Health Care Home for Persons with Disabilities Erin Simunds MSPT Nancy Flinn PhD OTR/L

1. Health Care Home for Persons with Disabilities Erin Simunds MSPT Nancy Flinn PhD OTR/L Age and Disability Odyssey June 21, 2011

2. Courage Center • Comprehensive rehabilitation and resource center for persons with disabilities • Provides services for individuals with lifelong and newly acquired conditions at every point in the life cycle • Because of correlation of disability and poverty: • 55% of our clients have incomes below 200% of Federal Poverty Guidelines (FPG)

3. Target Population • Adults with complex conditions: • Neuromuscular disorders • Traumatic brain injury • Spinal cord injury • Stroke • Arthritis • Cerebral palsy

4. Target Population • Require combinations of medical and non-medical services to live successfully and participate fully in their home communities • Many have failed in more traditional clinic settings • Require multiple services that span the continuum from acute to long-term medical care

5. Persons with Disabilities • Are more likely than the general population to have health insurance, 20.5% vs. 17.7% • In spite of better coverage and more expense, they are less healthy than the general population. • 14.9% of those with disabilities have diabetes, vs. 4.5% of the rest of the population • 57.3% of those with disabilities have hypertension, vs. 28.6% of the rest of the population. • Individuals with multiple chronic conditions cost up to 7 times as much as patients with only one chronic condition • CDC Health Disparities and Inequalities Report – United States, 2011 (2011). Morbidity and Mortality Weekly Report, Supplemental Vol. 60.

6. Primary Care • Management of chronic conditions requires strong primary care services • People with disabilities differ in their primary care needs • Greater emphasis on: • Prevention of functional decline • Early risk screening • Comprehensive assessment • Improved self-care capability • National Chronic Care Consortium, June 2000

7. Barriers to Primary Care • 22% of persons with disabilities report physical barriers to health care (Environmental barriers to health care among persons with disabilities, 2006) • In a weight management project at Courage Center, the average length of time since clients had been weighed was 13 months; for 1 client, 10 years • Average length of primary care visit is 7 – 12 minutes and this time is not adequate to address numerous chronic conditions

8. Primary Care Medical Home (PCMH) • Definition: • Accessible and continuous • Team-based and client- oriented • Comprehensive care delivery system • 2007 Joint Principles proposed by a collaborative of physician groups • Many PCMH have centered around specific population groups (e.g., economic, cultural, asthma) – ours centers around disability • Bitton, et al. 2010. A Nationwide Survey of Patient Centered Medical Home Demonstration Projects. J Gen Intern Med 25(6):584-92

9. HCH Model • Led by primary care physician with a nurse practitioner and care coordinator supported staff model • Based on the principles of patient-centered care as defined by NCQA and Minnesota DHS/DH • Comprehensive care plans and rigorous evaluation plan serve as a foundation to wrap services around each patient – some medical, some social – to optimize health

10. Model • This clinic is designed around a fee-for-service clinic, with a monthly care coordination fee based on the complexity of our clients • Fees range from $40.50 to $76 per month

11. Model • Courage Center has operated a primary care clinic for persons living with disabilities since December 2009 • Now serve 129 patients with disabilities or complex health conditions • Our HCH grew out of experience that people with disabilities are often not well served in the ‘generic’ health system

12. Model • Clients in this program are complex, with multiple health conditions, in addition to their initial disabling condition • Because of the complexity of care, co-locating this program in a clinic with already-existing physiatry and psychiatry made sense • A co-located clinic is able to effectively address the complex conditions that our clients present

13. Planning • In planning, conducted an extensive analysis of a dataset of 1,250 individuals who were similar to the patients we would see in HCH • Identified the five most common causes of avoidable hospitalization for this population • urinary tract infections • pneumonia • seizures • wounds • diabetes

14. Planning • Developed care pathways for these conditions, so that we could treat these conditions aggressively and early, and avoid hospitalizations • Found that those patients who had more than one of these conditions had increasing rates of illness and cost over the year • Planned multiple secondary conditions into the care pathways

15. Care Pathway • For example, the care pathway for urinary tract infections includes the effect that diabetes and a pressure wound might have on the progression of the condition • Model of a care pathway

16. Diagnoses of our Clients

17. Demographics Age

18. Insurance Coverage • Coverage for these clients includes: • 51% Medical Assistance, • 28% Medicare • 28% of clients are covered by both Medical Assistance and Medicare • The other clients are covered by private insurance.

