New models of healthcare, Oliver Wyman at For Later Life 2014
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This document discusses establishing an Extensivist model of care to coordinate care for high-cost, high-need patients. It describes how an Extensivist clinic would function, with an Extensivist leading a care team to provide integrated care for patients' medical, behavioral and social needs. It also outlines challenges in implementing this model, such as gaining hospital privileges, changing patient behaviors, and developing new capabilities. The goal is to improve outcomes and lower costs through coordinated, preventative and patient-centered care for the most complex patients.
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New models of healthcare, Oliver Wyman at For Later Life 2014
- 1. © Oliver Wyman HEALTH & LIFE SCIENCES New Models of Healthcare Age UK June 2014
- 2. 1© Oliver Wyman 1 2011 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Activity A&E Outpatient Inpatient Example: Anonymised Patient Profile High cost frail elderly patient Diagnosis: Hypertensive renal disease Procedure: Magnetic resonance imaging NEC 5 Source: Hospital Episode Statistics Note: some dates have been altered to maintain patient anonymity Details Service Utilisation Name Mr A. N. Other Activity 37 interactions Age 80-85 Cost £26,000 Patient Segmentation: Example high cost frail elderly patient These patients require complex care for a variety of different conditions, often delivered in an uncoordinated way Admitted from A&E Diagnosis: Complications of cardiac & vascular prosthetic devices, implants & grafts Procedure: Insertion of tunnelled venous catheter 6 Admitted from A&E Diagnosis: Unspecified nephritic syndrome Procedure: Percutaneous needle biopsy of lesion of kidney 1 Admitted from A&E Diagnosis: Other and unspecified injuries of abdomen, lower back and pelvis Procedure: None 3 Diagnosis: Unspecified nephritic syndrome Procedure: Intravenous chemotherapy 2 Admitted from A&E Diagnosis: Unspecified nephritic syndrome Procedure: Intravenous chemotherapy 4
- 3. 2© Oliver Wyman 2 Patient Segmentation: Example high cost frail elderly patient These patients require complex care for a variety of different conditions, often delivered in an uncoordinated way 2012 2013 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Inpatient Outpatient Activity Community GP A&E Example: Anonymised Patient Activity High cost patient i Diagnosis: Angina pectoris Procedure: None 3 Diagnosis: Non-specific chest pain Procedure: None Diagnosis: Non-insulin-dependent diabetes mellitus Procedure: None 1 2 Details Service Utilisation Name Mr A. N. Other Activity 34 interactions Age 45-50 Cost £10,000 Source: Hospital Episode Statistics Note: some dates have been altered to maintain patient anonymity
- 4. 33© Oliver Wyman Population cost segmentation, secondary care spend, 2011 85% 143k (32% used secondary care) 11% 19k 3% 5.6k 12% £14m 41% £45m 47% £52m Population segments Cost breakdown Spend per head: £9.3k £2.3k £0.1k High Cost Over £5,000 per year Moderate Cost £1,000 to £5,000 per year Low Cost Under £1,000 per year Source: Hospital Episode Statistics, 2011 Patient Segmentation: Cost concentration The most expensive 3% of patients account for 47% of secondary care costs
- 5. 44© Oliver Wyman Patient Segmentation: The cost pyramid by LHE High Cost Moderate Cost Low Cost 87% 112k 10% 13k 3% 4k 26% £20m 34% £25m 39% £30m Airedale, Wharfedale & Craven* Blackpool East Riding Fylde & Wyre High Cost Moderate Cost Low Cost NE Lincs North Tyneside Somerset Sunderland* 86% 148k 11% 19k 3% 5k 14% £16m 39% £42m 47% £51m 85% 257k 11% 35k 3% 10k 13% £26m 39% £79m 48% £96m 86% 130k 11% 16k 3% 5k 14% £14m 38% £36m 48% £46m 85% 246k 12% 35k 3% 9k 13% £25m 42% £81m 45% £85m Hull 85% 143k 11% 19k 3% 6k 12% £14m 40% £45m 47% £52m 82% 177k 14% 30k 4% 8k 13% £22m 66% £39m 48% £41m 87% 475k 10% 55k 3% 16k 15% £51m 36% £121m 48% £160m 84% 239k 12% 34k 3% 10k 14% £29m 36% £77m 50% £106m * Includes additional cost data
