Provider Insider

Issue 5

Table of Contents

Leadership Message

A message from Dr. Austin Bailey

 

Greetings to all our network providers. The new year is barely underway, and already we have seen significant changes occurring within our clinically integrated network.

 

Jean Haynes, chief population health officer, left UCHealth on March 1. Under her guidance four years ago, Coordinated Care began its journey toward population health management. With a thorough understanding of the Colorado health care marketplace, Jean directed the formation of the Coordinated Care and brought together all of us who work in population health on a daily basis and who comprise the network’s core infrastructure. She introduced value-based programs to us with strategic payer partners in the commercial and Medicare environments, and today we have grown into a formidable organization of more than 3,200 independent and employed providers spanning most of the state and serving nearly 160,000 patients. We are all thankful for having had the opportunity to work with Jean, and we wish her all the best on her future endeavors.

 

Anne Docimo, MD, MBA has joined us as chief medical officer. With past positions at University of Pittsburgh Medical Center and Jefferson Health in Philadelphia, Pa., Dr. Docimo has had vast experience in the value-based world. She has served as a physician provider, as EVP and chief clinical transformation officer of a large medical group and also as a chief medical officer for a health plan. Having seen this world through these varied lenses, Dr. Docimo brings the insights that will help us grow as a network, adding new value-based programs and provider practices in the future. Continued efforts toward clinical programming and analytical supports to achieve the Quadruple Aim will be under her direction.

 

Dr. Docimo’s full biography is included in this issue’s Network News.

 

The world of population health and value-based care continues to grow more complex. We are fortunate to have had the leadership of Jean Haynes to launch us and of Anne Docimo, MD to guide us forward.

 

Austin Bailey, MD
Medical Director, Network Engagement for Population Health

Pharmacy Integration Insights

Are our patients overmedicated? A toolkit addressing polypharmacy and deprescribing.

 

Polypharmacy, defined as taking five or more medications, was estimated to be 36% in 2011 and will likely increase in the coming years.1 Oftentimes, patients are started on medications that are never adjusted or stopped, leading to clinical inertia and poor outcomes of drug-related events, hospitalizations, etc. One way to prevent these outcomes is through deprescribing unnecessary medications. Deprescribing is defined as the planned and supervised process of dose reduction or stopping of medication(s) that may be causing harm or are no longer beneficial.2 This article will provide supportive literature for deprescribing, as well as helpful tools for doing so.

 

Why is this important?

 

Deprescribing has the potential to impact all aspects of the Quadruple Aim: improved population health, reduced costs (to patients and the health system), enhanced patient experience/satisfaction, and improved work life for providers. Improving the quality of health care, while decreasing costs is quintessential to the success of our health care system.

 

What is the Population Health team doing to address this?

 

Our clinical pharmacy team is currently performing prospective comprehensive medication reviews (CMRs) for patients with upcoming appointments with the intent of optimizing chronic condition management and ensuring accurate medication lists. Part of this process is recommending the deprescribing of select medications to prevent polypharmacy, improve adherence and decrease poor outcomes. Below is a list of medications that are recommended to be deprescribed, if appropriate.

 

Common medications to consider deprescribing:

 

Medication Deprescribing Recommendation Rationale
NSAIDs

(e.g., ibuprofen, naproxen, celecoxib, etc.)

Recommend deprescribing in patients with congestive heart failure, gastric/duodenal ulcers or CKD. NSAIDs are associated with worsening fluid retention, precipitation of ulcers, declined renal function, and risk of myocardial infarction.
Anticholinergics (antidepressants, antihistamines, antimuscarinics, muscle relaxants)

 