19. Income • Because of the intersection of disability and poverty: • 67% of the clients in our HCH have incomes below 100% of the federal poverty guidelines • 8% have incomes between 100% and 200% of poverty • 25% have incomes above 200% of poverty

20. Hospitalizations • The Minnesota Department of Human Services shared their data about hospitalizations, emergency department visits, and pharmacy data on the 73 clients on which they had data • By targeting the five most common causes of avoidable hospitalizations, we have successfully minimized hospitalizations

21. Hospitalizations for 60 MA clients

22. Outcomes • We are using a range of outcome measures to demonstrate the value of our clinic • In addition to hospitalizations and avoidable conditions, we gathered information about: • Number of healthy days our clients experience • Patient Activation Measures, • Secondary Conditions • Depression (self-report and PHQ-9) • Client Satisfaction

23. Healthy Days • CDC Healthy Days measure (CDC, 2000) • 41% of our clients experience fewer than 7 healthy days a month

24. Healthy Days

25. Healthy Days • We had 36 cases with more than 1 measurement per individual • 16 had increasing healthy days • 10 had decreasing healthy days • 10 stayed the same • We show a greater effect if we do not include people that have had their second measurement less than 5 months from their first date of service

26. Patient Activation Measure (PAM) • PAM is a proprietary tool that measures a client’s knowledge, confidence and competence to act in ways that will improve their health • Improvements in PAM are associated with improved health and decreased health care costs

27. Patient Activation Measure • We had 31 cases with more than 1 measurement per individual • 1 decreased PAM score (categorical score) • 15 increased PAM score • 15 stayed the same

28. Patient Activation Measure

29. Secondary Conditions • The Secondary Conditions Surveillance Instrument (SCSI) is a measure of the number and severity of the secondary conditions our clients experience (Ravesloot, 1998) • On average our clients report 7.7 health conditions

30. Secondary Conditions • However, in a chart review of 52 clients, there were 12 conditions reported, indicating that clients may be underreporting the conditions that complicate their health • The most common conditions reported by our clients include • 64% pain • 63% joint and muscle pain • 54% spasticity • 53% depression • 48% fatigue

31. Secondary Conditions

32. Depression • Depression is common in our client group, with 53% of the clients reporting depression • Using the PHQ-9, 52% of the clients have at least mild depression, with another 32% reporting minimal depression • We have found that depression, sleep disturbance or pain are present in at least 82% of our clients, and that 32% of our clients have all three

33. Client Satisfaction

34. Effectiveness of Clinic • Client reports of increased healthy days and increased activation to achieve improved health are one measure of the effectiveness of the clinic • In this time of limited resources, financial impact is at least as important as improved health • Because this group of clients is complex, they present an opportunity to demonstrate the cost savings associated with strong primary care

35. Effectiveness of Clinic • This clinic has focused on the 5 avoidable conditions associated with hospitalizations • In the last 8 months of operation, we have had only one hospitalization due to these five conditions • As a part of a Primary Care Clinic grant, Mn DHS has given us access to historical data regarding hospitalizations for those clients on Medical Assistance

36. Effectiveness of Clinic • Prior to admission the Health Care Home, these clients averaged .90 days in the hospital per month, or 10.8 days per year per client • After admission to the Health Care Home, this rate has dropped to .25 days per client per month, or 3 days per year

37. Effectiveness of Clinic • The cost savings associated with these changes is estimated to be $1428 per client per month, or $17,100 dollars a year • This would translate to $2.2 million if all 129 clients remained in the health care home for a 12 month period

38. Hospital Days and ED Visits

39. While it is still early in the process • It appears that we have met the triple aim of health care reform • reduced cost • better health outcomes • better client experience • It is yet to be seen if the clinic can operate as a financially viable operation.