Using Health Coaches

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Using Health Coaches To Decrease Health
Disparities
Harry S. Strothers III, M.D. MMM Medical
Director APS Healthcare The Seventh Annual
Primary Care and Prevention Conference September
12, 2007
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Seventh Annual Primary Care and Prevention
Conference 12th Annual HeLa Womens Health
Conference
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Faculty Disclosure

• In compliance with ACCME Guidelines, I hereby
  declare
• I have financial/other relationships with the
  manufacturer(s) of commercial product(s) or
  provider(s) of commercial service(s) discussed in
  this educational activity.
• APS Healthcare

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APS Public Programs National Presence
APS Public Sector

National Presence

• Missouri
• Medicaid Chronic Care Improvement Program
• New Jersey
• Medicaid Disease Management Program
• New York
• Department of Corrections UM Program
• Medicaid Disease Management Program (sub to
  Health Partners of New York)
• Oklahoma
• Medicaid Quality Improvement Organization (QIO)
  Program
• Pennsylvania
• Medicaid Specialty Program
• Puerto Rico
• TRICARE Behavioral Health Program
• Tennessee
• Waiver Transition
• Vermont
• Medicaid Chronic Care Management Program
• Washington
• External Quality Review Organization (EQRO)
  Program

WA
ME
MT
ND
MN
OR
VT
NH
ID
WI
NY
SD
MA
MI
CT
WY
RI
IA
PA
NJ
NE
NV
OH
OH
OH
DE
IL
IN
UT
CO
CA
WV

• Alabama
• Medical Quality Review Services
• Arkansas
• Medicaid Behavioral Health Program
• California
• External Quality Review Organization (EQRO)
  Program
• Florida
• Medicaid MR/DD Program
• Georgia
• Medicaid Disease Management Programs
• Medicaid Specialty Programs
• Maine
• Behavioral Health Administrative Services
• Maryland
• Medicaid Behavioral Health Program
• Medicaid MR/DD Program
• Massachusetts
• External Quality Review Organization (EQRO)
  Program

MD
VA
KS
MO
KY
NC
TN
OK
AZ
AK
SC
NM
GA
AL
MS
TX
LA
TX
FL
Medicaid Contracts
Medicaid Contracts
Other Public Sector Contracts
Other Public Sector Contracts
PR
Medicaid and Other
Medicaid and Other
PR

• Over 1,200 Employees
• A mix of centralized and decentralized operations
• Public Programs typically supported by local
  offices in state of contract award
• Privately held ownership structure allows for
  proper balance of short and long-term objectives
• Large enough to have resources and small enough
  to be customer focused

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APS Healthcare Basic Premises
APS Public Programs are unique in our breadth of
services to government clients. Our success is
due to community collaboration via our unique
Internet-based Electronic Health Record Systems,
a team of dedicated professionals with extensive
government health systems backgrounds and our
decentralized local programs. - David Hunsaker
President, APS Public Programs

• Empower patients
• Localized approach
• Collaborate

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APS Healthcare Georgia Improving the quality of
the life of those we serve and those who serve.

• Empower patients
• through education, encourage use of
  self-management tools, provide ongoing monitoring
  in support of the physicians treatment plan
• Localized approach
• employs health care workers from that location
  who understand the people, the environment and
  state-based resources
• Collaborate
• with local and national thought leaders

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A Private-Public-Academic-Community Partnership
Georgia Dept of Community Health (Medicaid)
APS Healthcare
National Center for Primary Care at Morehouse
School of Medicine
Community Health Centers (CHCs)
Mental Health Community Boards
Hospitals Health Systems
Private Physicians
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"the Georgia Enhanced Care program, developed by
APS Healthcare in partnership with the Morehouse
School of Medicine, represents an exciting new
model of community-focused, multi-level
intervention (patient, practitioner, and system)
designed to reduce Medicaid costs by reducing
suffering and improving health outcomes in this
high-disparity population."