- 6. 55© Oliver Wyman Population cost pyramid 2012/3 £17m Social care cost 2% ~2,000 0.5% ~600 0.4% ~400 ~20% ~£3.4m ~30% ~£5.3m ~50% ~£8.5m Population segments Cost breakdown High Cost Over £13,000 per year Moderate Cost £5,000 to £13,000 per year Low Cost £1,000 to £5,000 per year Patient Segmentation: Cost concentration For social care the picture is even more concentrated…… Source: South Somerset Symphony project data, Oliver Wyman analysis Note: Net social care costs used, self-pay contributions excluded Note: Over half of the highest healthcare cost cohort (~2,800 patients with >£7,000 healthcare spend) did not have a social care assessment or receive any social care No Cost £0 per year 97% ~112,000
- 7. 6© Oliver Wyman 6 A variety of patient-centric clinical models exist globally and are yielding outcome and cost improvements in targeted populations • Extensivist led multifunctional team wraps services around the sickest patients • Responsible for patient across all care settings • Single point of patient contact and capitated payments drive accountability • Ultra high efficiency ambulatory surgery model focused on a limited set of interventions • Exploits techniques borrowed from manufacturing • Very high patient and physician satisfaction • Reduced admissions and length of stay • 20% lower cost • Lower complication and infection rate • 30 to 40% lower cost • Specialised GP model focused on a polychronic population • Highly integrated care delivery with GP responsibility for all aspects of care • Model tailored to underlying population and cultural norms Extensivist model Systematised surgery Primary care medical home • Same day access utilisation reductions (40% A&E, 50% speciality, 20% primary care) Source: The Quiet Healthcare Revolution The Atlantic; AMSURG; Nuka Model of Care Provides Career Growth for Frontline Staff Southcentral Foundation; Oliver Wyman
- 8. 77© Oliver Wyman Extensivist clinics focus on the sickest patients, including a significant number of frail elders Frail elderly overview • Highest need patients aged over 65 at risk of catastrophic decline • Uncoordinated care and inadequate access leads to unnecessary admissions and poor disease management • Drive seven times more spend than the population average >2 comorbidities • Myocardial Infarction • Congestive Heart Failure (CHF) • Peripheral Vascular Disease • Cerebrovascular Disease • Dementia • Chronic Obstructive Pulmonary Disease (COPD) • Connective Tissue Disease • Ulcer Disease • Diabetes • Hemiplegia • Moderate to Severe Renal Disease • Liver Disease • Cancer – all types • HIV / AIDS • Multiple Sclerosis Patient segmentation
- 9. 8© Oliver Wyman 8 An Extensivist coordinates and reorients care around the patient Behavioural/ social care Chronic condition management Environment and equipment Home and community- based care Social Work “Life” support (e.g. finances) Substance Abuse Smoking Cessation Palliative Care Crisis management Diabetes and Wound Care CAD / CHF COPD Asthma CKD ESRD Hypertension General Co-morbidity Management Home Care Durable Medical Equipment (DME) Mobility Assistance Remote Monitoring Televisits Nursing Home / SNF Care Discharge management Diet / Nutrition Psychiatry / Psychology Transportation Hospice After-Hours Care Clinical Pharmacy Strength and Balancing Patient Navigation Case Manager Extensivist Clinical Care Centres (CCC) GPs Extensivist-led model
- 10. 9© Oliver Wyman 9 Care team roles Role Scope of Services Extensivist • Clinical leader and the “quarterback” for the patient’s care Advanced Practice Provider • Supports Extensivist by evaluating and caring for patients as appropriate Patient Navigator • Primary patient contact and care coordinator Nurses/ MAs • In-office patient care Behavioral health resource team • Provides mental health support services Pharmacist • Assists in pharmacy and medication therapy management Receptionist • Handles patient enquires and scheduling Office Manager • Manages practice staff, administration and compliance Social worker • Coordinates solutions to resolve home and family life issues Dietitian • Helps patients develop and maintain diets appropriate for their conditions Palliative care • Assists in reducing patients’ physical and psychological suffering at end of life Related services • Range of services including physical therapy, home care, post-discharge care, etc.
