The FirstHealth Care Management Model FirstHealth of the Carolinas, a comprehensive rural health care system based in Pinehurst, North Carolina, has developed an innovative care delivery model to ef­fectively manage high-risk patients with chronic disease. This model, referred to as the FirstHealth Care Man­age­ment Mod­el, was developed and is delivered by the organization’s home health care entity and includes three ma­jor components: 1. Evidence-based standards of care or Pathways 2. Innovative technology, including video-enabled telehealth remote monitoring and smart phone applications 3. Customized, disease-specific education and support that aligns with the principles of health literacy and patient activation. The FirstHealth Care Management Model is delivered by a highly functioning, specially trained, multidisciplinary team that is paid through an innovative performance-based compensation plan. Specifically designed for the management of high risk, complex patients with chronic disease in the home health setting, the Care Management Model is al­so the foundation for the FirstHealth Com­plex Care Management program for chronically ill patients who are not eligible for home health care per federal guidelines but still require ongoing support, monitoring and education. Home Health and Complex Care Man­agement form the foundation of a population health strategy for high risk, high utilizing patients that is effective, sustainable and replicable. Pathway-driven, Patient-centered Care Chronic Disease Pathways are standards of care that provide a road map for the clinician and ensure that pa­tients receive consistent and evidence-based care. Path­ways incorporate clear, consistent pa­tient education, are designed to en­hance self-management skills and re­inforce pa­tient self-monitoring of conditions through technology. Pathway standards were designed for heart failure, COPD, diabetes, and physical and occupational therapy for heart failure and COPD. Annually, approximately five hundred patients receive home health care utilizing the chronic dis­ease Pathways. FirstHealth Care Management Model Figure 1The evidence is clear that the best ap­proach to chronic disease management is to teach patients self management skills. Patients who know how to effectively man­age their own health have better outcomes and a better quality of life. Though self-management skills can be taught, not all clinicians teach in the same way or teach the same content. Thus, the clinical practice variation can be significant. This has the potential to create confusion among patients or gaps in their understanding of their disease and effective self-management approaches. Stand­ard­ized Pathways address this issue by en­suring that each patient receives consistent, evidence-based education in a way that they understand and can incorporate into their daily lives. To ensure standardized educational con­tent, disease specific video clips are delivered via telehealth technology. Pa­tients complete an electronic post-test to verify understanding and to identify for the clinician content that may need further reinforcement. Zone Tools also ensure clear, consistent content. Using the Zone Tool, the pa­tient is taught how to identify if they are in the Green, Yellow or Red Zone. If the patient feels well and vital signs are normal, the patient identifies as being is in the “Green Zone.” If the patient is ex­periencing an increase in symptoms, for example, more shortness of breath, the patient would report being in the “Yel­low Zone.” Finally, for patients that are experiencing extreme symptoms as taught in the Tool, such as chest pain, the patient would identify as being in the “Red Zone” and call 911 to seek emergency care. Additionally, each clinician asks the patient what Zone they are in during eve­ry visit and every phone call, further reinforcing self management skills and the patient’s ability to identify their own symp­toms and take appropriate action. Using the Zone language provides an easy way for the patient and clinician to communicate about the patient’s health status. To support self-management and re­inforce education, telehealth remote mon­itoring is also integrated into the Path­ways. By having the patient send their vital signs data to the FirstHealth Center for Telehealth daily, as well as having the patient measure his or her own vital signs during home visits, the patient is en­gaged more often in self-care. The pa­tient also begins to more clearly understand the relationship between their be­havior and their health. For example, a patient sees a weight gain a day after a salt-laden meal, connecting behavior with health status. Video enabled telehealth allows the clinician to complete a virtual video visit with the patient when appropriate, a powerful and effective alternative to a time consuming and costly home visit. The Activated Patient The Patient Activation measure or PAM, licensed by Insignia Health, is administered electronically to every Pathway patient at the beginning of care and at the end of care. The PAM is an evidence-based measure of the patient’s knowledge, skills and confidence in managing their own care. This is critical information to understand when working with patients with long term chronic illnesses. According to PAM-focused research, low­ly activated patients tend to be frustrated, negative and unaware that they have any control over their own health. When teaching these patients, FirstHealth staff keep information simple and to the point. Since these patients are often already frustrated, too much information has the potential to increase frustration rather than lessen it. In the case of a lowly activated patient, simple skill building tools like a weight log or food journal is often an ideal first step. Once the patient succeeds in completing a simple self management skill, their confidence im­proves. Additional tasks can be added in in­creasing difficulty building one success upon the other. As