Crozer-Keystone FMRP SuperUtilizer Fellowship Curriculum

1 Healthcare Hot-Spotting and Super-Utilizer Fellowship Curriculum Department of Family Medicine Crozer-Keystone Health System Camden Coalition of Healthcare Providers Cooper University Hospital Introduction A 2009 Medical Expenditure Panel Survey, adapted from the Commonwealth Fund, found that 1% of Americans account for 22% of total US healthcare expenditures; 10% generate 65% of charges These so-called high-utilizing patients have recently been the focus of studies and trial interventions throughout the country in an attempt to improve their health, lower their healthcare usage, and thereby decrease our escalating total healthcare costs Among the best known and most highly regarded efforts is the “hotspotting” or “super-utilizer” model of care coordination, developed by family physician Jeffrey Brenner, MD of the Camden Coalition of Healthcare Providers Dr Brenner’s model is designed to create intensive, time-limited, team-based interventions to reduce unnecessary hospital and emergency room admissions by assessing and addressing patients’ biomedical conditions (such as poorly managed chronic illnesses) and psychosocial circumstances (such as poverty, limited healthcare access, inadequate health insurance coverage, unsafe housing, lack of transportation, cultural influences, behavioral disorders, and patient and family beliefs) to greatly improve patients’ quality of life As specialists in holistic, biopsychosocially informed, and prevention-oriented medicine, family physicians are ideally situated within the US healthcare landscape to develop and implement systems of care to ameliorate the suffering and reduce the healthcare utilization of our most complex and fragile patients Through this joint CrozerKeystone/Camden Coalition/Cooper University Hospital family medicine fellowship, we seek to train family physicians in population health principles, hot-spotting data analytics and super-utilizer methodologies in order to enable them to assume leadership in improving patient care and lowering healthcare costs Goals The Fellow will be trained to become a clinical and administrative champion for the development of strategies and the implementation of systems to address the problem of excessive healthcare utilization The Fellow will learn how to analyze population and patient health data, select appropriate high-utilizing patients, develop clinical and care coordination approaches, and assume interdisciplinary team leadership in order to achieve improved clinical outcomes and decreased healthcare utilization 2 -The Fellow will learn to coordinate efforts between the interdisciplinary healthcare team and community-based healthcare and social service agencies, as well as foster greater responsibility, confidence and self-advocacy among the patients they serve General Duties The fellow will spend half of each week at the offices of the Camden (NJ) Coalition of Healthcare Providers, under the direct supervision of Jeffrey Brenner, MD, to learn healthcare data analytics and team-based care coordination, as well as engage in a community-based project to decrease healthcare utilization The other half of each week will be spent at the Crozer-Keystone Health System in Delaware County, PA, under the direction of the Crozer-Keystone Family Medicine Residency Program Director, Bill Warning, MD and Faculty Facilitator Barry J Jacobs, Psy.D., to oversee its residencybased super-utilizer program, participate in health system-wide programmatic initiatives to curtail high utilization, and provide general family medicine patient care at a CrozerKeystone primary care office Timeline The fellowship will be one year in duration, starting on July Qualifications of Fellows Graduate of an accredited Family Medicine Residency Program Excellent academic and clinical record Interest in developing skills in healthcare data analytics, clinical team leadership, and chronic care management Potential for assuming a leadership role in healthcare management and policy-making Fellowship Curriculum I Patient Care Goal The Fellow will provide care that is compassionate, appropriate, and effective for the promotion of health and the treatment of health problems Competencies Manage and coordinate clinical care for medically fragile, psychosocially complex, high-utilizing patients Understand how social determinants of health impact the delivery of healthcare services Objectives Integrate data on healthcare usage; findings from clinical interview, physical exam, laboratory and radiological studies; and environmental and family influences on lifestyle choices to develop biopsychosocial perspectives on patients’ well-being and health Devise primary care team-based interventions to decrease barriers to effective outpatient care, improve patients’ disease management, and reduce utilization of costly hospital and emergency room resources Provide evidence-based, case-specific recommendations about preventative medicine to promote long-lasting improvements in patients’ sense of self-efficacy and well-being Strategies Participate in care coordination activities at the Camden Coalition Oversee interdisciplinary team interventions for high-utilizing patients of the CrozerKeystone Center for Family Health-Springfield in office, home, hospital and nursing home settings Provide general family medicine patient care at one of the outpatient primary care offices of the Crozer-Keystone Health System II Medical Knowledge Goal The Fellow will demonstrate knowledge about