Personalized Care ClinicTim Johnson, MD and Dave Henriksen, MHA

October 2014

Objectives

As a result of the presentation, participants will:

• Understand the new model of care being implemented at Intermountain Healthcare to manage our most complex patients

• Be able to describe our intensive ambulatory model of care for complex patients

Intermountain Healthcare1975

SelectHealth1983

Medical Group1994

Intermountain HealthcareAn Integrated Health System

VisionTo be a model health system by providing extraordinary care and superior service at an affordable cost

MissionHelping people live the healthiest lives possible

Intermountain’s Mission and Vision

Intermountain Medical Group• 1,106 physicians

• 344 primary care• 506 secondary care• 95 hospitalists• 28 radiologists• 133 urgent care

• 275 advanced practice clinicians• 5,527 employees

Intermountain Medical Group Clinics and Services

• 165 primary or specialty care clinics• 27 InstaCare clinics• 8 KidsCare locations• 9 WorkMed locations• 8 on-site employer clinics• 5 community and school based clinics• Hospital-based clinical services

(NBICU, general, cardiac and neuro hospitalists, intensivists)

Dual Model for the Medical Home

Distributed Model Intensive Model

Personalized Care Clinic: Our patients

• Patients in the top 5-10% of costs for 2 of the last 3 years

• Patients ranked based on an algorithm

• Have multiple complex chronic health, social and psychological conditions

• Intermountain has full risk for the total cost of care

Intensive Model: Personalized Care Clinic

• An outpatient clinic that provides intensive medical, behavioral, and social management for Intermountain’s high-risk patients

• Opened February 3rd, 2014 on the Intermountain Medical Center campus

Personalized Care Clinic: The Team

• 2 Internal Medicine Physicians• Palliative Care Physician (0.2)• 1 PA• RN Care Manager• Psychiatry APRN (0.5)• 2 LCSW• Pharmacist• CDE (0.1)

• 4 Medical Assistants• PSR• Clinic Manager

Process of care• Functions like a primary care office with more resources to coordinate

care, treat mental health conditions, address financial challenges, and manage complex medical issues

• Ensure patients receive care in an appropriate setting; focusing on acute care utilization

• Coordinate and collaborate with all of the patient’s specialists

• Committed to eliminating all avoidable health care emergencies

Interaction with Primary Care Clinics

• Temporary transition of primary care

• Coordinate patient’s treatment plan with the primary care teams

• Warm hand-offs for all transitions • Length of time in the intensive

practice will vary for each patient

Establishing the Patient Population• Phase 1: Invite top-utilizing patients in the Medical Group

• Send patient lists to Medical Group PCP’s• Care managers talk with potential patients

• Phase 2: Invite other top-utilizing patients• SelectHealth reaches out to affiliated practices• SelectHealth care managers reach out to patients with no PCP

• Phase 3: Open to referrals from providers• Referral guidelines developed and shared

Who are the patients?

Top 5 Diagnoses

Personalized Care Clinic1. Other Malaise/Fatigue2. Depressive Disorder3. DM Uncomp Type II Uncontrolled4. Anxiety NOS5. Backache NOS

Typical Primary Care1. Routine Medical Exam2. Benign Hypertension3. DM Uncomp Type II controlled4. Hyper-cholesterol5. Depression

Current State of the Personalized Care Clinic

• 1,239 visits in 7 months• Includes care manager, physician, LCSW, PA, and psych

APRN visits

• Roughly 75 unique patients• Enrolling more patients with the addition of our

second internist

• Patients are much sicker than we anticipated

Personalized Care Clinic: Challenges• Patients changing insurance• The speed of bringing a patient

into the clinic and transitioning them back after stabilization

• High number of chronic pain patients

• Bringing in the right patient that the team can help

• All initial employees, except the manager, were new to Help2 and Centricity

Personalized Care Clinic: Successes• Preliminary feedback from an initial survey of 50 patients