Recommend deprescribing, if appropriate, especially in older individuals or those with BPH. Anticholinergics place patients at increased risk of falls, xerostomia, urinary retention, constipation, etc.
Non-statin medications (e.g., ezetimibe, colesevelam, colestipol, cholestyramine, etc.) Recommend deprescribing in patients using as monotherapy for cardiovascular risk reduction. Instead, assess indication for statin therapy in these patients. 2018 ACC/AHA cholesterol guidelines do not recommend use of these agents as monotherapy for cardiovascular risk reduction.
Proton pump inhibitors (e.g., omeprazole, esomeprazole, pantoprazole, lansoprazole, etc.) Guidelines recommend deprescribing PPI therapy in patients who have completed 4 weeks of PPI treatment for heartburn. This recommendation does not apply to patients using PPIs for esophagitis or GI ulcers.3 PPIs are associated with C. difficile infections, community-acquired pneumonia, hip fractures, vitamin B12 deficiency, chronic kidney disease and dementia.
Benzodiazepines

(e.g., alprazolam, clonazepam, diazepam, lorazepam, oxazepam, etc.)

Recommend deprescribing (via tapering) benzodiazepines in patients ≥65 years of age or 18-64 years of age who have used benzodiazepines for ≥4 weeks.4 Benzodiazepines are associated with dependency, falls, fractures and cognitive decline in older individuals.
Antipsychotics

(e.g., haloperidol, loxapine, aripiprazole, clozapine, olanzapine, paliperidone, quetiapine, risperidone, etc.)

Recommend deprescribing antipsychotics in patients who have had symptoms of dementia for ≥3 months.5 Antipsychotics are associated with drowsiness, headache, extrapyramidal symptoms, weight gain and death in patients with dementia.
Antihyperglycemics

(specifically ones that cause hypoglycemia—insulin, sulfonylureas, meglitinides)

Recommend deprescribing antihyperglycemic medications known to contribute to hypoglycemia and individualize targets for patients who are frail, have dementia, or have a limited life expectancy.6

 

Certain classes of antihyperglycemics (insulin, sulfonylureas, etc.) are associated with hypoglycemia and potentially subsequent falls and/or hospitalizations.
Cholinesterase inhibitors

(e.g., donepezil, galantamine, rivastigmine, memantine, etc.)

Recommend discontinuing if cognition/function has significantly declined, no benefit has been noticed since beginning treatment, or if individual has severe/end-stage dementia.7 If patient not receiving benefit, or cognitive function is declining while taking, it is likely the cholinesterase inhibitor is not working. Thus, in attempt to decrease pill burden, adverse effects from the drug and cost, deprescribing can be considered.

 

Key messages:

  • Deprescribing unnecessary medications can prevent adverse outcomes and should be considered when able.
  • There are many resources to help assess and guide deprescribing (see appendices below).
  • Deprescribing may have additional benefit of cost savings to both the patient and health system.
  • Population health clinical pharmacists are currently performing comprehensive medication reviews on high-risk patients to help guide deprescribing practices.

Questions or comments? Please contact Joseph.VandeGriend@uchealth.org.

 

Kyle Troksa, Pharm.D., PGY2 Ambulatory Care resident, authored this article.

 

 

References

  1. Qato DM, Wilder J, Schumm LP, et al. Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. JAMA Intern Med. 2016;176(4):473-82.
  2. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827-34.
  3. Farrell B, Pottie K, Thompson W, Boghossian T, Pizzola L, Rashid FJ, Rojas-Fernandez C, Walsh K, Welch V, Moayyedi P. Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline. Can Fam Physician. 2017 May;63(5):354-364.
  4. Pottie K, Thompson W, Davies S, Grenier J, Sadowski CA, Welch V, Holbrook A, Boyd C, Swenson R, Ma A, Farrell B. Deprescribing benzodiazepine receptor agonists: Evidence-based clinical practice guideline. Can Fam Physician. 2018 May;64(5):339-351.
  5. Bjerre LM, Farrell B, Hogel M, Graham L, Lemay G, McCarthy L, Raman-Wilms L, Rojas-Fernandez C, Sinha S, Thompson W, Welch V, Wiens A. Deprescribing antipsychotics for behavioural and psychological symptoms of dementia and insomnia: Evidence-based clinical practice guideline. Can Fam Physician. 2018 Jan;64(1):17-27.
  6. Farrell B, Black C, Thompson W, McCarthy L, Rojas-Fernandez C, Lochnan H, Shamji S, Upshur R, Bouchard M, Welch V. Deprescribing antihyperglycemic agents in older persons: Evidence-based clinical practice guideline. Can Fam Physician. 2017 Nov;63(11):832-843.
  7. Reeve E, Farrell B, Thompson W, Herrmann N, Sketris I, Magin P, Chenoweth L, Gorman M, Quirke L, Bethune G, Forbes F, Hilmer S. Evidence-based Clinical Practice Guideline for Deprescribing Cholinesterase Inhibitors and Memantine: Recommendations. Sydney: The University of Sydney; 2018.