established and evolving biomedical, social, behavioral and epidemiological sciences as the bases for clinical interventions and care coordination Competency Use empirically sound medical and psychosocial knowledge to inform clinical problem-solving and decision-making for complex, high-utilizing patients Objectives Master funds of knowledge about medical and psychosocial conditions that commonly lead to high utilization of healthcare resources—e.g., congestive heart failure, diabetic complications, pulmonary diseases, addictions, domestic violence, posttraumatic stress disorder, psychoses Learn established clinical protocols for specific diseases and conditions Strategies Review data from hospital and emergency room admissions records and outpatient electronic medical records of patients under consideration for enrollment in a highutilizer program Discuss analyses of healthcare utilization data with Jeffrey Brenner, MD and other leaders of the Camden Coalition and with the Family Medicine Residency Program Director and Practice Manager of the Crozer-Keystone Center for Family HealthSpringfield Discuss clinical cases with attending family physicians and other healthcare professionals at the Camden Coalition and the Crozer-Keystone Health System III Practice-Based Learning and Improvement Goal The Fellow will demonstrate the ability to investigate and evaluate the care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning Competencies Analyze patients’ clinical progress and healthcare usage using digital databases to evaluate the effectiveness of team-based biomedical and psychosocial interventions Critique the effectiveness of team communication and decision-making processes through periodic assessments Teach population health principles, healthcare data analytics and super-utilizer care coordination methodologies to family medicine residents and medical students Objectives Locate, appraise and assimilate evidence from scientific studies related to patients’ health problems Incorporate formative evaluation feedback into daily practice Accurately identify strengths, deficiencies and limits in one’s knowledge and expertise Set learning and improvement goals Appropriately seek formal and regular feedback on performance Improve ability to teach population health principles, healthcare data analytics and super-utilizer methodologies through the use of evaluations by resident and medical student learners Strategies Attend regular planning and feedback sessions with Camden Coalition leaders and Crozer-Keystone Family Medicine Residency Program Director and Faculty Facilitator Participate in yearly super-utilizer program evaluation process designed and administered by Widener University business professor Participate in monthly Super-Utilizer Steering Committee meetings to assess and revise team processes Participate in weekly Super-Utilizer Huddle meetings to review cases and revise team-based clinical plans Use written and verbal feedback from residents and medical students to improve twice-monthly trainings during the Center for Family Health resident rotations, monthly Super-Utilizer Case Conference presentations, and quarterly Super-Utilizer Program lectures IV Professionalism Goal The Fellow will demonstrate a commitment to fulfilling professional responsibilities, upholding ethical principles, and interacting sensitively and judiciously with a diverse patient population Competencies Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients, family members and other helping agents/agencies and society that supersedes self-interest Demonstrate accountability to patients, society and the profession; and a commitment to excellence and ongoing professional development Demonstrate a commitment to ethical principles, including confidentiality of patient information and informed consent Demonstrate sensitivity and responsiveness to patients’ culture, age, gender and disabilities Objectives Demonstrate sensitivity to the diverse psychosocial backgrounds of complex, medically fragile patients and their family members Fulfill clinical and management duties in a timely manner and alert appropriate supervisory personnel when difficulty is encountered Demonstrate effective, professional and respectful working relationships with staff members of other disciplines, including psychology, social work, pharmacy, nursing and case management, as well as health educators and volunteers Strategies Strive to ensure that super-utilizer patients and their family members feel heard, understood and cared for Interact in a respectful, collaborative manner during Super-Utilizer Huddles, SuperUtilizer Steering Committee meetings, Super-Utilizer Fellowship meetings and other planning and care management meetings at the Camden Coalition and the CrozerKeystone Center for Family Health-Springfield Work to foster and preserve super-utilizer patients’ relationships with their primary care physicians and other helping healthcare and social service professionals Represent the Super-Utilizer team to medical specialists and social service professionals across intervention settings in a respectful manner that promotes the establishment of collaborative partnerships, overarching goals and coordinated intervention plans V Interpersonal Skills and Communication Goal The Fellow will utilize interpersonal and communication skills that are effective in conveying information among patients, their family members, and healthcare and social service professionals Competency Communicate with patients, family members