• 50% of patients feel they have better health• 80% of patients have more confidence that their healthcare is moving in the right

direction• 70% of patients feel they are more engaged in their healthcare• Creating reciprocity from the patient (increased confidence in themselves

causing them to do more for their own care and health)• Getting patients on right meds/dosage and figuring out medical issues

• Receiving good feedback from secondary providers about the patients in the clinic• Example: “she is seeing a provider at the personalized care clinic and this seems

to be doing wonders for the patient” - Cardiologist

Personalized Care Clinic: Metrics

• Improve quality of care • DM Bundle, cancer screening, MHI

• Improve quality of life • surveys, patient stories

• Decrease cost and utilization • inpatient stays, ED visits, overall cost of care

Patient Story 1• 43 year old female• Hx of severe depression, anxiety, post-traumatic stress disorder,

severe sleep apnea, chronic back pain, chronic ankle pain, GERD, migraines, hypothyroidism, shoulder injury, vitamin B12 deficiency, Vitamin D deficiency, insomnia, hyperlipidemia, and pre-diabetes

• Patient had a work related injury to her back and ankle and had been on long-term disability through her employer, Intermountain Healthcare

• Uninsured – had applied for Social Security disability, but was denied, and COBRA was expired

Patient Story 1• January 2014 Prescreen Data

• #1,456 out of #2150+ (top 10% utilizers)• 36 month cost: $51,966• 12 month cost: $9,257.26• No ED visits or hospitalizations

• First appointment at the PCC was March 3, 2014• Patient was severely depressed and had thoughts of hurting herself and young

child. The child was in the custody of friends at this time• She would not make eye contact and spoke in a soft tone which was extremely

difficult to hear

Patient Story 1• Seen by internist, care manager, LCSW, psych APRN, and pharmacist• Signed up for SelectHealth Community Care (Medicaid)• Referred to PT, orthopedics, sleep medicine, and the Neurosciences

Clinic for chronic pain• Unable to afford her medications

• The total cost of her medications for a one month supply was $36• Care manager met with the patient to discuss resources• Pharmacist met with the patient to discuss pharmacy resources• Clinic manager approved medications being charged to the clinic until she

was able to put into place the resources the care manager had offered

Patient Story 1

• No longer in need of the medication co-pay assistance• Her interactions with the clinic are positive, makes eye contact,

laughs, and talkative • The patient’s child is back living at home and they have a great

relationship• This patient feels like a new person because of the whole team

pulling together• As of June 4, 2014 her 12 month cost is $4,791

Patient Story 2

• Restricted Access Medicaid Patient• January 2014 Data:

• Ranked #225 out of #2150+ (top 10% utilizers)• 75 ED visits in 2013• 3 Intermountain Hospitalizations• $90,764 – 36 month cost – in the Intermountain System• $45,839 – 12 month cost – in the Intermountain System

Patient Story 2

• 11 office visits with internist and LCSW• Weekly standing appointments with the Personalized Care Clinic along with

another specialty provider in the same office building• Identification of several health issues that can help explain some of her health

complaints

• Regular psychiatric treatment through psych APRN• Consult from Palliative/Pain/PM&R Physician

• Modification of pain meds to better meet her pain needs

• Clinical Pharmacist monitoring medications, DOPL, and usage

Patient Story 2

• Care manager requesting authorization from the State of Utah for a medication not covered by her Medicaid plan

• Coordinating with SelectHealth care manager due to her restricted status

• Coordinating care with specialty providers • Helping with transportation

• Arrangement of transportation via cab vouchers• Currently teaching her how to use the public transportation and para-transit

system

Patient Story 2• Since being seen in the clinic on March 5, 2014

• 3 Intermountain Healthcare Facility ED visits• 2 Non-Intermountain Healthcare Facility ED visits• 0 Hospitalizations• Patient is calling the Personalized Care Clinic prior to going to the ED

• Subjective comments from members of the team• She is calling the clinic with questions and concerns• She follows up on her appointments• She looks better in her appearance• She is a new woman . . . what a difference!

Your comments and questions…