• National Center for Primary Care Morehouse School
  of Medicine

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NCPC Activities

• Training Education
• Support for Clinicians in Underserved Areas
• Demonstration Projects Research
• Policy Analysis Dissemination

Promoting Excellence in Community-Oriented
Primary Health Care and Optimal Health Outcomes
for All Americans.
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Muddy Boots Research

• If we can make it work here, we can make it work
  in higher-resource settings.

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Translation Squared
T2 Usual Care ? Optimal Care
?

• Real-World Practices
• High-Disparity Populations
• In Underserved Communities
• With Limited Resources

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Coordinate Interventions to Eliminate Disparities
Community Resources
Physician
Patient Family
Psychologists Behavioral Health
Payment System
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APS Healthcare - Multi-Disciplinary Approach
Informatics
Medical Directors

• Psychiatrists, psychologists and physicians with
  numerous specialties

• statisticians, managed care specialists, nurses,
  health policy experts, data analysts, programs
  evaluators and survey specialists

Registered Nurses
Social Workers

• Specializations in case management, psychiatry,
  wellness, nutrition, home health care and chronic
  medical conditions

• Specializations in EAP, family therapy, children,
  substance abuse, depression, workplace trauma and
  anxiety

Pharmacists

• Specializations in psychotropic and medical
  pharmacy management

Working together to improve the total health of
each member in our care
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APS Disease Management Programs

• Georgia Enhanced Care (GEC) Program Region 1
• A free service to Medicaid members who are in the
  Aged, Blind and Disabled (ABD) category not in a
  CMO Medicaid program.
• Began in 2005
• GAMMP
• Statewide free service medically fragile
  ABD population not on CMO but on waiver
  programs, began April, 2007. DM and
  Case Management.

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What are Disease and Case Management?

• Disease Management A system of Coordinated
  health care interventions and communications for
  populations with conditions in which self-care
  efforts are significant.
• Disease Management Association of America
• Case Management A collaborative process of
  assessment, planning, facilitation, and advocacy
  for options and services to meet an individuals
  health needs through communication and available
  resources to promote quality and cost-effective
  outcomes.
• Case Management Society of America

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Medicaid Providers in North Georgia by County
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Patient Characteristics

• Multiple co-morbidities -85
• High prevalence of mental illness- 50
• Mental retardation, medically fragile children
• Services as alternatives to institutionalized
  care
• Social needs predominate homeless,
  transportation
• Low health literacy
• High use of caregivers

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Medical Complexities
Persons with gt 4 diseases (index dz 3 or more
co-morbids)
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Engagement Challenges

• Welcome letter with high volume of returned mail
  30-40
• Skeptical reception on initial call
• Wrong phone numbers/ use of cell phones

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APS Healthcare Health Coach Approach

• Seasoned Nurses
• Culturally comptent
• Experienced in Medicaid or telephonic care
• From the local area
• Enthusiastic about providing a service to this
  population

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Level One - Base Services

• 24/7 Nurse Call Center Services
• Member Profiling and Education Services
• Care Coordination Services
• Provider Profiling and Education Services
• Claims Analysis Services

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Success Story

• A member had heart failure and hearing
  impairment. The Health Coach and our member were
  having difficulty communicating because of the
  members hearing impairment. Our social worker
  was able to connect the member with resources to
  supply a hearing aid thus allowing better Member
  Health Coach interaction.

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Level Two - Disease Management

• Telephone or face to face
• Self-management education
• Communication with doctor regarding treatment
  plan
• Community resources that may address their social
  needs
• Medication instruction
• purpose
• side effect management
• access
• compliance

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Success stories

• Our Health Coach has been working with a member
  for one year. The member has Bipolar disorder,
  asthma, hypertension and diabetes. During the
  last year, he has lost 40 pounds and stopped
  smoking. He has not had an asthma attack in
  approximately one year.

