Outreach Programs:

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• Outreach Programs
• Strengthening Patient-Physician Medical Home
  Relationship for Enhanced Chronic Care Management

David R Smith, MD, MPH Medical Director Care
Management
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Presentation Learning Objectives

• Develop a chronic disease management and
  preventive services strategy appropriate for
  their practices.
• Assess the potential value of introducing an
  ongoing care management program to the patient
  population, as well as the clinical and financial
  impact on the practice.
• Identify and prepare for the most pressing
  challenges likely to arise when launching a
  proactive patient outreach initiative for care
  management.

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Agenda

• Opportunity
• The PCMH Model
• Activating Patients for Necessary Care
• Solution
• Extending Care Management with Automated Outreach
• Results and Lessons Learned
• A look at Influenza
• Aurora Experience
• Questions

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Health Reform Built on Quality

• "Lets invest in health information technologies,
  preventive care, and mechanisms that look at
  whos doing a better job controlling costs while
  producing good-quality outcomes in various
  states, and lets reimburse on the basis of
  improved quality as opposed to simply how many
  procedures youre doing."

Source Second Prime-Time News Conference,
President Obama, March 24, 2009
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The Cornerstone for Change The Patient
/Physician Relationship

• Patients that have a primary care doctor as
  their usual source of care had 33 lower annual
  health care expenditures and had a 19 lower
  mortality rate

Source Shi L, Macinko J, Starfield B, Wulu J,
Regan J, Politzer R The Relationship Between
Primary Care, Income Inequality, and Mortality in
US States, 1980-1995. J Am Board Fam Pract 2003
16(5)412-422 PMID 14645332
Health Affairs - Primary Care Solving Employers
Health Care Dilemma October 2008
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The Future
Mindful of growing P4P incentives, the real need
going forward is to find and manage all of those
patients who we are not seeing and who we
therefore are not managing. Paul J. Wallace,
M.D. Former Executive Director, Care Management
Institute (CMI) Kaiser Permanente
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Improving Chronic Care
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Why Support the Patient Centered Medical Home?

• A practice model that would more effectively
  support the core functions of primary care and
  the management of chronic diseases. NEJM -
  September 18, 2008
• Endorsed by multiple primary care professional
  organizations, CMS and other payers including
  American Academy of Family Physicians (AAFP),
  American Academy of Pediatrics (AAP), American
  College of Physicians (ACP), and American
  Osteopathic Association (AOA)

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Embracing the PCMH Impact on Care
Todays Care
Medical Home Care
Our patients are those who are registered in our
medical home
My patients are those who make appointments to
see me
Care is determined by todays problem and time
available today
Care is determined by a proactive plan to meet
health needs, with or without visits
Care varies by scheduled time and memory or skill
of the doctor
Care is standardized according to evidence-based
guidelines
I know I deliver high quality care because Im
well trained
We measure our quality and make rapid changes to
improve it
A prepared team of professionals coordinates all
patients care
Patients are responsible for coordinating their
own care
Its up to the patient to tell us what happened
to them
We track tests and consultations, and follow-up
after ED and hospital
Clinic operations center on meeting the doctors
needs
An interdisciplinary team works at the top of our
licenses to serve patients
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Source Adapted with permission with IBM from
Daniel F. Duffy, M.D.
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NCQA Physician Practice Connections-Patient-Cente
red Medical Home (PPC-PCMH)

• Measures evaluate
• Use of systems
• Effectiveness in prevention
• Management of chronic illness and patient safety
• Measures are actionable at physician practice
  level
• Measures are validated by relating them to
  performance
• Recognition is based on
• Responses in Web-based Survey Tool
• Supporting documentation attached to Survey Tool
• Each element specifies type of documentation
  Reports Documented processes Records or files

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PPC-PCMH Content and Scoring
Must Pass Elements
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PPC-PCMH NCQA May 2007 criteria

