The Health Coach Model A novel approach to

The Health Coach Model A novel approach to provide comprehensive primary health care George Samraj M. D. , Marvin Dewar M. D. , JD Laura Gruber, MBA, MHS For more information about this project or to receive copies of the slide set, please contact Laura Gruber at grubela@ufl. edu 1

UF & Shands Health System Shands Vista 81 beds Shands Rehab 40 beds Two Academic medical centers: Shands at UF, Shands Jacksonville Specialty hospitals: Shands Vista, Shands Rehabilitation Hospital, UF&Shands Childrens Hospital Colleges: Dentistry Medicine Nursing Pharmacy Public Health & Health Professions Veterinary Medicine Shands Jacksonville 695 beds Shands at UF, Shands Children’s Hospital, and Shands Cancer Hospital 853 beds • Approximately 1, 000 faculty physicians, over 600 residents and fellows • $394 M research awards annually • 74, 000 discharges • 1. 2 million outpatient/clinic visits; 80+ outpatient sites • Trauma, Movement, Transplant, Diabetes Centers • Proton Therapy, Genetics, Cancer, Aging, CTSI, Emerging Pathogens, Brain Institutes 2

University of Florida Physicians • One of largest and most diverse multispecialty physician practices in the Southeastern United States • Excusive clinical practice arm of the University of Florida College of Medicine • Almost 600, 000 outpatient visits annually • 73 specialty, subspecialty, and subsubspecialty areas 3

Patient Centered Medical Home (PCMH) models are not alike Family Medicine model: patient-centered, physician-directed Unifying goal of PCMH models is to provide care that is: • Accessible • Continuous • Coordinated • Comprehensive • Patient centered Great Outcomes Practice Organization Quality Measures Health Information Technology Patient Experience AAFP Family Medicine Medical Home Model Patients in PCMHs are managed centrally by a primary care physician 4

Examples of some Patient Centered Medical Home (PCMH) models • Transfor. MED: 2 -year national project (2006) in 36 practices • CIGNA and Dartmouth: launched a medical home pilot in New Hampshire in 2008 • Massachusetts Coalition of Primary Care Reform: established a framework for a medical home model • Geisinger Health Care: piloted a medical home program in Pennsylvania • CMS: initiated a Medical Home demonstration to improve service quality • United Health. Care, Aetna, Blue Cross and Blue Shield: all developing Medical Home pilots • Multiple other pediatric and adult pilot programs across country 5

Medical Home: a place or a program? All patients Typical PCMH Chronic conditions Disease Management Programs Practice sited Externally or practice sited Enhanced needs patients High Needs PCMH Practice sited 6

Origin of the IMPACT (Improving Patient Care and Treatment) project • Project origination • Redirection of hospital LIP funding for competitive grant award process • Awards prioritized for projects designed to reduce unnecessary ER visits and hospitalizations • Competitive application • Project submissions from hospitals, academic medical centers, health departments, and social service groups located in all areas of the Florida • Competitive review • $750 K awarded to each of four selected projects • Two given to UF&Shands 7

IMPACT • Two medical homes for high needs patients embedded within existing primary care residency practice sites – FM & IM • Patients selected hierarchically for membership in one of the participating practices PLUS high risk medical conditions (asthma, diabetes, COPD, HTN, heart failure) PLUS frequent system ED and hospital utilization • Study is a randomized IRB-approved study in two residency programs to reduce hospital visits and improve health care for patients with one of the five target conditions (asthma, COPD, CHF, diabetes, and hypertension) • Health coaches (RNs) hired to recruit, enroll, and manage a high risk panel of patients • 200 patients recruited each to intervention and control groups • Patient ER visits, hospital admits, patient satisfaction, health outcomes, HEDIS measures monitored semiannually for two years 8

The UF&Shands proposal • Recruitment process • Initial recruitment packet by mail with consent and phone follow-up • “Natural” randomization by practice pod assignment • Current recruitment • Total sample size: 341 • Family Medicine site: 97 control, 102 intervention • Internal Medicine site: 81 control, 61 intervention • 65% female • Mean age: 58 years Medicare Medicaid Self Pay Managed Care Commercial • Study Intervention • Patients given IMPACT coach contact information • Materials provided • IMPACT coaches receive daily lists of patients in ED, hospital and who are scheduled for any clinical visits 9

IMPACT: Intervention Protocol 10

Weekly IMPACT Coach Report University of Florida & Shands Study Protocol Medical Home Care IMPACT Program Overview The Project The Intervention Pre-interview Chart Review I. First Interview II. Social Issue Evaluation III. Follow-up Interviews IV. Documentation V. Contacting Difficult to Reach Patients VI. Ineligible Patients Pre, Initial, and Follow-up Interviews – Quick View Appendix A. FAQ About the Medical Home B. Initiating First-Interview Letter Template C. Contacting Difficult to Reach Patients Letter Template D. Ineligibility Letter Template E. Pre-Interview Chart Review Checklist from EPIC F. Medical Homes First Interview Checklist from EPIC

IMPACT coaches – key to any success • IMPACT coaches work directly with primary physician, reducing demands on physician time • Panel size 100 -300 patients • Primary responsibilities • Initial comprehensive chart review • Medications and social history review • Evaluations of standards of medical care • Patient encounters – face to face and phone • Self management action plan • Communicate with PCP • Facilitate health care access • EMR records and weekly notes • Acute care and consultations follow up • Supervised by Medical director 12

Weekly IMPACT Coach Report 13

Weekly IMPACT Coach Report 14

IMPACT : Study Outcomes Primary Outcomes: • ER visits • Hospital admissions • 80% power to detect 20% difference in primary outcomes at 18 months Secondary Outcomes: • Key HEDIS (Healthcare Effectiveness Data Information Set) indicators for chronic medical conditions • CAHPS® (Consumer Assessment of Health Care Providers and Systems) scores 15

IMPACT: Preliminary Learnings • Select the right IMPACT coach - optimal background not clear • IT coordination across hospital and practice challenging • Heavy need for social services • Difficult for patients to address medical needs when dealing with social needs • Examples – phone , lights, meds, rides • Difficult to contact some patients • IMPACT coaches use more electronic interaction than we anticipated • When you turn a good idea into a “clinical trial” • Takes longer than expected (should) • Consenting process • Full IRB review • Intervention validity across sites • Can’t always just “do the best thing” 16

Contact information For more information about this project or to receive copies of the slide set, please contact Laura Gruber at grubela@ufl. edu Thanks to our IMPACT team: R. Whit Curry, MD Elizabeth Shenkman, Ph. D Eric Rosenberg, MD Jacqueline Baron Lee, Ph. D Sally Walker Vera Brecken-Marquis 17