Longmont Community Health Network

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LCHN Summary May 2013 Page 1 CITY OF LONGMONT

Longmont Community

Health Network

Better health at a lower cost

V 2.1 5/24/2013 V 2.0 5/22/2013 V 1.1 5/21/2013 V 1.0 5/15/2013

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LCHN Summary May 2013 Page 2

EXECUTIVE SUMMARY

Health affects every person in our community. Poor health results in excess costs, loss in productivity, inefficient use of community resources and we are seeing those effects in our community. However, we have the opportunity to change that. If we continue to support the Longmont Community Health Network, our community will be the example of how public private partnerships and the appropriate role of government can result in a local health care system that provides better care at a lower cost with greater patient satisfaction than anywhere else in the country.

This is a very exciting time for the City of Longmont. The Longmont Community Health Network (LCHN) has been in place since February of 2012 and is a model for how partnership can benefit all of us. The Public Safety Department has embraced the appropriate governmental role of convener in this process. We are galvanizing the health and medical providers in our community and working side by side to identify gaps in existing services and systems and developing partnership arrangements to fill those gaps.

What you will read in this document and see in the presentation is a system that in the long-term can be completely self-funding through cost savings and will not place any additional burden on the taxpayers of our community or impact the General Fund. There are easily enough dollars in our local health care system to create a lower cost, higher quality system, they are just not currently being used effectively. That is why our role as a governmental entity can be so successful here. When we act as the convener and coordinator of partners, we can identify gaps and work with our partners to fill them. Profit is not a motive for us, so we can engage in discussions with every segment of the health care system with no competitive intent.

You will see in this document how successful the LCHN has already been. There are several pilot

programs ready or close to being ready for implementation, all of which utilize existing resources. These include an alternate destination model where we will take non-urgent patients to a more appropriate level of care rather than the emergency department. You will also see an innovative care coordination model married with a community paramedicine initiative designed to connect patients with existing services and improve their relationship with primary care. This model targets the expensive complex cases involving substance abuse and mental health issues, and uninsured or underinsured members of our community. We will utilize the pilot programs to prove the cost savings that can result from full implementation. We have built these models from best practices research combined with our partner agency subject matter experts.

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LCHN Summary May 2013 Page 3

Introduction

Longmont is a city of approximately 22 square miles in Boulder and Weld counties. The population is estimated at nearly 90,000 people, nearly 17,000 of which have no insurance. There is one hospital in the city, one Federally Qualified Health Center (FQHC), several private clinics and an array of specialty services. We are experiencing the same health care challenges as other communities in the United States. We have a shortage of primary care providers, we use the 911 transport system to take patients to the hospital emergency department that don’t need to go there, we do not coordinate care at an efficient level, and our mental health and substance abuse needs far exceed the supply. The difference in our community is we are doing something about it. The Public Safety Department is coordinating an effort to improve the level of health care services provided in our community. We strongly believe that solutions lie at the local level and we believe that government can and should act as a convener and coordinator rather than a sole provider. The Longmont Community Health Network (LCHN) is a

partnership between the public and private sectors that leverages the resources and expertise of both. The health care system in our country is broken. The Institute of Medicine said in a report from an 18-member panel of prominent experts, including doctors, business people, and public officials that "Health care in America presents a fundamental paradox, the past 50 years have seen an explosion in biomedical knowledge, dramatic innovation in therapies and surgical procedures, and management of conditions that previously were fatal. ... Yet, American health care is falling short on basic dimensions of quality, outcomes, costs and equity."

If banking worked like health care, ATM transactions would take days, the report said. If home building were like health care, carpenters, electricians and plumbers would work from different blueprints and hardly talk to one another. If shopping were like health care, prices would not be posted and could vary widely within the same store, depending on who was paying.

Dr. Jeffrey Brenner, the founder and executive director of the Camden Coalition of Healthcare Providers and the medical director for the Urban Health Institute at Cooper Hospital puts it this way. “What we have found is that our healthcare system doesn’t do a good job of meeting the needs of very sick patients. We are really good at cutting, scanning, zapping and hospitalizing sick people. We are not good at talking to them; we are not good at educating them, coordinating care for them. The system doesn’t really meet the needs of these patients.”