• Domains
• Access and communication (9 pts)
• Use of data systems to enhance safety and
  reliability (50 pts)
• Care management and coordination (20 pts)
• Support for patient self care (6 pts)
• Effective performance reporting and quality
  improvement (15 pts)

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PPC-PCMH Scoring

• 9 standards 100 points
• 10 Must Pass elements linked to Level 1, 2 or 3

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PPC-PCMH Elements Addressed with Automated
Outreach

• STANDARD 2 Patient Tracking and Registry
  Functions
• Element F Generates lists of patients and
  reminds patients and clinicians of services
  needed (population management).
• STANDARD 3 Care Management
• Element A Adopts and implements evidence-based
  guidelines for three conditions
• Element B Generates reminders about preventive
  services for clinicians.

Must Pass Elements
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Telephonic Outreach Evidence

• Behavior Change Interventions Delivered by
  Mobile Telephone Short Message Service BS
  Fjeldsoe et al AJPM Feb 2009
• Impact of Mailed and Automated Telephone
  Reminders on Receipt of Repeat Mammograms A
  Randomized Controlled Trial AJPM April 2009
• Effectiveness of Interventions to Improve Patient
  Compliance A Meta-Analysis DL Roter et al.
  Medical Care Aug 1998
• Pressing the key pad trial of a novel approach
  to health promotion advice Preventive Medicine
  R. Corkrey et al. Apr 2005
• Interactive voice response reminder effects on
  preventive service utilization Am J Med Quality
  AG Crawford et al. Nov 2005
• Testing Reminder and Motivational Telephone
  Calls to Increase Screening Mammography a
  Randomized Study JNCI Jan 2000 SH Taplin et al

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Aurora Overview

• Aurora has an extensive program in place to
  address patients with chronic conditions.
• We added telephonic outreach as a means of
  reducing any avoidable gaps in care.
• Automated outbound phone calls to patients with
  treatment needs encouraging them to come back to
  the office.
• 12 Chronic Protocols.
• 13 Preventive Protocols.
• No Show and seasonal Flu outreach protocols.
• Service has delivered more than 750,000 Outreach
  Calls Delivered to Aurora Patients.

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What convinced Aurora Medical Group that this was
worthwhile?

• Only half of patients with chronic diseases
  receive follow-up care2005 NCQA HEDIS study
• As many as 70 percent of patients do not receive
  adequate preventive care.2006 DOQ-IT study
• Analysis that at least 29.3 of Aurora patients
  needed recommended care.

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Ready Set Go!!

• Phase I, April August 2008
• 24 practice locations with 164 primary care
  physicians, 139 specialists and 1,000 support
  staff.
• Patient records from the previous 24 months were
  mined to identify those who were due for care.
• Staggered the first rounds of automated calling.
• The number of calls per provider each week was
  carefully managed to avoid bottlenecks in the
  appointment schedule.
• 12,500 patients who were due for care scheduled
  appointments.
• Phase II, August 2008 present
• Bringing the remaining 126 sites online, quickly
  followed (600 providers).

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Selected Outreach Protocols

• Preventive Care
• Welcome to Medicare
• Adult routine physical
• Adolescent physical
• Well child exam
• Cervical Cancer / Pap
• Influenza

• Chronic Care
• Diabetes
• Hypertension
• Thyroid Disease
• Congestive Heart Failure
• Coronary Artery Disease
• Asthma
• Hypercholesterolemia
• COPD / Emphysema

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Outreach Protocols that were Declined or Delayed

• Prostate cancer / PSA
• Colon Cancer screening
• Osteoporosis / DEXA scanning
• CHF / Echocardiogram testing

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• Managing the Health of a Chronic Population

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Study Overview

• Purpose To investigate the impact of automated
  outreach to patients in need of treatment for
  chronic conditions.
• Study Design Interrupted Time Series
  Retrospective Analysis
• Control Group Timeframe 4/21/08 8/23/08
• Outreach Group 8/23/08 4/30/09
• Conditions included Asthma, COPD, Coronary
  Artery Disease, Diabetes, Heart Failure, High
  Cholesterol, Hypertension, Thyroid Disorder

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Methodology

• Compared visit rates specific to chronic
  conditions for Aurora patients who were
  successfully called by vendor after program
  inception.
• The ICD-9 codes included in the analysis were
  only those billed specifically for a chronic
  condition.