and healthcare and social service professionals of diverse backgrounds using appropriate language and means in order to foster the establishment of working partnerships based on shared understandings Objectives Gather essential and accurate information from patients, family members and healthcare and social service professionals using effective listening skills Clearly and compassionately communicate key issues to patients and families in order to develop consensus about treatment and care management goals Develop appropriate means of describing hot-spotting and super-utilizer rationales and methodologies to other healthcare and social service professionals in order to forge working partnerships with them Develop communication processes among patients, family members and healthcare and social service professionals in order to promote timely and ongoing consultation, feedback and consensus-building Maintain timely, comprehensive and comprehensible medical records Strategies Communicate directly with patients and family members during visits in the medical office, home, hospital and nursing home, as well as through telephone, encrypted email and traditional mail, in order to foster engagement and align treatment goals and strategies Confer regularly with medical specialists, other healthcare consultants, and social service professionals through digital, telephonic and in-person exchanges in order to create biopsychosocially informed, coordinated care plans Participate in care planning meeting and case presentations at the Camden Coalition 10 Lead/participate in the Super-Utilizer Huddles, Steering Committee meetings, case conferences, and other presentations at the Crozer-Keystone Center for Family HealthSpringfield Convey information about hot-spotting and super-utilizer approaches through scholarly pursuits, including conference workshop and poster presentations and academic articles Educate the general public about super-utilizer rationales and methodologies through accurate contributions to articles, blog posts and other news reports in the media 11 VI Systems-Based Practice Goal The Fellow will demonstrate an awareness of the larger healthcare and social service systems that impact the lives of patients and their family members Competencies Promote patient and family engagement with the healthcare and social service programs/professionals within their communities Promote coordination of the broad range of helping resources to improve patient and family health and well-being Objectives Foster the development of consensus among patients, family members, healthcare and social service professionals about patients’ problems and potential solutions Promote an interdisciplinary team-based healthcare approach that is applicable across treatment settings and sustainable over time Partner with social service professionals and other patient advocates to align helping goals and strategies Strategies Promote engagement of patients and family members with the Camden care coordination and Crozer interdisciplinary healthcare teams and with other healthcare and social service professionals and agencies across settings Counsel patients and family members on successfully navigating complex healthcare, social service, legal and financial systems that impact their health and well-being Model a respectful, collaborative stance toward fellow team members during care coordination meetings at the Camden Coalition and Super-Utilizer Huddles at the CrozerKeystone Center for Family Health-Springfield Work toward refining and improving team processes at the Crozer-Keystone Center for Family Health-Springfield through the monthly Super-Utilizer Steering Committee meetings 12 Teaching Methods Didactic sessions Case-based and team-based experiential learning Case conferences Attending population health and super-utilizer conferences/meetings Participating in super-utilizer online learning communities Review of pertinent literature (see “Educational Resources” below) Evaluation of the Fellow The Fellow is asked to self-assess at the beginning and the end of each quarter and to document this assessment on the Fellowship Evaluation Form The Supervisors of the fellowship (Dr Brenner of the Camden Coalition and Dr Warning of the CrozerKeystone Family Medicine Residency Program) are required to complete an evaluation form on the fellow’s performance and to provide direct feedback to the fellow at the end of the quarter Fellows who are not meeting the goals, competencies, objectives and strategies outlined above are given feedback by the Supervisors on an ongoing basis In instances in which the Fellow’s performance is persistently deficient, an individualized education plan will be developed by the Supervisors to remedy those deficiencies Evaluation of the Fellowship Program The Fellowship Education Committee, composed of representatives from the Camden Coalition, Crozer-Keystone Health System and Cooper University Medical Center, will meet semi-annually to review and evaluate the fellowship’s goals and objectives The Committee’s work will be aided by the annual review of the Crozer-Keystone’s SuperUtilizer program, conducted through written responses to questions designed by Widener University business professor, Caryl Carpenter, PhD and posed to the fellows and all other program team members Scholarly Requirements The Fellow will be required to present at least one workshop or poster presentation on super-utililzer approaches at a national conference for family medicine or other professional or