MODERATOR: Erik Gulbrandsen, DO-Family Medicine, Intermountain Healthcare

PRESENTERS: Neal Davis, MD, Intermountain HealthcareSarah Petersen, MSN, ICM Director-Ambulatory & Comm., Intermountain Healthcare

Integrating Team-based Coaching for Patients & Families with Complex Medical & Social Needs

Objectives

• Identify and integrate into practice strategies how to empower patients and families as leaders in achieving their health goals

• Develop and foster qualities needed for leaders to implement a continuum of integrated team-based care

• Integrate team coaching into current care models in order to improve outcomes for patients and families with high-risk needs

IntroductionTeam-based Coaching for Complex Medical & Social Needs

Erik Gulbrandsen, DO-Family PracticeIntermountain Healthcare

• Living Adults

• Not enrolled in a care management program

• Within defined regions defined by Care Management

• In Top 15% of hospital* & MG Cost in the previous year & in Top 15% in one of two prior years

Subset

• Hospital and MG Costs* in the previous year

• Charlson Comorbidity Index Score

Data • Likelihood of pre-screening patients being In top 15% of cost for 2 of 3 future years

• Ensemble model enables us to use as much data as possible for each individual

• Gradient Boosted Trees maximized proportion of correct positive predictions.

Predict

PreScreening 3.0 – Ensemble Learning

*Hospital costs exclude chemotherapy, dialysis, IV therapy, spinal fusion, knee & hip replacement

+ Additional Patient Demographics+ Additional Health Information+ Claims Cost History (when available)

Back End Front End

Bringing Statistical Modeling into the Workflow

Demographic & Health Information

Additional Comorbidities

Obstructive Sleep Apnea

Hyperlipidemia

Morbid Obesity

Coronary Artery Disease

Hypertension

Top 15% ~ Demographic Factors + Patient Utilization History + Health Complexity + ε

Behavioral Health Conditions

Schizophrenic Disorders

Depression

Bipolar

Affective Disorders

Organic Psychotic Conditions

Nonorganic Psychoses

Neurotic Disorders

Personality Disorders

Alcohol/Drug Dependence

Eating Disorders

Childhood/Adolesence Disorders

Intellect Disability

Charlson Comorbidities

Myocardial Infarction

Cancer

Connective Tissue Disease-Rheumatic Disease

Chronic Pulmonary Disease

Cerebrovascular Disease

Metastatic Carcinoma

Dementia

Moderate or Severe Liver Disease

Diabetes with complications

Diabetes without complications

Mild Liver Disease

Periphral Vascular Disease

AIDS/HIV

Peptic Ulcer Disease

Congestive Heart Failure

Renal Disease

Paraplegia and Hemiplegia

Patient Health HistoryCost DistributionConsistent Healthcare UseRising/Falling Use TrendsPhysician VisitsPharmaceutical UseExternal Healthcare Use

Demographic FactorsAgeGenderMarital Status

Measure RankingPrescreen 1.0

LogisticPrescreen 2.0

EnsemblePrescreen 3.1

Likelihood of Pre-Screening Patients Remaining In Top 15% of Cost For 1 of 3 Future Years

63.0% 79.0% 94.9%

Likelihood of Pre-Screening Patients Remaining In Top 15% of Cost For 2 of 3 Future Years

31.0% 48.1% 84.0%

Identified Patients 1,400 1,800 8,400

Avg. Prior Year Cost $38,700 $44,000 $36,700

% with Area Deprivation Index > 115 (Top Quintile) 16.9% 18.0% 16.2%

Avg. Number of Charlson Comorbidities 3.6 5.0 3.3

Avg. Number of Behavioral Health Conditions 1.7 2.2 2.5

Avg. Number of Other Comorbidities 1.4 2.3 2.1

Diagnosed With Behavioral Health Condition 63.2% 82.8% 80.1%

Diagnosed With Obesity 27.8% 54.9% 52.8%

Number of Rising Risk Patients (Not in Top 15% but Predicted to Move to Top 15% 2 of 3 Future Years)