- 11. 1010© Oliver Wyman The Symphony Expert Care Hub Network will be modelled as a number of local Expert Care Hubs, sharing central support The Symphony Expert Care Hub Network Local Expert Care Hubs • Location for co-located multi-skilled Care Coordinator and Key Worker teams to enable effective team working • Initial point of contact for all patient needs, e.g. Questions, concerns, urgent enquiries, carer concerns • Locally accessible to cohort patients, e.g. – Delivery of care as part of care plans – Meeting core team members for review Central Office Symphony central office • Shared infrastructure and support functions e.g. IT, Finance / accounting, patient identification and tracking, etc. • Central business functions and Symphony management, e.g. Care model refinement, geographic expansion, planning for extension to new cohorts, etc. Care Hub 1 Care Hub 4 Care Hub 2 Care Hub 3
- 12. 11© Oliver Wyman 11 The Extensivist clinic can provide a one-stop shop for patients and helps reduce isolation Basic Care Pre-Op Strength Training Foot Care Example Care Center Layout Class-roo m Medical Records Room Registration Desk Office – Exam Rooms– Supplies/ Equip. Storage NP Office Waiting Community TVRoom Podiatry Room Extensivist Office Strength Training Room Lab/Diagnostic Room – Exam Rooms– Blood Pressure Management Nutrition & Wellness Classes Social SpaceNurse Practitioner Hospitalist’s Office Wound care Fall Prevention Source: “Delivering Integrated Patient Care for Seniors,” CareMore 11/2008, p. 33 Example Extensivist clinic For discussion In some areas, a smaller clinic can be supported by existing virtual or distributed infrastructure to provide the same levels of care
- 13. 1212© Oliver Wyman Extensivist practice overview Chronic care-specialized physician is interested in building a suite of services to fully meet the need of the most fragile patients Day in the Life • Physician sees 8-10 patients, with visits ranging from 30 to 90 minutes • Average panel size of 400 patients • Physician practice includes supporting care team, including NPs/PAs, embedded health navigator, and other embedded services Core Patient Profile • 95%+ of patients have more than 4+ chronic condition and have serious health needs (sickest 5% of patients – to be discussed further) Embedded Patient Services • All patients will be eligible to receive health navigation from the embedded health navigator • Other in-house patient services and built out based on patient volume and may include Behavioral Medicine, Pharmacy, Hospice, Nutrition, and others • Patients may be connected to other community-based services by their health navigator Compensation (TBD) • Combined compensation model based on salary or a combination of on RVUs and gain share Extensivist Practice Focused on the most complicated chronic care within one practice
- 14. 1313© Oliver Wyman Patients selected for the Extensivist clinic will fall into one of three categories 1Catastrophic Patients 2Future Catastrophics 3 Physician Referrals • The biggest, most catastrophic and costly cases • Small number of patients • A portion of these patients won’t be catastrophic “tomorrow” (e.g. trauma patients, other one-off episodes) • Patients with comorbidities, behavioral risk factors, and heavy system utilization • Patients who may not be top spenders today, but are likely to be higher cost “tomorrow” • Patients referred to the clinic by their physicians • “We know them when we see them” • Referrals to the clinic will be greeted with a quick answer and a quick decision Will be identified via an analytic-based approach Will be identified via ongoing engagement with physicians Extensivist patient categories
- 15. 14© Oliver Wyman 14 A number of potential issues need to be overcome when establishing an Extensivist model HOSPITAL Total population: 168k Future NE Lincs Health Economy – overview HOSPITAL Scunthorpe General Need to manage perception of preferential treatment given to urban patients • CCG needs to contract based on risk to enable provider upside • Patients must be prepared to change their main point of contact as they move between models • Federated GP clinics share information, capabilities and patients • Risk and outcomes based payments demand risk pricing and flow of fund management capabilities Hospital specialists must work alongside the Extensivist in order to co-ordinate care Extensivist needs privileges for ward rounds within the hospital setting The Humber A&E Department GP surgeries Acute provider hospital Mental health/ Social care providers Extensivist clinic • Provider build of significant capabilities to launch – Extensivist lead clinician – Care team composition – Workflow redesign – Risk stratification – IT / systems – Scheduling • Change in patient behaviours will be required • Community-based resources will need to have aligned incentives and coordinated activities For discussion
- 16. 1515© Oliver Wyman The model has 6 major elements, providing us with a view of the overall impact of the Expert Care hub, and impacts across the system New cohort costCurrent cohort cost Expert care hub costs Other incremental services Efficiency, de- duplication & re-use Lower cost of care 1 2 3 4 5 Symphony economic model elements Cost 6 Illustrative – not to scale
- 17. 1616© Oliver Wyman • Integrated, team-based delivery • Shift to prevention and wellness • Transformed outcomes and value for money, partly through selective partnerships • New non-traditional healthcare players • Intent to improve accessibility and wellness • Extensive use of partnerships • Widespread genomics sequencing • Likely to entirely change health systems • Baseline established for: – Quality – Safety – Primary Care and Hospital efficiency Wave 0 BASIC SAFETY AND EFFICIENCY Wave 1 PATIENT-CENTRED CARE Wave 2 CONSUMER ENGAGEMENT Wave 3 SCIENCE OF PREVENTION The UK healthcare system will undergo waves of innovation, transforming care delivery Early effects already impacting the UK, continuing over the next decade Future waves Source: Oliver Wyman Health Innovation Centre