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Patient Response
Of the Outreach Group patients that schedule a
first chronic visit within 90 days, 41 do so
within the within 30 days
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Speed to Visit Results
47 of all chronic care visits occurred within 30
days of the first successful outreach contact
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Response For Chronic Protocols
42 of patients called scheduled 2.5
appointmentswithin 30 days. 51 scheduled 3.1
appointments within 60 days of outreach.
Includes Initial Plus Ancillary Visits
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Creating a Lasting Response
Significant Patient Scheduling Activity Occurs up
to 180 Days after Outreach
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Creating a Lasting Response
Once re-engaged, patients schedule multiple
office and ancillary visits well into the first
year.
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What is the Impact on Non-Compliance?
Average days since last chronic visit has dropped
by 34.
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Addressing No Shows
More than 43,000 patients had a visit within 30
Days of a No Show
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Financial Impact

• Assuming 80 Visit
• Visit revenue scheduled at 60 days reached 134K x
  80 per visit 10.7M

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• Impacting Flu Vaccination Rates

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Study Overview

• Purpose To investigate the impact of Phytel
  automated phone calls to patients in need of Flu
  Vaccinations.
• Study Design Control Group
• Timeframe 2008 Flu Season
• Patient Populations Analyzed
• Patients over 50 years of age.
• Patients under 18 years of age.

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A Look at Influenza

• The estimated total direct hospitalization
  costs of a severe influenza epidemic are over
  3 billion

• 36,000 Annual Deaths
• 226,000 hospitalizations
• Source Centers for Disease Control and
  Prevention
• The National Committee for Quality Assurance
  (NCQA)

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Methodology

• Compared clinic vaccination rates for patients
  contacted via an Flu outreach call to those not
  contacted.
• The CPT billing codes included in the analysis
  were only those billed specifically for influenza
  vaccination.
• In order to avoid calling a household multiple
  times for several patients, only one outreach
  call occurred with each phone number.
• All patients with the same phone number were
  considered contacted

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Enhancing Immunization Response

• 18 and Under Results

• 50 and Over

• Outreach Group
• 114,412 patients
• 22,917 (20) success rate
• Control Group
• 175,659 patients
• 10,033 (5.7) success rate

• Outreach Group
• 139,412 patients
• 22,801 (16) success rate
• Control Group
• 339,676 patients
• 16,983 (5) success rate

Note Only measuring those visits at an Aurora
Facility
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Time to Vaccination
Of the 53,538 patients who received flu
vaccination after a outreach, 56 (29,874)
received one within 30 days.
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Study Summary

• Patients in high risk population intervention
  group had a vaccination rate at an Aurora clinic
  three times that of control group.
• Assuming an average revenue of 25 per
  vaccination, the value of the additional
  vaccinations was over 800,000.
• Staff time was freed up for other tasks while
  vendor delivered more than 250,000 automated
  calls to high risk flu patients.

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Outreach Lessons Learned

• Clean database removing patients who are
  deceased or known to have left the practice, for
  instance.
• Respond to internal problems that are revealed
  for example, some providers may not be coding
  every service provided (such as preventive
  services provided during a problem-oriented
  exam)..
• Gain support from providers
• reassure them that they will be the key person in
  directing individual patients care .
• modify protocols to fit ones culture practice
  values
• Inform patients about higher level of service,
• reassure them that they will continue to receive
  personal care.
• Support front desk staff when increased numbers
  of appointment requests are generated.

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• Questions