1. 1 Reform-Minded Care Coordination For the Low-Income Uninsured SCHA Reengineering Committee Meeting February 11, 2011

2. An effective Delivery System Primary Care Medications Specialist Care Urgent/Emergent Care Hospitalizations Ancillary Services Home Care Dental Care Mental Health Services Health Education

3. 3 Access Gaps Identified 3 Safety Net providers – all at capacity Limited Specialist availability for uninsured No Adult Dental Care for uninsured ERs: 48% visits, non-emergent Frequent utilizers: 3 contacts/month/person $116 million charity care 2009

4. Societal Factors Education: < 20% Adults have College Degree Poverty: > 14% Unemployment: > 10%

5. 5 AccessHealth South Carolina The Duke Endowment Helping Communities Build Networks of Care for the Uninsured

6. Timeline March 2009 Application for year long planning grant July 2009 Planning Grant awarded October 2009 Application for Implementation grant December 2009 Implementation Grant awarded July 2010 Doors open

7. 7 A Coordinated Community Approach to Caring for the Uninsured

8. An effective Delivery System Primary Care Medications Specialist Care Urgent/Emergent Care Hospitalizations Ancillary Services Home Care Dental Care Mental Health Services Health Education

9. 9

10. 10 Mission To improve access to healthcare for the uninsured of Spartanburg County through sustainable health system change that will result in better health outcomes and 100% access to effective, efficient, safe, timely, patient-centered, and equitable healthcare. Access to Care = Improved Outcomes + Decreased Costs

11. 11 Clients :  Uninsured  Spartanburg County residents  150% Federal Poverty Level or below  Ages 19 to 64 Program Overview 29,183 potential participants!

12. 12 Services:  Eligibility for Fed/State/Local programs  Initial Assessment  Connection to medical homes and specialty services  Care coordination  Approach: Team-oriented, Holistic, Patient-centered Focus:  Measurement-based Outcomes  Community provider IT connectivity ( a minimal risk testing ground for Healthcare Reform-Redesign) Program Overview

13. 13 Engaged community partners Better Use of Local Resources Improved health status  Shift from “ crisis care ” to “ prevention, early intervention and disease management ” More efficient care and reduction in healthcare costs  Reduction in inappropriate EC and IP use  Reduction in hospital readmission rates  Coordinated entry into program at time of discharge Reduction in demand for taxpayer-funded services Program Outcomes

14. 14 Structure Separate Non-profit 10 Community Partners 5 Member Board Currently seeking 501 c 3 status

15. 15  Public Health Department  Both Hospital Systems  FQHC  Free Medical Clinic  Department of Mental Health  Alcohol and Drug Abuse Commission  Welvista (Statewide Medication Program)  Spartanburg County Medical Society  USC Upstate Community Partners

16. 16 Director Eligibility Specialist RN Care Navigator LBSW Care Navigator Americorps VISTA Program Staff

17. Capacity with Internships Multiple college partnerships  Virginia College  USC Upstate Mary Black School of Nursing  Limestone College  Converse College Multiple roles to fulfill

18. 18 Falls under the Americorps VISTA Development of Volunteer Manual and Orientation Recruitment Strategy 3 volunteers currently; 4 additional needed Duties include reception/front office, answering phones, data entry, assisting with Gift in Kind, creating client cards Capacity with Volunteers

19. 19 Physician Recruitment Primary care and Specialists What’s in it for me? Volunteer Provider Network

20. 20 Provider Network What Primary Care Providers want: Case management support to assist patients with psychosocial needs and barriers to care What Specialists want: Buy in from Primary Care, medical homes for current patients

21. Provider Network Current count of PCPs in network: 108 Current count of Specialists: 166 Efforts by Regional Physician Network and Mary Black Hospital practices Model: No reimbursement for services

22. All Aboard or derailment Doctors Hospitals Social services

23. 23 Technology Component Care Management software (Care Scope) Coordinated Eligibility program (Benefit Bank)  web-based platform  Federal, State, and Local Services Community Health Information Exchange  Mechanism for providers to access health information about shared patients

24. 24  285 client participants enrolled in pilot  385 eligibility screenings performed  193 medical home assignments  38 Specialist Referrals to date  1,855 appointments made  112 Rx program enrollment and/or assistance  104 applications for benefits through The Benefit Bank  37 clients in smoking cessation programs  7 GRADUATES! Progress to Date

