1. Sutter Care Coordination Program (SCCP) Supporting Patients and Practitioners in Optimizing Health

2. 2 Care Coordination and Population Risk Complexity 10% of the Population Utilizes 60% of the Resources

3. Sutter Care Coordination Program: Focus 3 Transitions of Care & AIM Behavioral Health & Medication Complexity Social Determinants of Health Impacted HIGH RISK PATIENTS TOP 2%

4. SCCP Background & Purpose: Current State Doctor RN Case Manager Health Care Coord. SW Case Manager Patient Reactive Non Targeted Diffuse Loose Team Work Passive Pt Reactive Non Targeted Diffuse Loose Team Work Passive Pt Episodic Care 70% Longitudinal Care 30%

5. SCCP Background & Purpose: Future State Proactive Targeted Precise Tight Team Work Activated Pt Proactive Targeted Precise Tight Team Work Activated Pt Episodic Care 30% Longitudinal Care 70% Patient RN Case Manager Pharmacist Health Care Coord. LCSW Physician

6. Sutter Care Coordination Program: Structure 6 6 Geographic Teams & 1 Specialized Team 250 Primary Care Physicians260,000 Patients

7. SCCP Metrics MEASUREGOAL 1.Percent of patients with advance care planning discussion within 90 days of enrollment 95% 2.Percent of patients with patient developed goal within 90 days of enrollment 90% 3.Percent of high risk patients with transitions of care call (TOC) within 48 hours of discharge 100% 4.Percent of SCCP patients meeting at-risk criteria per targeted At-Risk patients 70% 5.% of high risk patients with medication reconciliation by pharmacist within 72 hours of discharge 100% 6.Percent of discharged patients assisted by SCCP with TCM codes billed 100%

8. SCCP: Focus & Portals of Entry 8 Program Admission Risk Profile Activation Physician Referral Transitions of Care AIM

9. Targeted At-Risk Population vs. SCCP

10. Common Interventions –Provides integrated care planning and coordination of care –Assists with complex psychosocial conditions –Assist with referrals to Sutter services and community resources –Assists patients with end of life issues and advance directives. –Provide complex medication review and reconciliation –Coordinate alternate patient placement such as SNF and assisted living.

11. Readmission Prevention Management of patients at times of transitions –Discharge from Hospital setting –Discharge from SNF –Discharge from Home Health Communication regarding shared patients –Acute case managers to Ambulatory case managers –Ambulatory case managers to Acute case managers Phone Midas

12. Daily Acute and SNF Census Review to Identify patients for follow-up SMG or SIP physician Discharge to home without home health High Risk patients identified for follow up –Unplanned readmission within 30 days – ≥ 2 admissions/year –≥ 2 ED visits/year –≥ 3 Chronic Conditions –CMS Targeted Readmission diagnosis COPD, pneumonia, stroke, AMI – Polypharmacy ≥ 7 medications

13. Transition of Care Process Select Patients Conduct post discharge home/telephonic visits –Medication Reconciliation –Review “red flags, medications and warning symptoms –Ensure follow up visits are arranged –Assess patient treatment adherence –Support systems in place

14. Transitions of Care Follow up

15. Transitions of Care Reduces Readmissions YearTOC Pts Phone Calls Readmitted Pts Readmission Rate 20139733063626.4 First Qtr 2014241826145.8 The historical Medicare 30Day readmission rate was at 15% and above.

16. Pharmacist Role 1.Team Integration: Serve multiple teams vs. single Broad geographic area 2 PharmD cover Sacto/ Placer/ Yolo EPIC / EMR coordination 2.Transition of Care: PharmD second pt call (48-72hrs) EPIC / huddle hand off to RNCM (total vs. shared) Medication Reconciliation & follow up calls day 7-14 Capacity: 4-6 med rec./ day F2F FU with complex pts at office visit

17. Pharmacist Role 3.Lessons Learned: Benefit of LEAN to integrate Prior habits/ PCMH hangover (Pilot evolution) Complexity of med rec when done correctly = energy expended How to do telephonic work (cold call). Importance of provider relationships. MD & PharmD working in PCP practice 4.Next Steps Continue program roll out Monitor & adjust

18. Pharmacy Medication Reconciliation

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