 

Appendix

 

Deprescribing resources (click link to access resource):

 

Stepwise approach to deprescribing:

  1. Review patient’s medications (in person if possible).
  2. Discuss the goal and expectations of deprescribing with patient.
  3. Deprescribe medications that:
    • Are potentially inappropriate.
    • Lack therapeutic efficacy.
    • Lack a clear indication.
    • Are unlikely to provide benefit in the patient’s lifetime.
    • The patient would like to stop (i.e., adverse side effect).
    • Have complex dosing regimens.
  4. Create follow-up plan.

Clinical Transformation Insights

2019 Engagement Summit recap

 

On January 31, 2019 more than 100 members of Coordinated Care convened at the Hyatt Regency Aurora-Denver Conference Center to participate in the second annual Engagement Summit. Austin Bailey, MD, medical director for population health, facilitated the daylong event.

A summary of the presented material follows. For more information about any of these topics, please contact Michelle.McLeod@ucheatlh.org.

“It gave great context to the work I do in-clinic and I was surprised by how much I took from the day. Everyone was really engaged and I enjoyed the discussion.”

    • Jean Haynes, chief population health officer, shared important details about the network’s exit from Medicare Shared Savings Program Track 3 (MSSP Track 3). The network had an opportunity to withdraw from MSSP Track 3 to avoid financial reconciliation as a result of the negative financial performance of the program. The network will still receive the 5% Alternative Payment Model (APM) bonus. Most importantly, UCHealth and the network remain committed to population health and will continue to be focused on managing nearly 160,000 lives attributed to value-based programs.
    • Anne Docimo, MD, MBA, chief medical officer for population health, provided an overview of the health care landscape. The United States spends more on health care per capita than many other countries; however, the U.S. ranks in the bottom 24% of those countries on life expectancy (Harvard Business Review, April 2010). Americans spend a notable portion of their income on health care and expect high-quality care. Insurers are requiring health systems to take on risk and achieve quality and cost targets to avoid financial losses. Coordinated Care is building the infrastructure and skills sets to provide the value the consumers and insurers desire.

“This was a great opportunity to bring a group of people together, many of whom had never met or had corresponded only by phone or email previously.”

  • Bailey focused on the skills and expertise of the network. The network has a successful track record in improving quality and lowering total cost of care resulting in millions of dollars in shared savings payments. Over the last four years, the network has increased its footprint along the Front Range to improve access to primary care. Care management addresses the complex needs of patients and coordinates care across the continuum. Centralized resources such as data governance and analytics, pharmacy and value-based contracting exist to continue the journey to improve quality and reduce cost.
  • Brenda Benzel, director of pricing and performance management for population health, highlighted the benefits of the network’s centralized data analytics. She described the complex task of compiling data from a multitude of sources into a simplified format. The network can provide to our partners intuitive and actionable reports. In the near future, as the capabilities progress, Brenda shared that the network can expect claims data to integrate with clinical data, access to cost and utilization dashboards, provider-friendly attribution logic and cost trend analysis.
  • Joseph Vande Griend, PharmD, FCCP, BCPS, BCGP, director of pharmacy for population health, facilitated a presentation that identified existing opportunities to improve medication use for patients and strategize ways to engage all existing resources, both clinic-based and population health, to optimize medication use and leverage existing clinical pharmacy resources, including population health resources, to help achieve the Quadruple Aim.