- - 700

Modeling Results

Camden Coalition COACH Model

C: Connect Tasks with Vision and Priorities

O: Observe the Normal Routine

A: Assume a Coaching Style

C: Create a Backwards Plan

H: Highlight Progress with Data

camdenhealth.org/the-coach-model/

Clinical PerspectivesTeam-based Coaching for Complex Medical & Social Needs

Neal Davis, MDIntermountain Healthcare

Life Course Theory and Social Determinants

Prenatal Birth Childhood Adulthood

Optimal Trajectory

Sub-optimal Trajectory

Health

And

Wellness

Medical Homes and Homes

• A medical home is only as effective as it’s ability to reach into the real home/life of a child and his or her family

Trust and Team

PPC/MHI Team

Community Partner-Home

Visitation

Changed Life

Course

And decreased cost…Increased productivity…

Matching Risk and Resource

High

Medium

Low

Don’t Forget the Kids!!!

Care Manager ViewpointTeam-based Coaching for Complex Medical & Social Needs

Sarah Petersen, MSNICM Director-Ambulatory & Comm.Intermountain Healthcare

Integrated Care Management Efforts and CCM

• Great efforts are underway to integrate care management across the system and across settings including: Ambulatory, Acute, Specialty and Community.

• Efforts to educate what care management really is – it is not just disease management – we miss great opportunities when we think of care management in terms of disease management

o For example – managing diabetes – story of CCM patient

What are we doing?

• Changing reporting structures of CMRC’s (Care Management Regional Consultants) to myself to allow for “one Intermountain” and improved efficiency, effectiveness, education, standardization, and to ensure we meet goals related to Population health, ACO, as well as meet the patient’s needs.

• Working on metrics to show how care management can help people live the healthiest lives possible.

• Introducing the idea of social determinants and how they affect health, as well as what to do as a care giver to address these.

Insights into the Camden Coalition COACH ModelTeam-based Coaching for Complex Medical & Social Needs

Erik Gulbrandsen, DO-Family PracticeIntermountain Healthcare

Camden Coalition COACH Model

TECHNIQUES

O: Observe the Normal Routine

C: Connect Tasks with Vision and Priorities

A: Assume a Coaching Style

camdenhealth.org/the-coach-model/

TOOLS

C: Create a Backwards Plan

H: Highlight Progress with Data

Camden Coalition COACH Model

TECHNIQUES

O: Observe the Normal Routine

C: Connect Tasks with Vision and Priorities

A: Assume a Coaching Style

camdenhealth.org/the-coach-model/

TOOLS

C: Create a Backwards Plan

H: Highlight Progress with Data

Connect Tasks with Vision and Priorities

Patient Goals

Fly my airplane

Go fishing

Go to the cabin

Get married

Get a job

Find a house

Care Provider Goals

Control Diabetes

Control High Blood Pressure

Come to appointments

Reduce narcotic use

Quit smoking

Take Medications

Connect Tasks with Vision and Priorities-Tug of War

• Diabetes and Food for Kids

• Opioids and housing

Camden Coalition COACH Model

TECHNIQUES

O: Observe the Normal Routine

C: Connect Tasks with Vision and Priorities

A: Assume a Coaching Style

camdenhealth.org/the-coach-model/

TOOLS

C: Create a Backwards Plan

H: Highlight Progress with Data

Camden Coalition COACH Model

TECHNIQUES

O: Observe the Normal Routine

C: Connect Tasks with Vision and Priorities

A: Assume a Coaching Style

camdenhealth.org/the-coach-model/

TOOLS

C: Create a Backwards Plan

H: Highlight Progress with Data

Discussion Questions

o How should Intermountain Healthcare best integrate and align to perform chronic care management?

o How do concepts of clinic team-based care (TBC) help allow clinicians to practice together, at the top of their license, and meet complex patient needs?

o How can health care clinics (service sites) begin to implement concepts shared in this presentation? Where should they start?