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