The overall cost of care in the United States is becoming unmanageable. The bulk of the national debt is made up of Medicare and Medicaid, and the overall healthcare system is 18% of the GDP. (See Table # 1, Appendix A)

The United States spends far more than any other country on health care, approaching $8,000 per person, per year. (See Table # 2, Appendix A)

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LCHN Summary May 2013 Page 4 On an individual level, the cost of health care (for those that have any) has risen drastically in the last decade. The premiums have outpaced earnings by nearly four times, which has significant impact on our community. Cost is a primary reason why people avoid care, or opt not to get insurance which often results in unnecessary trips to the emergency department once the issue has gotten out of control. (See Table # 3, Appendix A)

With all of this money spent on health care in the United States, it would stand to reason that it should result in the best possible care. However, this is not the case, the United States in the bottom tier in nearly all of the health care quality and access categories. (See Table # 4, Appendix A)

One pattern is constant in every community in the United States. A small number of patients account for an overwhelming percentage of the costs. The sickest 5% of the population incur 50% of the overall healthcare costs while the healthiest 50% of the population incur only 3% of the costs. (See Table # 5, Appendix B)

Locally, one more statistic drives the need for health care change. There are 16,875 uninsured people in the City of Longmont, 19.4% of the overall population. This is the second highest percentage in the State and Longmont is one of the few communities where this percentage is growing year over year. (See Table # 6, Appendix A)

The Public Safety Department has been providing medical services in our community for many years. Fire services personnel respond on every medical call and police services personnel are often the first to confront behavioral health (mental health and substance abuse) issues.

The Fire Department completed a strategic plan in 2010 with many of these issues in mind. The process engaged the entire department and culminated in a two day retreat with nearly 80 people including members of our community, other governmental and non-profit agencies along with members of our medical community.

The process identified several strategies related to health and medical services. • Tiered Response Model

• Resource Advocate

• Collaboration with Local Clinics • Alpha Truck Utilization

• Self Transport

• Fire Department Right of Refusal

These strategies were the starting point for the development of the LCHN. As we worked on the strategies and kept in mind our partnership philosophy, a new idea began to emerge. We believe that the role of government should be that of a convener. We should work to identify ways we can leverage existing services in our community to solve common problems.

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LCHN Summary May 2013 Page 5 In February of 2012, Public Safety Chief Mike Butler convened the first meeting of Longmont Community Medical Services Network (since re-named to the Longmont Community Health Network). We invited every health and medical service provider we could think of to the first meeting.

What we found out that day was surprising. The people in the room largely did not know each other. That further supported the idea that care is fragmented and needed a convening force. We presented the group with three overarching goals, a reactive goal, a proactive goal, and an outreach and education goal. Those goals were ratified by the group and we moved forward with our process.

A five month Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis followed. Each agency completed an analysis and we did one as a group. This was a process of discovery that allowed

everyone in the group to work together and identify gaps.

The gaps became evident and we created five task forces to address the gaps in support of the three overarching goals.

Task Force 1: Outreach and Education Task Force 2: Alternate Destinations

Task Force 3: Mental Health and Substance Abuse Task Force 4: Care Coordination

Task Force 5: Data Analysis

We have since combined the Mental Health and Substance Abuse task force with the Care Coordination Task Force and added a Health Portal task force.

Each task force recruited subject matter experts in those various fields from all partner agencies and went to work on a SWOT process of their own. The task force then created a purpose statement and some initial strategies to work on in support of the overarching goals.

These task forces will be the backbone of the LCHN moving forward.

See Appendix A for more detail on the LCHN, the partner agencies and recent task force notes.

The Solutions:

There are four distinct areas that are addressed by the LCHN. To increase the quality and reduce the cost of health care in our community, we must:

• Address the inappropriate usage of our community’s emergency department • Facilitate a system to address the complex cases (the 5% / 50% problem)

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LCHN Summary May 2013 Page 6 • Build the level of patient self-sufficiency in our community

• Evaluate Public Safety’s response to medical calls for service.

Solution # 1: Reduce the number of non-urgent cases that are seen in the emergency department. National studies show that at least one-third of all emergency department (ED) visits are “avoidable” in that they were non-urgent or ambulatory and therefore treatable by physicians in primary care settings.i

The Longmont United Hospital Emergency Department sees approximately 33,000 patients each year. This study would suggest that 10,000-12,000 of those visits are avoidable. Of course, that number does not take into account time of day issues or other complicating factors, but there are certainly thousands of visits per year that are avoidable.

The cost of care in the emergency department is much higher for non-urgent care than in a primary care or urgent care setting.ii Each year in our community, millions of dollars are spent at the emergency

department for care that is more appropriate in a primary or urgent care setting at a far lower cost. If we were able to capture a percentage of those excess costs and re-invest them into the LCHN, the network would be self-sustaining.