the patient’s confidence rises, so does their ability to self manage as does the activation score. The PAM is patient centered because it meets the patient where they are, building their confidence at their own pace and moving towards effective self management. FirstHealth Care Management Model Figure 2The Teach Back method is used through­out the educational process. Teach Back is the evidence-based way to verify a patient understands what has been taught. Asking the patient to repeat what they have just learned requires the patient to put it into their own words. Teach Back gives the clinician critical feedback as to the level of patient understanding and cues as to the need for re­view or the readiness of the patient for additional education. Finally, all educational approaches and methods also take patient’s health lit­eracy levels into account. Studies show that patients with low health literacy are less likely to manage their chronic condition effectively or seek medical help when indicated and have higher hospitalization rates. Using plain language and clear visual tools are effective for pa­tients with low health literacy. With this in mind, deliberate efforts are made to ensure that education and information is provided in alignment with a patient’s ability to obtain, process, and understand health information. Because of the prev­alence of low health literacy, all patient education materials are appropriately designed. Advanced Illness Management The Pathways also incorporate the principles of Advanced Illness Management or AIM. These principles include advanced care planning and active symptom management for patients with complex, chronic disease. A key strategy is to identify what symptoms are the most problematic and stressful for the patient. Again, this patient centered approach focuses on what troubles the patient the most. For example, shortness of breath most likely causes extreme anxiety and fear. Once the clinician identifies this and offers solutions that empower the patient to manage their own symptoms more effectively, the patient begins to understand that they can have more control over their illness then they ever realized. This can reduce anxiety and im­prove the quality of life for patients with life limiting illnesses. Accordingly, a pa­tient-centered care plan includes very spe­cific interventions to help manage the symptoms the patient is experiencing. As part of a holistic approach to pa­tient care, the Pathways also focus on im­proving the patient’s functional, nutritional and clinical status using very specific nursing, physical and occupational therapy interventions. While the underlying disease cannot be cured, targeted strat­egies can significantly improve the pa­tient’s quality of life. For example, the Occupational Therapist works with heart failure patients teaching very specific, standardized interventions to help mitigate their shortness of breath, again em­powering the patient to mitigate their own care. Transitioning to the Next Level of Care The Pathways are designed to transition the patient home from the hospital and provide targeted, holistic support during those critical first few weeks. A series of specific risk assessments completed on the admission visit identify issues to be addressed in the care plan. Prior to discharge from Home Health or Complex Care Management, patients are assessed for eligibility for the next level of care. At the completion of the Care Manage­ment Program, referrals are facilitated to Pulmonary Rehabilitation, Cardiac Re­ha­bilitation or the Diabetes Self Man­age­ment Program to provide additional support and education and to further the goal of the highest level of self-management. The Care Delivery Team To ensure continuity and accountability, FirstHealth uses the multidisciplinary team concept as part of its care delivery model. The geographically designed team manages 60-70 patients and consists of 2-3 Registered Nurse Care Managers, a Physical Therapist, Physical Therapist As­sistant, a Home Health Aide and a shared Occupational Therapist and Occupational Therapist Assistant. Patients are assigned on admission to the team and remain with the team until discharge. Patients may not be assigned outside of their team, so the team has to work to­gether to meet the patient’s needs. The team fosters collaboration, coordination and an equitable sharing of the workload. Clinicians and patients alike benefit from a consistent team ap­proach to de­livering a comprehensive plan of care. Defined e-mail groups allow communication to the patient’s team via their smart phones. For example, if a patient falls, the team is notified by e-mail in real time, everyone who needs to know knows what is going on and can reinforce falls prevention and safety precautions during their visits. The team model is designed to make every visit count no matter the discipline. The team is responsible for de­livering a comprehensive plan of care. The RN Care Manager heads the pa­tient care team and is responsible for de­veloping the patient centered plan of care. Accountable for all patient outcomes, the Care Manager mobilizes the team to achieve the patient’s goals. With the ad­dition of smart phone enabled, video capable telehealth technology, the Care Manager is also responsible for reviewing all patient data and coordinating all interventions. This shifts the traditional responsibility of the Telehealth Nurse to the front line Care Managers and reduces unnecessarily fragmented care. Creating a High Performing Team No single component of the Care Man­agement Model is more important than the development of a clinically competent multidisciplinary team. The team members must be highly skilled clinicians, effective communicators and decisive critical thinkers. To foster the development of an effective team leader, FirstHealth places a strong emphasis on providing new Care Managers with a comprehensive orientation program with required milestones – an orientation that