AtlantiCare Special Care Center Best Practice Case Study
AtlantiCare Special Care Center: Best Practice Case Study Best Practice The Special Care Center (SCC): an innovative primary care practice for patients with chronic conditions About AtlantiCare AtlantiCare Health System is the largest health system in southeastern New Jersey. The organization includes AtlantiCare Regional Medical Center (ARMC), a 567-bed, two-campus teaching hospital, which received the Malcolm Baldrige National Quality Award in 2009, and AtlantiCare Health Services, which offers primary, urgent, surgical, specialty, lab and other care and services. Impetus for developing best practice • Casino union leaders approached AtlantiCare to jointly develop an innovative solution to address the rising healthcare costs associated with the increasing incidence of chronic diseases among their members. • AtlantiCare was also looking for a way to address the increasing cost of uncompensated care, for which the organization assumes the majority of responsibility in the local area. Timeframe Design began in the spring of 2006 and the SCC was fully implemented in July 2007. Description • SCC is a clinically integrated, financially accountable, high-performing primary care practice for patients with high-cost chronic conditions • Key elements include: > Identification of medically complex patients > Team-based care from physician and culturally matched health advisor > Creating and maintaining an individualized care plan > Ongoing engagement and support of patient as needed > Seamless communication across providers > Patient registry to ensure receipt of needed care > Flat-fee structure for services Development of design • The SCC is based on a care model called the Ambulatory Intensive Care Unit (A-ICU), the creation of which was funded by the California HealthCare Foundation and shaped by a multiple-disciplinary team. • The model is based on four premises: > Focusing on the 20 percent of patients with the highest projected cost > Combining the “technologies” that save costs while improving quality and changing the overall culture by adopting an EMR, e-prescribing, and a patient web portal > Asking patients to actively participate in care in exchange for lower cost and an enhanced relationship with care providers > Implementing a fee structure with no cost for visits and no cost for medications
ATLANTICARE SPECIAL CARE CENTER: BEST PRACTICE CASE STUDY
Key implementation steps These steps were overseen by a committee of 12 members that included the medical director, administrative director, nurse practitioner, health coaches, and client service representatives. Each step took several weeks for completion. 1. Identifying and building the practice site 2. Hiring staff and creating practitioner relationships 3. Initial and ongoing training of health coaches 4. Creating a communication plan with the hospital to receive data on SCC patients who were admitted or visited AtlantiCare’s emergency department 5. Adopting information technology 6. Inviting initial patients to join Outcomes • As of the summer of 2012, the program has served over 2,500 patients with one or more chronic illnesses, including hypertension (74 percent), diabetes (56 percent), asthma (18 percent), COPD (18 percent), and CAD (12 percent). • The SCC has achieved improved health and clinical outcomes, patient satisfaction, cost savings, and staff satisfaction and productivity, including: > Improved health outcomes: – Many smokers quit: Nearly one-half (48 percent) of all smokers quit after 6 months in the program, while nearly two-thirds (63 percent) of smokers with coronary artery disease quit over this time period. – More prescriptions filled: Prescription fill rates have averaged around 98% among > Improved clinical outcomes: – More prescriptions filled: Prescription fill rates have averaged around 98% among program participants, well above the community-wide average of 70 and 80% – Better control of hypertension: The percent of patients with hypertension in good control (defined as systolic blood pressure or SBP of less than 140 mm Hg) increased from 68.4 percent at enrollment to 82.3 percent after 6 months. The percent with poor control (an SBP greater than 160 mm Hg) fell from 8.5 to 2.4 percent over the same time period, with an average drop of 26 points in this group. The percentage of diabetes patients with SBP greater than 140 mm Hg fell from 26.1 to 15 percent. – Lower cholesterol levels: Patients who entered the practice with a low density lipoprotein (LDL) level of 130 mg/dL or above experienced an average decline of 30 points after 6 months in the center, while those who entered with an LDL above 160 mg/dL experienced an average drop of 50 points. The percentage of patients with low cholesterol (defined as LDL less than 100 mg/dL) increased from 69.9 percent to 77.1 percent. The percentage of diabetes patients with poorly controlled cholesterol fell from 15.8 to 11.4 percent. – Better blood glucose control: The proportion of patients with diabetes and poor blood sugar control (defined as a hemoglobin A1c greater than 9 percent) dropped from 20.2 to 11.9 percent after 6 months in the program, with an average drop of 2.4 percentage points in this group. The proportion with excellent control (hemoglobin 1c less than 7 percent) rose from 40.8 to 52.5%. > Higher patient satisfaction: – Survey data show a 30 to 40 percent improvement in patient satisfaction survey results compared with their previous care experiences.
ATLANTICARE SPECIAL CARE CENTER: BEST PRACTICE CASE STUDY
> Less steep cost increases, lower utilization: – Total health care spending among program participants rose by only 4 percent in the year after enrollment, well below both the 31 percent increase for this same group of individuals in the year before enrollment and the 12 percent average increase for the local union’s Atlantic City population as a whole. – SCC patients showed significant declines in inpatient days (29.6 percent), length of stay (8.1 percent), admissions (23.9 percent), readmissions within 30 days of discharge (about 80 percent), and ED visits (22.4 percent) after enrollment. – Generic prescribing rates jumped from 43.4 percent in the third quarter of 2007, which was roughly the average for the community, to 64.5 percent in the first quarter of 2010. – Overall net spending relative to controls was $208 per enrollee per month lower than controls, which represented 12.3 percent of total spending. > Financial ROI: average saving of $174 to $200 PMPM for self-insured partners. > Staff satisfaction and productivity: – High rates of staff satisfaction and low rates of staff voluntary turnover. – Staff in the SCC performs at 95 percent capacity, based on a productivity report automatically calculated by the EMR and based the pre-determined visit time: one hour for new patients and 30 minutes for returning patients. Facilitators and challenges: • Key facilitators: > Strong leadership > Complete use of the AIC-U model of care > Continuous monitoring • Most significant challenges: > Avoiding the return to previous primary care practice habits; avoidance has required continuous monitoring. > Reluctance of patients to leave their previous care provider. Advice for peers looking to implement this innovation: • Remember the patient experience: put the chronic care patients’ needs and wants first and foremost. • Hire health coaches who can relate to patients • Embrace new methods of payment: partner with payors willing to consider global fees that encourage flexibility in how care is provided, with a focus on overall care rather than billable events. • Assess the capabilities of your EMR • Set an ideal patient-to-staff ratio: each health coach has a panel of 150 to 175 patients; each physician has a panel of 800 patients; the nurse practitioner does not carry a panel but provides the service and attention in open access for sick visits and transitions of care services.
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