An increasing number of patients (regardless of insurance status) are using the emergency department as a primary care provider (PCP). 52% of Boulder County residents that visited the ER in 2011 felt they could be treated by a PCP. Of those 52%, the top reason for going to the ER instead was the need for care outside normal business hours (90%).iii This is supported by research done by the LCHN Data Task

Force that identified the 6 p.m. to 9 p.m. time frame accounting for almost 25% of the total visits to the LUH emergency department.

This is the problem that the LCHN Alternative Destinations Task Force is working on. The core purpose of the Alternate Destinations Task Force is stated below:

Our task force is focused on the development and utilization of alternative destinations to our community's emergency department. We want to be able to better serve the uninsured, underinsured and those with potentially chronic medical problems more effectively, efficiently and less expensively. We want to be able to guide people to the appropriate medical facility and be able to do that the first time. Identifying various medical facilities within our community that can serve as alternate destination sites and the parameters for how they operate will be important to our success.

This task force has made considerable progress. Nextcare, Rocky Mountain Urgent Care (RMUC), Longmont Clinic, Kaiser, AMR and Public Safety are all represented. The task force’s progress is outlined below:

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LCHN Summary May 2013 Page 7 1. Alternate Destination sites identified. We have identified all of the clinics in the City, and five

are participating at this point (NextCare, RMUC, Longmont Clinic, Kaiser, Salud). Their capabilities have all been assessed.

2. The public safety medical director has identified a list of ten call types that will be used for the pilot project. In the future, this list could grow substantially.

a. Simple lacerations – not involving obvious tendons or on head, neck, etc b. Sprains and simple fractures

c. Spider bites and straight forward cellulitis

d. Falls (not elderly, no Coumadin, not trauma activation) e. Back pain

f. Chronic pain

g. Animal bites not to hands or face h. Upper respiratory infections i. Earaches

j. Mild allergy – no respiratory distress or Epi Pen usage

Our research estimates that for these call types, the cost savings at in a clinic setting vs. the emergency department is approximately $1,000 per incident. If we apply this amount to the total number of visits that could be seen by a primary care provider (stated above at 10,000 – 12,000) the amount of money wasted each year at an inappropriate level of care is a staggering 10-12 million dollars in our community alone. If even a small percentage of those savings are put back into the network, the entire network would be self-funded.

3. Logistics of the program.

Initially, the triage process will be done in the field by paramedics. They will start to utilize a “menu” type approach to calls. The paramedic will be empowered to determine whether or not the patient needs to go anywhere, whether they can be treated in the field with no transport, taken to an alternate destination clinic, or transported to the emergency department. Alternate modes of transportation were discussed, basic life support (BLS) ambulance, taxi, wheelchair transport, etc. As we evolve, a telephone triage system could be implemented that could dispatch the appropriate level of transport.

The clinics are geographically located to split the City into thirds. The patient will be taken to the closest clinic, regardless of their insurance status. Three clinics (NextCare, RMUC, Longmont Clinic) have agreed to extend their hours to 9 p.m. to address the 6-9 p.m. issue. The field paramedic will notify the clinic of the patient, and if the clinic is able to take them, the patient will be transported there. If the clinic is swamped, the paramedic will call the other clinics. Time is not of the essence, the patient has been triaged to be non-urgent. Clinics are working

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LCHN Summary May 2013 Page 8 out the internal logistics of how they will receive a patient. Possible exceptions to this process are Salud and Kaiser patients that want their patients transported to their clinics if possible. The patient will receive a copy of the services performed and all pertinent details to take to their PCP for inclusion in their record.

A quality assurance (QA) process will be established for each transport early on to make sure the process is working.

4. Baseline paramedic triage assessment. The field crews will start an assessment process soon to determine the current level of triage accuracy. Currently, this level of triage is not part of a normal paramedic curriculum. In the test phase, the crews will check a box in the patient care report if they feel the patient could have been taken to a clinic rather than the emergency department. The medical director will then review all of these cases to determine whether or not the assessment was accurate.

5. Training program for "menu" approach. Based on the results of #4, a training program will be established for the field crews to address any gaps that exist in the triage process.

6. Move to alternate modes of transportation. Down the road, alternate modes of transport will be investigated. Can we partner with non-medical transport agencies like Via to take patients without ambulance and paramedic involvement? Are there other community partners that could provide non-medical transport services? If we are successful with non-ambulance modes of transport, the savings per incident will increase an additional $1,300 (the average cost of a 911 ambulance transport), bringing the total per incident savings to $2,300.

7. Increase patient connectivity to primary care. Two of the clinics, Nextcare and Rocky Mountain Urgent Care have offered to take new Medicaid patients. With the Medicaid expansion in the Affordable Care Act, thousands more people will be eligible for benefits. Currently, Salud takes the majority of Medicaid clients but may be reaching capacity. Adding two additional Medicaid providers that are willing to become the medical home for the patient is a significant positive step.