25. 25  Referrals 5 Rehabilitation (Regional Rehabilitation Services) 6 Alcohol and Drug (SADAC) 7 Housing (Mostly to Housing Authority) 28 Financial Assistance 37 Counseling (10 to PACE, 10 SADMH, 17 to Westgate) Progress to Date

26. 26  Race Client Demographics

27. 27  Age Median Age is 46 years, 308 days Oldest: Born 6/30/1929, 81 years 193 days old Youngest: Born 11/29/91, 19 years 72 days old Client Demographics

28. 28  Location 160 live in the City of Spartanburg (56.7%) Client Demographics

29. 29  Poverty level Client Demographics

30. AccessHealth Measurement System Case Management Software  Stores Client Case Files & Record of Encounters  Potential to Connect with Other Systems… HIE State Level Data Warehouse  Connectivity among Hospitals  Data Warehouse Assigns Unique Identifier to Records, so Anonymity is maintained In-House Tools  Return on Investment Calculators with Excel & Access 30

31. AccessHealth Measurement System Feeds Logic Model Measuring Inputs  Number and Types of Volunteer Physicians  Number of Medical Homes  Outlets for Obtaining Prescriptions  Dollars Invested & In-Kind Contributions Measuring Outputs  Number of Appointments Made & Number Kept  Types and Counts of Services Provided 31

32. 32 Self-Pay Hospital Outcomes Model with and without AccessHealth, Controlled for size of group 18mo pre-AccessHealthAccessHealth Start 3yrs post-AccessHealth Self-Pays w/o AccessHealth AccessHealth Clients only All Self-Pays Annual Charges or # visits Among $elf -Pays

33. 33 AccessHealth ROCI Investments  Grant dollars in  In-Kind Support (e.g., rent for donated space)  Calculated value of physician office visits, labs, radiology, scheduled OP surgery Outcomes/Returns  ER & IP Cost Savings  Economic Value of Health Behavior Changes  Economic Value of Employable Clients

34. 34 AccessHealth ROCI Investments  Total Year 1 = $480,000 Outcomes/Returns  Total Year 1 Hospital Est. Cost Savings = $574,096  Total Year 1 Client Est. Benefit = $120,967  Total Year 1 Employer Est. Benefit = $12,472  Total Year 1 Community Est. Benefit = $9,094 149% Return on Community Investment “For every $1 invested in the program, there is $1.49 returned in benefits.”

35. First Annual Report 30-365 days pre-post Welvista enrollment Decreases in Visits & Charges 9/1/2009 thru 7/1/2010 (138 IP or ER patients Enrolled in 12 months) Emergency (-25% reduction in visits) Inpatient (-60% reduction in visits) -$1,126/Patient -$23,755/Patient 90 Pre 90 Post

36. Comparative Sample Self-pays (no Welvista) 30-365d pre-post Increases in Visits & Charges (501 IP or ER patients in 9 months) Emergency (14% increase in visits) Inpatient (62% increase in visits) $596/Patient $8,579/Patient 90 Pre 90 Post

37. all before-after  2 tests sig. at p<.001 Welvista Patients vs. Comparative Sample with no Welvista Pre-Post Charge Comparison

38. ROI Welvista Charge savings = $3,433,655 Welvista Cost Savings = $515,048 Hospital Investment in Welvista = $250,000 ROI = 206% + Charge Avoidance = $904,388 Cost Avoidance = $135,658 Net Cost Return = $650,706 NROI = 260%

39. Challenges Continued partner engagement Uncovering system failures Fundraising

40. United Way’s Safety Net Council Community agencies Case submissions each month “Grand rounds” Case follow up

41. 41 “System Issues”  Patient-centered Medical Homes Chronic Disease Mgt Strategy  Mental Health resources  Dental Care What’s missing?

42. 42 “Tonya” Female, age 33 Dropped from Medicaid while 5 months pregnant Type I Diabetic Need for medical home, support services for Tonya and her children Medical home established, readmission of Tonya with OB Healthy baby born on (date) Medicaid application completed, accepted…client graduated Get to know a patient…

43. 43 “Frank” Male, age 55 Resident of homeless shelter Need for medical home, suspected he had high blood pressure Assigned to medical home Provider diagnosed high blood pressure and diabetes Medication and education provided; health disaster prevented Get to know a patient…

44. 44 Questions?