2019 ACMA National Poster: Core Health Program

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Core Health Program An Innovative Health Care Delivery Model in the Self-Management of Chronic Disease Results

• Objective and

Positively impacting cost efficiencies through the appropriate use of health care services.

clinical data • Social Determinants of Health (SDOH)

29.4%

30%

10%

12.8%

9%

( p=.0005, N=36 )

20%

19.4%

21.1%

Co Morbidity: Heart failure and diabetes

education tailored to client’s learning style • Connection to community resources • Telehealth monitoring for those at risk for readmission • Motivational interviews to assist with development of health goals

36.7% 34.4%

• Home visits • Chronic disease

Improving client satisfaction through an individualized and collaborative plan of care.

Reduce Cost

EVALUATION

40%

(p<.0001, N=183)

Improve Patient Care and Experience

IMPLEMENTATION

52.8%

42.1%

Diabetes only patients

ASSESSMENT

50.3%

(p=.045, N=38)

Coordinated care with primary care providers as well as collaboration with care managers from inpatient and ambulatory settings

Core Health has demonstrated: • Improved patient health • Decreased inpatient utilization • Improved quality of life

After

Co Morbidity: Heart failure and diabetes

Coordinated Care

Improved

52.6%

(p=.006, N=218)

Improving long term health of community members through education and eliminating barriers related to disease self–management.

Improved

40.9%

Diabetes only patients

Population Health

PAM—13 Behavioral Assessment

Hgb A1c less than 7%

Diabetes only patients

RN/MSW Case Manager and CHW Team

50%

Before

(p=.0055, N=71)

Critical factors to Core Health success:

Program goals:

Healthcare Effectiveness Data and Information Set (HEDIS), Patient Activation Measure (PAM – 13) and the Patient – Reported Outcomes Measurement Information System (PROMIS) were adopted as outcome measures to monitor sustainable health improvements.

Co Morbidity: Heart failure and diabetes

Core Health is a free home visiting program that helps underserved adults manage chronic disease and reduces barriers to health care for the at–risk members of the Greater Grand Rapids community.

Decreased

(p=.043, N=390)

Program Overview

Inpatient Utilization

• Review

assessments and data collection • Weekly update of care plan and goals • Monitor progress toward readiness to self manage

The program supports:

PROMIS Global Assessment

Social determinants of Health (SDOH)

Improved

Improved

86.5%

58.3%

69%

98.9%

Increased their quality of life score

Lowered their pain score by at least 1 point

Lowered risk score on SDOH by 1 point

Recommend Core Health to others

Care Plan

Chronic disease— diabetes and heart failure

Those with economic, demographic or cultural barriers to health care

Heart failure symptom recognition Blood pressure control Blood sugar control

Population Health

Clients that have Medicaid, Medicare or are underinsured

Improving quality of life and access to health care

Client

Positive behavior change Managing medications Connection to community resources

Improve Patient Care and Experience

Reduce Cost

• R0I net savings in terms of actual ED and inpatient utilization

• For fiscal year 2017 and 2018 , the estimated cost savings (cost avoidance) $1,674,159.00

Future Next Steps Continuous Process Improvement: Plan–Do–Study–Act (PDSA) Expand program to include service to clients with Chronic Obstructive Pulmonary Disease (COPD)

Program outreach to Spectrum Health providers, case managers, community agencies and clinics to increase the number of referrals and client case load

Integrate new data tools for measurement of client success: • Self efficacy questionnaire • Mental Health questionnaire: PHQ 9/GAD anxiety, and the Columbia Suicide Risk Assessment


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