8. Make medically based decisions that are not financially driven. The clinics are taking patients regardless of insurance status. This level of collaboration between competing clinics is incredible. The partnership shown by this group is inspiring and truly shows what we can accomplish in the LCHN if self-interest and the bottom line are secondary to the patient’s health. 9. Engage the payors with a business plan. Currently, insurance companies will only reimburse

ambulance providers for trips to the emergency department. We are working with the Medicaid office in Colorado on a solution. We will also be engaging the private insurance providers in the near future.

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LCHN Summary May 2013 Page 9 How will we measure success?

1. In the context of 911 calls for service - we see an increase in number of patients being directed to alternate destination facilities.

2. Enough alternate destination sites are located geographically throughout the city. 3. Public and private insurance reimburse ambulance services for transporting to alternate

destination sites.

4. In the long-term, we will see definitive trends of people not calling 911 and are in fact self-directing themselves to alternate destination sites.

5. Increase in number of patients connected with a primary care provider. 6. We see fewer overall medical transports in our community.

7. System costs for non-urgent care decrease by at least 10% (for 911 Calls)

To further address the inappropriate usage of the emergency department, we are investigating a fire station “Health Portal” idea prototyped in Alameda County, CA. These portals could be located in City facilities or in other strategic locations. They are designed to be an access point for care, but the scope of care could vary. For example, the portals could help people access insurance or other social services with navigators, could provide some limited mental health and substance abuse counseling or crisis intervention, deliver educational programs or a limited scope of primary care medical services that could assist with filling the 6-9 p.m. gap.

As we look further down the road with the health portal concept, we are looking into ways we could supplement City employee health and medical services. Could a Physician’s Assistant or Nurse Practitioner lead a staff in a City sponsored clinic that could also serve as a community health portal? Could this portal offer additional preventive care services to further improve the health of our employees?

These portals could be places for health care navigators or advocates to be stationed to link people to eligible services or insurances plans.

Solution # 2: Create a patient-centered, in home, intensive care coordination system that fills the current gaps in our system and focuses on the 5%/50% issue.

The fee for service model has created a fragmented care system that does not work for the complex cases.

“When a primary doc walks in the room, they make more money from treating a head cold than they do from treating an extremely sick patient… If I can run into a room and treat a head cold, I’ll make way more money for that visit. If I walk into the room of a patient that’s in a wheelchair, that doesn’t speak English, that’s just been in

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LCHN Summary May 2013 Page 10 the hospital, that’s confused about the meds, I could be in there for 40 minutes, and then I am going to have tests, follow-ups, phone calls, coordination – all that work is unpaid work. So we have really an utterly failed model of primary care. And, if that patient has three or four specialists, there is nothing about how we pay the specialists that encourages them to coordinate with each other so they each start and stop medications that conflict with one another, they order duplicate tests. There is just no one quarterbacking.”

Dr. Jeffrey Brenner – Camden Coalition

The predominant method of paying physicians in the U.S is through fee-for-service (FFS) payments such as those set by the Medicare Physician Fee Schedule. The FFS model provides little reward for the core primary care functions.iv While this creates a barrier to effective primary care for any patient, it imposes

even greater challenges to comprehensive and coordinated care for patients with complex illness or substance abuse and mental health issues. For example, it is more efficient under current FFS payment mechanisms to identify and document the health problems of a complex-needs patient and then refer that individual to specialists for diagnosis or treatment. Moreover, physician fees do not cover the extra costs of comprehensive geriatric assessmentsv, nor do they cover the additional time required to

communicate with patients with cognitive impairments or to examine those with physical disabilities. Furthermore, FFS payments are generally based on documented services provided during encounters, which means there is no additional payment for non-visit-related care coordination activities like outreach to patients, collaborating with community agencies on care plans, determining patient eligibility for public assistance benefits, or consultations with specialists, family members, or home care providers. For most PCPs, the additional effort to provide comprehensive assessment and management as well as care coordination for patients with complex needs will result in a financial loss to the practice, even if these efforts generate savings for the overall health system. The current FFS system also makes it hard for PCPs to provide care coordination activities, an important service for complex-needs patients who often have urgent issues. Existing practices struggle to maintain adequate “same-day” openings in their schedules for urgent visits during regular business hours.vi Additionally, there is no payment to

offset the higher costs of after-hours visits or weekend services, either in the office or in the patient’s home. Current FFS payment does not support 24/7 telephone or email communication access, even though patients with complex illness often need assessment and advice that does not require an office visit. Some of these patients, in fact, have considerable difficulty getting to the office for face-to-face encounters due to limited physical mobility, frailty, transportation issues, or cognitive impairment.