Rounding out the day, Paul Staley, director of network engagement for population health, led a panel discussion that provided effective strategies to reduce avoidable emergency department utilization. The panel included provider representatives from Matthews-Vu Medical Group, Parkview Medical Center and Dublin Primary Care. Roundtable discussions presented attendees an opportunity to brainstorm the actions they will take back to their practice to improve the quality and/or cost of care.

 

A post-event survey indicated our audience was very satisfied with the summit overall. On behalf of my colleagues, thank you to everyone who participated in the summit this year. We look forward to hosting you again in 2020! —Michelle

Care Management Insights

Care Management in value-based health care

 

Value-based models of care are intended to deliver better health outcomes than traditional fee-for-service models, and at a lower cost. Effective care management plays a critical role in delivering on those results. But how is this service different from what providers have been offering all along?

 

 

Providing ambulatory care management

 

A care manager’s primary function is to identify any barriers that will prevent a patient from successfully following his or her physician’s prescribed care plan, and offer the appropriate interventions to neutralize those barriers. These interventions could include education around disease management or behavioral health, connection with community resources, coordination of medical services or appointments among different providers, emotional support and more.

 

Care management often begins with a transition of care, e.g., an inpatient or acute hospitalization, emergency department (ED) visit, discharge from a post-acute facility or an inpatient behavioral health facility. Or a care manager may become involved when a patient has been identified as high-risk or high-complexity.

 

Registered nurses, social workers, licensed practical nurses and medical assistants are among those who comprise the care managers represented within Coordinated Care. In some cases, these individuals are centralized supporting a group of providers and/or clinics, in others they are embedded in-clinic as an integral part of the care team.

 

One thing they all have in common is the support service they provide across the entire care continuum.

 

In a traditional fee-for-service model of care, patients are often left alone to navigate the health system. And many, for one reason or another, fail to execute their care plan. Care managers help close that gap by providing patients tools and education to successfully self-manage their care plan. And, if all options are exhausted and a change in plan is required, care managers work collaboratively with providers to help patients find an alternative solution.

 

This level of care helps patients, many with complex medical conditions, better manage their health—potentially preventing unnecessary doctor and/or ED visits which in turn increases patient satisfaction and reduces the financial burden to the patient and health care system.

 

 

The CIN difference

 

The Population Health Service Organization (PHSO) has developed comprehensive assessments for Coordinated Care to standardize workflows for the network’s care managers. These assessments are functional tools to help our teams identify barriers in care and recommend the appropriate resources or interventions to allow patients to better self-manage their own health.

 

Assessments include:

  • Inpatient Transitions of Care
  • ED Follow-Up
  • Care Management assessment
  • Social Work assessment

Each of these assessments are available in Epic. Users can find Inpatient Transitions of Care and ED follow-up assessments through the Patient Outreach encounter, and authorized users can find all five assessments in the Care Management or Social Work encounters.

 

Any notes or work saved to these assessments is communicated in real time and is available to the entire care team on the Encounters tab. This process ensures proper documentation and helps streamline patient care and communication.

 

For questions about care management or the PHSO assessments available to Coordinated Care, please contact Dawn.Morrissey@uchealth.org.

Network News

An update about what is happening within Coordinated Care:

  • New members and general information
  • Cigna CAC
  • IT updates
  • Network administration staff updates

If you have news or announcements to share with network colleagues, please send to PopulationHealth@uchealth.org and include Provider Insider News in the subject line.

 

 


New members and general information

The Pueblo Regional Advisory Council meeting is scheduled for April 11. Please contact Paul.Staley@uchealth.org with questions regarding the proposed agenda.