spans the first twelve months of a Care Manager’s tenure. For example, at six months, the Care Manager is to have com­pleted one Clinical Pathway episode with a 100% audit score. The ongoing education of all clinical staff to maintain competencies, incorporate up-to-date evidence and ensure high quality care is equally important. To this end, FirstHealth provides deliberate re­quired education that directly relates to chronic disease management and the Path­way standards of care. For example, there is an annual educational requirement in pharmacology in recognition of the rapid changes in pharmacology and the impact of medication regimens on patients. FirstHealth Care Management Model Figure 3Staff education is provided using a variety of approaches from a monthly elec­tronic article of the month with a post test to on-site trainings on a specific targeted topic. The entire multidisciplinary team receives the same initial and ongoing training as it relates to chron­ic disease management. Additionally, all clinical staff is trained in Integrated Care Management through Sutter Health. Training includes the key foundational principles of integrated care delivery including patient and family centered care, motivational interviewing, health coaching, health literacy as well as disease specific training. Regard­less of the discipline, every visit to the patient’s home is an opportunity to identify is­sues, reinforce education and deliver the care plan. To ensure all disciplines are consistent in what specifically is re­quired to be reported, FirstHealth Clini­cal Guide­lines were created to establish standardized parameters for vital signs and other health related measures or symptoms. So, for example, for diabetics, all visiting clinicians are to review and document the patient’s last recorded blood sugar. According to the Clinical Guide­lines, any blood sugar reading that is great­er than 250 is to be reported to the Care Manager. The Care Manager is then responsible for any follow up and for ob­taining physician established parameters for patients who routinely fall outside the established Clinical Guide­lines. Pay for Performance The long accepted standard of a productivity or visit-driven home health compensation plan has created a culture that focuses primarily on the number of billable visits completed in an eight hour work day as the marker of financial viability. A full-time nurse is justified based on the number of visits that must be com­pleted – whether pay per visit, hourly or salaried, billable visits serve as the foundation of all home health compensation plans. Unfortunately, if the focus is on the billable visit, then the visit becomes the key metric by which administrators, managers and front-line nurses judge success, rather than the quality of care delivered. FirstHealth Care Management Model Figure 4The FirstHealth Pay for Performance Plan is designed to shift this focus from billable visits to an emphasis on quality of care. To this end, Care Managers are responsible for a defined number of pa­tients. Visits are determined by patient need and the established standards of care. No financial incentive or compensation is offered for additional visits over a productivity goal. There is no productivity goal for RN Care Managers. Any extra pay beyond their salary is exclusively for delivering positive pa­tient outcomes. Bonus dollars are paid to Care Mangers for achievement of quarterly clinical goals. Quarterly goals are established that are unique to the individual Care Manager and include: the hospitalization rate; emergency department utilization rate; one clinical outcomes measure; one process measure; and annually, the individual home health CAHPS (patient satisfaction) score are included. The transition from a visit driv­en compensation model to a performance driven payment model aligns the compensation plan with the core quality objectives of FirstHealth. It also gives the Care Managers more flexibility, au­tonomy and accountability for effectively managing their patients using all the tools and resources available. All other staff including clerical support staff is also paid quarterly bonuses based on or­ganizational quality goals. Everyone in the organization has a critical role to play in the consistent delivery of high quality and effective care. Conclusion The FirstHealth Care Management Mod­el is designed to deliver high quality, out­comes driven care that demonstrates con­sistent and measurable results. With the focus on helping the patient learn effective self management skills, the patient centered model, is an effective component of any population health strategy. Trends and Projections in Hospital Stays for Adults with Multiple Chronic Conditions, 2003-2014 Highlights: Between 2003 and 2014, nonmaternal hospital stays among adults were two to three times more likely to involve multiple chronic conditions (MCC) than no MCC. The percentage of stays for adults with MCC increased from 63.5 percent in 2003 to a projected 78.1 percent in 2014, whereas adults without MCC decreased from 36.5 percent in 2003 to a projected 22.0 percent in 2014. The percentage of hospital stays for adults with MCC increased with patient age; the percentage was lowest among patients aged 18-44 years and highest among patients aged 65 years and older. However, the percentage of stays for adults with MCC increased most rapidly for those aged 18-44 years. Hospital stays for adults with MCC cost nearly 20 percent more on average than stays for adults without MCC. Average inflation-adjusted hospital costs for stays of adults with MCC increased from $12,000 in 2003 to a projected $14,500 in 2014, compared with an increase from $9,800 to $12,200 over this time period for stays without MCC. The average cost of stays for adults with MCC was about 20 to 25 percent higher among patients aged 45 years and older than among those aged 18-44 years. Source: AHRQ Author: Patty Upham, RN, Director, FirstHealth Care Transitions