These cases are the most expensive and require social and medical support

“There are risk factors to being a high utilizer of the ER and hospital. If you are blind, if you are deaf, if you are in a wheelchair, if you are disabled, if you are older, if you have co-morbidities, if you have a low literacy level, if you don’t have family support, if you don’t have a car, if you are an addict, if you are mentally ill, all these things are compounding risk factors. These things add up and if you’ve got four or five of them, you become a more extreme, high utilizer…. What we have found is driving this is that our healthcare system doesn’t do a good job of meeting the needs of very sick patients. We are really good at cutting, scanning, zapping and hospitalizing sick people. We

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LCHN Summary May 2013 Page 11 are not good at talking to them; we are not good at educating them, coordinating care for them. The system doesn’t really meet the needs of these patients.” Dr. Jeffrey Brenner, Camden Coalition

Mental health and substance abuse are almost always a factor

“The sickest and most complex patients—the most expensive people—often don't have the mental faculties to be informed consumers. ... I think with the science of complexity, you have to break the problems down into small pieces and do it in a patient-centered way. We put them through the same process that we put everyone else through. We make them wait on hold, fight with the reception desk, and sit in the waiting room to spend just a few minutes with the primary care doctor. It is not the kind of care that the person needs. Meanwhile the American

public is paying for it." Dr. Jeffrey Brenner

The Care Coordination Task Force of the LCHN was given the monumental task of addressing the complex cases and finding a way to help. Expert care coordinators from our community have examined the current programs in place and created a mechanism to better address the complex cases. Based on the national best-practice Camden Coalition model, the team has altered the Camden model to fit our community.

We define care coordination as the deliberate organization of patient care activities between two or more participants (including the patient) involved in the patient’s care in order to facilitate the

appropriate delivery of health care services. These collaborative resources and services are organized in a manner which addresses the individual’s health care needs at an attainable level of understanding in order to optimally enhance the patient’s quality of life and promote an increased level of

self-sufficiency.

To deliver this model of care coordination, we will utilize a best-practices based systems approach to coordination that is continuous, collaborative, intensive, patient centered and integrated in to the patient’s home environment.

The system should ease the transitions between services and providers through an increased level of communication and collaboration, and identify access points in our community that support our vision for care coordination.

Numerous evidence based best practices exist for in-home care coordination programs. We have modeled our program primarily after the following programs:

• Camden Coalitionvii,

• The Transitional Care Model: Mary D. Naylor, Ph.D., R.N.; University of Pennsylvania School Of Nursing

• The Care Transitions Program: Eric Coleman, M.D.; Division of Health Care Policy and Research at the University of Colorado Denver, School of Medicine

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LCHN Summary May 2013 Page 12 • Transitions of Care Program: Salud Family Clinics and Longmont United Hospital

LCHN Care Coordination Task Force goals:

1. Provide immediate and intensive follow-up coordination post discharge; Clinical assessment and first home visit within 24 hours. Build a care plan, gather resources, determine goals.

2. Connect the patient to a primary care provider as quickly as possible (target = 7 days post discharge)

3. Improve the relationship between patient and their primary care provider

4. Place an equal or greater emphasis on coaching social skills. Remove the barriers to accessing care.

5. Connect to and utilize existing community programs and partners as much as possible. This includes home health care providers, social service providers, other City departments, etc. 6. Transition the patient to the primary care provider in 60-90 days.

We have a long-term goal of full-time care coordination teams staffed by a registered nurse or nurse practitioner as the team leader, supported by a social worker or case manager, a paramedic and Americorp HealthCorp volunteers. No full-time teams currently exist in our community.

These care coordination teams will address the highly complex cases that account for the vast majority of health care spending (the 5% / 50% problem). It is not an easy task, and we will not be successful all the time.

During the pilot phase, Longmont United Hospital’s care coordination team has offered to complete the in-hospital part of the process. Their care coordination manager will identify 3-4 hospitalized patients who fit our model. The LUH team will approach the patient and explain the process. If the patient is willing to participate, they will sign the appropriate release forms and complete a risk assessment and enrollment packet.

The patient will then be visited at home by the care coordination team. The nurse lead for the pilot program (not yet identified), a Mental Health social worker, a paramedic, and Salud volunteer HealthCorp workers will form the pilot project in-home team.

The Salud clinic already has a “Transitions of Care” program in place with LUH that is staffed with HealthCorp workers that has been successful. Salud has offered their volunteers to be part of this pilot program.

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