 

New clinic openings include:

UCHealth Quincy Medical Center. Urgent care opened in January 2019, primary care opens this spring.

UCHealth Internal Medicine – Orchards. Opened in February 2019.

UCHealth Arvada West Medical Center. Urgent care and primary care opened in March 2019.

UCHealth Primary Care – Cripple Creek. Opens in April 2019.

 

 


Cigna CAC

The current performance year closes March 31. Network members have until that date to close any outstanding care gaps for the current period. Final reconciliations and notification of any shared savings will be available late summer.

 

The new performance year begins April 1. Cigna will maintain the same quality metrics for the coming year.

 

 


IT updates

For network members using Epic electronic health records, please note the following IT updates:

  • Recently launched new care management, social work and clinical pharmacy assessment documentation tools. Users can find new initial assessments within the Care Management and Social Work encounters. They may also find IP/Observation Follow-Up and ED Follow-Up assessments within the Care Management encounter. For clinical pharmacists, IT updated the entire encounter workspace within the Clinical Pharmacy Consultation encounter, and rolled out assessments for comprehensive medication review, transitions of care, and statin therapy. For training or questions, users should reach out to their managers.
  • MSSP reporting will conclude at the end of this month. Each CIN TIN (UCHealth Medical Group, CU Medicine, Associates in Family Medicine, Family Medicine Center) is reviewing the output of the measure details as well as manually reviewing all negatives to ensure accurate and optimal reporting. Final reporting is due to CMS March 22. This will be the last time Coordinated Care needs to report for MSSP, and practices will transition to reporting MIPS in 2019.
  • Claims data integration will go live in Q2 2019. For the Anthem claims, users will begin to see encounters in Chart Review as well as information in Health Maintenance and the Reconcile Outside Information activity that has come from claims. All claims encounters will be called out with “- Claims Data Only” in Chart Review as the claims encounters are inherently less detailed than Care Everywhere encounters. The claims encounters include Place of Service, Visit Diagnoses, and Procedures. For questions, contact Kate.Lipstein@uchealth.org or a physician informaticist.


Network administration staff updates

Meet Anne Boland Docimo, MD, MBA – chief medical officer for population health.

 

Anne Boland Docimo has served as a physician leader in the evolving health care marketplace for over 20 years. As a practicing clinician in primary care and emergency medicine, she worked in private practice; as a government contractor, in a staff-model HMO and in academic medical centers. This varied clinical service has continued to inform her work as she transitioned to the “payer side” and then back to leading population health efforts for physician practices and health systems.

 

Most recently, Dr. Docimo served as the EVP population health and chief clinical transformation officer for Jefferson Health in Philadelphia, Pa. In this role, she established the infrastructure needed to succeed in population health and value-based reimbursement across the enterprise, including the formation of a clinically integrated network (CIN) and an enterprise-wide team to support clinical and actuarial analytics, care management and the pharmacy service line. All work was completed in close collaboration with clinical operations, finance, IS&T and payer contracting. The Jefferson CIN grew to include over 2,100 physicians with more than 289,000 lives under payer contracts and millions of dollars per year in quality, pay-for-performance and shared savings revenue.

 

Prior to joining Jefferson Health, Dr. Docimo served in two capacities at the University of Pittsburgh Medical Center (UPMC): chief medical officer for UPMC Health Plan and senior medical director of UPMC Hospitals. As chief medical officer for UPMC Health Plan, Dr. Docimo led the design and development of a proprietary system for care management (HealthPlaNET) and a claims-based member record. These applications are in use at UPMC and served as the platform for Evolent, a joint venture between UPMC and the Advisory Board. As a physician executive in both provider and payer organizations, Dr. Docimo has experience in using clinical and claims data to design and implement population health programs to improve clinical and financial outcomes.

 

Dr. Docimo received her undergraduate degree from University of Notre Dame, her medical degree from Johns Hopkins University School of Medicine and a Master of Business Administration from John Hopkins University.