Red Chart Rounds Healthcare Hotspotting Using Red Chart

Red Chart Rounds: Healthcare Hot-spotting: Using Red Chart Rounds to Teach Population Health STFM May 2014 Bryan Hodge, DO MAHEC Family Medicine. Hendersonville Rural Track

Disclosures Nothing to disclose

The Problems • How do we improve outcomes, patient experience, and utilization for the most unhealthy, challenging patients within a population that do not achieve good access and continuity within traditional primary care models? • How do we teach team-based care? • How do we teach population health?

Red Chart Rounds • Dedicated didactic time to identify, track, and develop multidisciplinary care plans for high risk co-horts

Red Chart Rounds • Objectives – Identify patients at highest risk for poor outcomes, high utilization/cost, and marginalized patient experience – Develop management skills and tools for assessing practice and provider- specific patient panels – Improve communication between resources and disciplines through a multi-disciplinary approach

Identify the Patients • Primary provider initiation • High Utilizing Reports – Hospital admissions > 3/ 12 months – Hospital re-admission < 30 days – ED overuse > 5 visits/ 12 months – Risk Prediction Tools

Assemble the Team • Faculty- Inpatient and Outpatient Attendings • Community Faculty • Residents • Behavioral Health • Nurse Care Managers • Pharmacists

Format • • 1 Hour Didactic Block per month Minimal Preparation Goal 15 -20 minutes per patient 3 basic steps with each case – PCP -the patient story • Outpatient Chart Review – Utilization Summary • Hospital Chart Review – Discussion and Multidisciplinary Care Plan Designation

Questions to ask during review • What are the primary health drivers to the patient behavior? • What resources might help augment the patients care? • How can we improve the patients’ care as a team? • Care plan: detailed steps to be included in patient chart, hospital chart, and registry

Educational Outcomes • • • Culture change System changes Milestones How to deal with difficult patients Team communication Community resources

Patient Utilization

Patient Outcomes • • • Employment Abstinence from substances Ongoing substance abuse ICU admission Improved health screening

Patient Experience • More PCP continuity • More continuity across the spectrum