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Social Complexities
Community
Neighborhood
Family
Covered Lives(Individuals)
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Why Do We Need a Comprehensive,
Community-Centered Primary Care Approach?
Example To prevent complications of obesity and
diabetes, all you have to do is modify a persons
health beliefs and attitudes, daily habits,
eating preferences, daily activities, exercise
habits, grocery stores, neighborhood
walk-ability, food advertising, self-care,
employability, economic empowerment, access to
medical care, provider quality, and medication
adherence, all in the context of his or her
family and social relationships.
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Success Story

• A member with multiple medical conditions
  including COPD confided to the Health Coach that
  although she has medication, she is not taking as
  prescribed. She smokes and had not received a flu
  shot.
• The Health Coach encouraged the member to make an
  appointment with her Physician. The member made
  and kept the appointment where she received the
  flu shot, a refill for prescriptions to control
  her COPD and a prescription to assist with
  smoking cessation.

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What is the Value of a Primary Care Home?

• . . . evidence shows that primary care helps
  prevent illness and death, regardless of whether
  the care is characterized by supply of primary
  care physicians, a relationship with a source of
  primary care, or the receipt of important
  features of primary care.
• -- Barbara Starfield, M.D. Johns Hopkins
  University

Starfield B, Shi L, Macinko J. Contribution of
Primary Care to Health Systems and Health. The
Milbank Quarterly 83 (3), 457502.
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Impact on Preventive Services
Receipt of Preventive Care Among Adults
Insurance Status and Usual Source of Care
Jennifer E. DeVoe, MD, DPhil, George E. Fryer,
PhD, Robert Phillips, MD, MSPH and Larry Green,
MD American Journal of Public Health, 2003
93(5)786-91.
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Impact on Costs
For 23 out of 24 health problems studied,
first-contact primary care had lower costs
relative to other sources of care.
Forrest CB, Starfield B. The effect of first
contact care with primary care clinicians on
health care expenditures. J Fam Pract 1996
43(1)40-8
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Why is a Primary Care Home especially important
for High-Disparity Populations?

• Medically Complex
• Culturally Complex
• Living in Complex Families Communities
• Served by Complex (Fragmented) Health Human
  Services

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Level Three - Case Management

• Role
• Advocate to achieve wellness
• Educate on benefits and disease process
• Facilitate communication among care providers
• Negotiate for extra services
• Navigate - through the healthcare system
• Assessment determine patient needs
• Planning develop a care plan
• Case identification
• High cost
• Multiple active co-morbidities

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Success Story

• A member with COPD, seizures, arthritis and
  osteoporosis, had not been seeing her PCP
  regularly. The Health Coach assisted the member
  to schedule an appointment and prepared her for
  the visit. During the appointment, the member was
  given the flu vaccine, received a spirometry test
  and develop an action plan for managing her
  breathing. The physician discovered the members
  COPD had worsened and changed her medication to
  Spiriva.

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Success Story

• A Health Coach was working with a member with
  Type 2 Insulin Dependent Diabetes. She was on a
  sliding scale formula to control her blood
  sugars. The member admitted to the Health Coach
  that she was unable to do the math necessary to
  calculate the doses. The Health Coach provided
  basic math formulas to assist the member in
  practicing the calculations, provided home work
  and enlisted the assistance of the members adult
  son to help her practice.
• Follow-up contact found the member elated that
  she had finally figured out the formula!
  Additionally, the member had consistently been
  logging her blood sugars and was able to provide
  the information to the Health Coach. Member
  states that she feels better about herself now
  that she knows more about her disease

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APS Clinical and Outreach Staff

• Facilitate access to
• NCQA certification
• Grants to improve quality of care
• Develop tools to address
  identified gaps in patient
  education
• Participation in local organizations (ADA, AHA,
  ALA, asthma camp, etc.) health and wellness
  events
• Provide tools to support disease management and
  evidence-based medical practices

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Moving from a Usual Care Home to a
Best-Practice Primary Care Home

• Usual Care Sub- Optimal
  Care

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Ten Areas of Documented Sub-Optimal Primary
Care

• Asthma
• Hypertension
• Heart Disease
• Diabetes
• Depression

• Cancer Screening
• Adult Immunizations
• Obesity / Diet
• Smoking / Tobacco
• Alcohol Other Substance Abuse