interprofessional field The fellow will also be expected (but not required) to participate in scholarly exchanges about care coordination or transition programs for high-utilizing patients—e.g., attending conferences or participating in 13 online learning communities on population health, disease management or primary care healthcare delivery system redesign Educational Resources Badger, T, Gelenberg, AJ & Berren, M (2004) Consultative intervention to improve outcomes of high utilizers in a public mental health system, Perspectives in Psychiatric Care, 40(2): 53-69 Billings, J & Mijanovich, T (2007) Improving the management of care for high-cost Medicaid patients—Evidence from New York City that it is possible to predict the future health care use of a costly population, Health Affairs, 26(6): 1643-1655 Christensen, CC, Grossman, JH & Hwang, J (2008) The innovator’s prescription: A disruptive solution for health care New York: McGraw-Hill Coburn, KD et al (2012) Effect of a community-based nursing intervention on mortality in chronically ill older adults: A randomized clinical trial PLOS Medicine, downloadable at http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001265 Collins, J (2001) Good to great—Why some companies make the leap…and others don’t New York: HarperBusiness Evidence of quality—evidence on the effectiveness of the patient-centered medical home on quality and cost, posted online by the Patient-Centered Primary Care Collaborative and downloadable at http://pcpcc.net/content/evidence-quality Garrison, GM, Mansukhani, MP & Bohn, B (2013) Predictors of thirty-day readmission among hospitalized family medicine patients, Journal of the American Board of Family Medicine, 26(1): 71-77 Gawande, A (2011) The hot-spotters—Can we lower healthcare costs by giving the neediest patients better care?, The New Yorker, Jan 24: 41-51 Gifillian, RJ et al (2010) Value and the medical home: Effects of transformed primary care, The American Journal of Managed Care, 16(5): 6-7-614 Goldhill, D (2012) What healthcare needs: Real consumers and dynamic competition, The Atlantic Monthly, downloadable at http://www.theatlantic.com/health/archive/2012/10/what-health-care-needs-realconsumers-and-dynamic-competition/264026/ Heifetz, RA & Laurie, DL (1997) The work of leadership, Harvard Business Review, Jan-Feb, 124-134 14 Joint Principles of the Patient-Centered Medical Home (2007) by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association, downloadable at http://www.aap.org/en-us/professional-resources/practice-support/qualityimprovement/Documents/Joint-Principles-Patient-Centered-Medical-Home.pdf Linkins, KW, Brya, JJ & Chandler DW (August 2008) Frequent users of health services initiative: final report (prepared by the Lewin Group for the California Endowment and the California HealthCare Foundation), downloadable at http://documents.csh.org/documents/fui/FUHSIEvaluationReportFINAL.pdf Nielsen, M (2012) Benefits of implementing the primary care patient-centered medical home: A review of cost and quality results, (prepared by the Patient-Centered Primary Care Collaborative), downloadable at http://www.pcpcc.net/sites/default/files/media/benefits_of_implementing_the_primary_ca re_pcmh.pdf Okin RL et al (2000) The effects of clinical case management on hospital service use among ED frequent users, American Journal of Emergency Medicine, 18(5): 603-608 Peikes, D et al (2009) Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries—15 randomized trials, Journal of the American Medical Association, 301(6): 603-618 Porter, ME, Pabo, EA & Lee, TH (2013) Redesigning primary care: A strategic vision to improve value by organizing around patients’ needs, Health Affairs, 32(3): 515-525 Raven, M & Gould, D (2012) Time and again: Frequent users of emergency department services in New York City—an issue brief (prepared by the United Hospital Fund of New York), downloadable at https://www.google.com/search? q=united+hospital+fund+super+users&aq=f&oq=united+hospital+fund+super+users&aq s=chrome.0.57j61l2.5159j0&sourceid=chrome&ie=UTF-8 Reid RJ et al (2010) The Group Health Medical Home at year two: Cost savings, higher patient satisfaction, and less burnout for providers, Health Affairs, 29(5): 835-843 Rohrer, JE, Rasmussen, N & Adamson, SA (2008) Illness severity and total visits in family medicine, Journal of Evaluation in Clinical Practice, 65-69 Shier, G et al (2013) Strong social support services, such as transportation and help for caregivers, can lead to lower health care use and costs, Health Affairs, 32(3): 544-550 The TransforMED Patient-Centered Model: A Medical Home for All (2008) A handout developed by TranforMED and downloadable at http://www.transformed.com/pdf/TransforMEDMedicalHomeModel-letter.pdf 15 Thom, DH et al (2013) Impact of peer health coaching on glycemic control in lowincome patients with diabetes: A randomized controlled trail, Annals of Family Medicine, 11(2): 137-144 ... remedy those deficiencies Evaluation of the Fellowship Program The Fellowship Education Committee, composed of representatives from the Camden Coalition, Crozer-Keystone Health System and Cooper... semi-annually to review and evaluate the fellowship? ??s goals and objectives The Committee’s work will be aided by the annual review of the Crozer-Keystone? ??s SuperUtilizer program, conducted through... of the Crozer-Keystone Center for Family HealthSpringfield Discuss clinical cases with attending family physicians and other healthcare professionals at the Camden Coalition and the Crozer-Keystone