010 15

2011 11

2012 4

ER visits broken down by reason…2009: 21 visitsDate (visits since 5/5/09) Adm/ER Reason Other

5/18/2009 ER Urticaria  

5/19/2009 ER Urticaria  

6/2/2009 Admit Chest pain  

6/5/2009 ER Nephrolithiasis  

6/7/2009 ER Nephrolithiasis  

8/3/2009 Admit r/o CVA CT head

8/16/2009 ER Arm strain  

8/19/2009 ER Arm pain  

10/11/2009 ER Head injury CT head

10/12/2009 ER Headache  

10/20/2009 ER Abscess forehead  

10/24/2009 ER Abscess forehead  

11/10/2009 ER Folliculitis  

12/8/2009 ER Fall  

12/14/2009 ER Flank pain  

ER Visit breakdown: 201015 visitsDate Adm/ER Reason Other

1/2/2010 ER HA/HTN  

1/29/2010 ER Hand contusion Fall

3/2/2010 ER Flank/abdominal pain  

3/6/2010 ER Angioedema Allergic to cipro Rx

3/14/2010 ER AMS/slurred speech CT head

4/26/2010 ER Shingles  

5/13/2010 ER Foot contusion Fall

6/7/2010 ER Headache, HTN CT head

6/27/2010 ER Urinary Retention  

6/28/2010 ER Urinary Retention  

7/1/2010 ER Urinary Retention  

7/15/2010 ER Rash  

9/8/2010 Admit Arm pain/elevated CK CT head -slurred speech, L weakness

11/22/2010 ER HTN CT head

11/24/2010 ER Head injury CT head

ER Visit Breakdown: 201111 visitsDate Adm/ER Reason Other

1/18/2011 ER Hematuria Left before visit completed

1/31/2011 ER Knee contusion Dilaudid, Rx vicodin

3/23/2011 ER Headache CT head

4/27/2011 ER Lumbar/cervical strain  

5/2/2011 ER Cervical strain  

7/19/2011 ER Syncope CT head

8/19/2011 ER Angioedema  

8/21/2011 Admit Angioedema/?CVA CT head

8/28/2011 ER Head injury CT head

8/29/2011 ER Contusion shoulder Dilaudid

10/18/2011 ER Angioedema Allergic reaction to grape

ER visits 2012

2/8/12- admit 24 hour observation for chest pain and palpitations

3/10/12—lower leg contusion 4/28/12—cough 7/10/12—post-traumatic headache; had head CT

How many CT scans has CB had since 1996?

Answer- 113 CT scans!

CT scans since 1996

72 CT head scans 31 CT abdomen/pelvis 3 CT chest 2 CT cervical spine 2 CT coronal/sagital/oblique 1 CT soft tissue of neck 1 CT thorax 1 CT lumbar spine

The Makings of a Super-Utilizer

Personal and family histories of serious medical problems

Patient unable to distinguish routine from life-threatening medical problems

Husband: encourages ER use to decrease pt’s anxiety; he has own neurological issues

Patient tends to strongly suppress negative emotions and then experience distress somatically

Lack of PCP continuity

Lack of Continuity of Care

1st office visit May 5th 2009 18 office visits at CFH in 2009

Saw 11 different providers in 2009 Saw one provider 6 times (Borgia)

16 office visits at CFH in 2010 Saw 11 different providers Saw one provider 3 times (Yun)

18 office visits at CFH in 2011 Saw 11 different providers Saw one provider 4 times (previous PCP Colterelli)

Interventions

Psychotherapy: first session with Barry Jacobs, Psy.D. on 5/11/2011

Ensure consistent primary physician: Laura Finocchio MD, current PCP, has first office visit with patient on 7/28/2011, becomes PCP 8/22/2011

Neuropsychology Evaluation with Andrew J. Borson, PhD on 10/31/2011

Psychiatric referral 8/12

Neuropsychology Evaluation Results Difficulties with short-term visual and verbal memory

and poor processing speed Executive function intact, good verbal abilities Poor listening skills No Cortical or Subcortical dementia Dissociative or Histrionic-type personality Memory and organizational issues seem to be

related to psychological issues

Meeting with CB and Husband Reviewed neuropsychological results Told her no evidence of underlying

neurological disease Said “stress” manifesting itself as somatic

(neurological) symptoms CB and husband agreed with findings Agreed to goals of decreasing stress and

decreasing ER visits

Results Since Interventions

Reduced ER visits and hospitalizations Regular visits with one PCP Patient acknowledgment of impact of anxiety,

anger and family stressors on overall sense of wellness

CB ER visits since Interventions (as of 2/12)

00.5

11.5

22.5

33.5

44.5

Identified as Superutilizer

Lessons Learned and Work Ahead We failed patient lack of PCP continuity of

care, took us over 2 years to realize patient was a super-utilizer; lack of adequate behavioral health services initially

Our patient CB had many office visits for ER f/u and “sick” visits, but few preventative care, f/u general medical issue visits, and psychotherapy sessions

Closer coordination with ER and Radiology

SU Fellowship

One year fellowship in which 2 fellows split time between the Camden Coalition and Crozer-Keystone outpatient practices

Supported by two-year, $175,000 Aetna Foundation grant

Goals: become “clinical champion” for the development of strategies and implementation of systems to address frequent utilization

SU Fellowship (cont.)

Goals (cont.): Work in multi-disciplinary team Understand social determinants of healthcare

utilization Improve care coordination protocols Analyze data Apply knowledge gained to CKHS

Keys to SU Operations

Clinical champions—often based in family medicine residencies

Motivated health system Rich electronic data base Interdisciplinary collaborative team Engaged primary care network and social

service community Outcome measures for utilization, costs,

patient and provider satisfaction

Keys to SU Funding

Seed monies generally coming from health systems themselves

Brenner has attracted state and national funders, including CMS and Aetna Foundation

Difficult to sustain concerted efforts by collaborative teams without dedicated funding—despite fact that SU programs are intended to save money