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High Variance ? High Disparity
Racial Disparities In Care Among Equally Insured
Patients
Krishnan JA, Diette GB, Skinner EA, Clark BD,
Steinwachs D, Wu AW. Race and sex differences in
consistency of care with national asthma
guidelines in managed care organizations. Arch
Intern Med 2001, July 9 161(13)1660-8.
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Bad Care Bad Outcomes
1999 data ED visits Hosp. Stays per 10,000
pop. Deaths per 1 million
Surveillance Summary for Asthma -- United States,
1980-99. MMWR, 2002 Mar 29 51(1)1-13.
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Blood Pressure / Hypertension

• According to NHANES III, only 27.4 of
  hypertensive patients had adequate control of
  their blood pressure, and only 53.6 were
  receiving any treatment at all.

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Triangulate Interventions to Achieve
Best-Practice Outcomes
Community
Patient
Provider
Systems
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Patients come first!

• Cochrane Database Systematic Review (2003)
  Patient self-management education reduces
  relative risk of adverse outcomes
• Hospitalizations RR 0.64
• ED Visits RR 0.82
• Days off work or school RR 0.79
• Nocturnal Asthma RR 0.67
• Caveat Little change in measurable lung
  function

• Patient Self-Management Education

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HEART DISEASE ACTION PLAN (to be completed by you
and your primary care provider)
PREPARED BY DISEASE MANAGEMENT APS
HEALTHCARE 5-2006
Health Coach ___________________
__________________________1-866-220-1747
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Triangulate Interventions to Achieve
Best-Practice Outcomes
Community
Patient
Provider
Systems
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Improving Primary Care Practice Depression
Screening

• IF YOUR PRACTICE HAS A 10 prevalence of major
  depression, AND you see 100 patients / week
• 32 patients ? positive screening score.
• 23 (72) would not meet criteria for major
  depression
• Unknown of these have other psychosocial
  diagnoses
• 10 patients ? major depression
• 9 patients with major depression correctly
  identified
• 1 patient with major depression missed

Williams Jr. J.W. Noël P.H. Cordes J.A.
Ramirez G. Pignone M. Is this patient
clinically depressed? JAMA, 6 March 2002.
287(9) 1160-1170
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Improving Primary Care Practice Protocol Driven
Point-of-Care Testing for HbA1c in an Urban CHC
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Why Did POCT Work?
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The ABCDs of Treat-to-Target!Cardiometabolic
Risk Clusters

• A A1c
• B BP
• C Cholesterol / lipids
• D Depression
• S Smoking

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Diabetes What Makes the BIGEST Difference?

• A A1c
• B BP
• C Cholesterol / lipids
• D Depression
• S Smoking

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Diabetes What Makes the BIGEST Difference in
Morbidity and Mortality?

• A A1c
• B BP
• C Cholesterol / lipids
• D Depression
• S Smoking

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Triangulate Interventions to Achieve
Best-Practice Outcomes
Community
Patient
Provider
Systems
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Changing the System

• Georgia Medicaid to Pay for Flu Shots and
  Pneumonia Vaccine

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Closing the Loop, Accelerating Cycle Times

• Cycle Times
• Program-Level Data
• Monthly ED Visit Rates
• Person-Level Feedback
• Missed refills
• Inadequate Care
• ED Visit yesterday!

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Moving from Medical Care Silos to an Integrated
Delivery System of Care
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Electronic Data System for Care Coordination
White, Kay
15317809342 Charles James
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401.0 Heart Failure 250.0 Diabetes (Adult)
Procedure 199214 office/outpt. visit Procedure
1 90471 immunization admin
Lisinopril 20 mg Glimepiride 4 mg Metformin HCL
500mg Premarin 0.3 mg
CareConnection is a proprietary, HIPAA
compliant, web-based tool
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Community Based Health Coaches

• Placed by APS Healthcare within the following
  locations
• At Risk Hospitals
• Strategic high volume practices
• Community Health Centers
  (FQHC)

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Case study
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GEC ABD
24,322 members with 3 years of continuous
eligibility
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Team 1 Patients - 466 Intensive Management
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Hstrothers_at_msm.edu

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• Integral part is provider education
• SF 8
• 10 outreach coordinators
• Conferences