Document Text Contents
Page 1
T H I R D A N N U A L R E P O R T
HCIA Disease-Specific Evaluation
FEBRUARY 2016 PRESENTED TO:
Caitlin Cross-Barnet &
Erin Murphy Colligan
Center for Medicare & Medicaid
Innovation
7500 Security Blvd Mail Stop:
WB-06-05
Baltimore, MD 21244
(410) 786-0263
PRESENTED BY:
NORC at the University of Chicago
Adil Moiduddin
Vice President, Health Care Research
4350 East-West Hwy, Suite 800
Bethesda, MD 20814
(301) 634-9419
Contract No. HSSM-500-2011-00002I,
Order No. HHSM-500-T00009
Page 2
NORC | HCIA Disease-Specific Evaluation
THIRD ANNUAL REPORT | I
Disease-Specific Awardees
Awardee Name Abbreviation
Christiana Care Health Services, Inc. Christiana
Duke University’s South Eastern Diabetes Initiative SEDI
FirstVitals Health and Wellness, Inc. FirstVitals
The George Washington University GWU
Health Resources in Action, Inc. HRiA
Trustees of Indiana University Indiana
Innovative Oncology Business Solutions, Inc. IOBS
Joslin Diabetes Center, Inc. Joslin
Le Bonheur Community Health and Well-Being Le Bonheur
Mountain Area Health Education Center, Inc. MAHEC
Nemours Children’s Health System of the Nemours Foundation Nemours
Ochsner Clinic Foundation Ochsner
University of Alabama at Birmingham UAB
Regents of the University of California, Los Angeles UCLA
The Trustees of the University of Pennsylvania UPenn
Upper San Juan Health Service District USJHSD
The Rector and Visitors of the University of Virginia UVA
Vanderbilt University Medical Center Vanderbilt
Page 199
NORC | HCIA Disease-Specific Evaluation—Third Annual Report Vanderbilt University Medical Center
THIRD ANNUAL REPORT | 187
with high socioeconomic status, and most focus group participants from that site reported little need for
assistance following discharge. Maury served a more rural and lower-income population and included a
social worker on its team to help address social needs following discharge. VUMC’s patients had access
to an array of resources in the large academic medical center and in the urban setting of Nashville.
The three sites targeted different conditions, and the target conditions changed over time. As
described in the quantitative analysis section, the sites varied in the number and type of conditions they
targeted. For their TCC programs, VUMC and Maury targeted congestive heart failure (CHF), chronic
obstructive pulmonary disease (COPD), acute myocardial infarction (AMI), and pneumonia; Williamson
targeted only CHF. Over the course of the intervention, the OCCs at all three sites expanded their
inclusion criteria from hypertension (HTN), CHF, and diabetes mellitus to include active smokers and
individuals with multiple or complex health conditions.
Workforce
OCCs reported high satisfaction with their
work. High satisfaction was reflected in the low
turnover among OCC staff.
Maury’s single TCC was well integrated into
the hospital’s workflow, whereas multiple
TCCs at the other two sites were not. Maury’s
TCC reported having good communication with
inpatient nurses and discharge social workers, as well as support from the hospital administration. She
managed the disease-specific portion of the patient’s transition to home from the inpatient stay and
conducted follow-up, whereas social workers handled all other aspects of the discharge process. In
contrast, there was turnover among TCCs at VUMC and Williamson. Williamson’s TCCs experienced
difficulty integrating into the inpatient team’s workflow, and VUMC’s TCCs reported being asked to take
on more case management and discharge planning than expected. Over time, VUMC and Williamson did
not replace the TCCs who left, and only Maury sustained the TCC role as developed through the program.
With the addition of patients with complex concerns to the target conditions, some OCCs worried
that they may not have the skills to support patients remotely. They reported that knowledge about
CHF, COPD, and diabetes was a fundamental part of their training and practice as nurses. However,
patients with complex conditions—including those who had more than two admissions in the past year
and sought care from multiple specialists—presented challenges beyond their knowledge and expertise.
“I used to work as a PCP nurse. You would see
[patients] in clinic, send them home, and not know
outcomes. We are the resource between visits, so we
see the A1c going down because the patient is on-
board with counting carbs [so we can] help them
educate their families. You know, they see you as
someone they can call on as a resource to them. That
is the most satisfying for me.”
—Outpatient Nurse Coordinator
Context
As a large teaching and research center, Vanderbilt engaged in many other complementary
research projects; this situation might have interfered with our ability to assess the impacts of the
HCIA program. For example, Vanderbilt was the recipient of another HCIA grant aimed at reducing
hospitalizations among Medicare beneficiaries through a collaboration between VUMC and one of 23
partnering skilled nursing facilities (SNFs) in Tennessee and Kentucky. This essentially removed from the
TCC target population all of the patients who were being discharged to a SNF.
Page 200
NORC | HCIA Disease-Specific Evaluation—Third Annual Report Vanderbilt University Medical Center
THIRD ANNUAL REPORT | 188
Trends in health care toward value-based payments put pressure on Vanderbilt to develop a care
coordination program. Health care financing is shifting from fee-for-service to value-based payment
models. Although Vanderbilt was not an accountable care organization (ACO), there were two ACOs in
the Nashville area and six others throughout the state.
Sustainability, Scalability, and Spread
Vanderbilt sustained its OCC program beyond
the award period through internal institutional
support. In light of the environmental pressure to
move toward value-based care, program
leadership committed to sustaining the program
beyond the award period despite limited evidence of effectiveness.
Maury sustained its TCC program through internal institutional support and sought to expand it,
whereas the other two sites did not. VUMC reported that it was considering how to integrate the TCC
program into its general case management program; Williamson disbanded its TCC program altogether.
Hospital staffs at VUMC and Williamson were generally unclear regarding the role of the TCCs and
therefore had difficulty integrating the TCC role into the existing case management structure.
Working with a private payer, Vanderbilt began testing a remote model of care coordination using
claims data rather than providers’ patient panels. OCCs began to recruit patients based on their claims
records by calling and sending letters to high-risk patients. They found that many patients at first were
skeptical, so they modified their approach by offering face-to-face office visits.
“Society has demanded improved value, and the
payers are demanding it and all the consultants tell the
leadership here that care coordination has to be a part
of it. So it is sustained.”
—Program Leader
Limitations
For our quantitative analysis of the OCC program, we excluded patients with conditions other than
hypertension and/or diabetes mellitus, as those were the only enrollment criteria identifiable in claims.
Our analyses, therefore, may not capture the overall impact of the Vanderbilt OCC program. Our OCC
analysis only focused on Medicare beneficiaries in part because of the availability of claims and
Vanderbilt’s policy of not serving Medicaid patients in outpatient settings.
We developed our findings from site visits and telephone interviews with program leaders and staff
members and four focus groups with participants at VUMC and Williamson. We also conducted three
telephone interviews with patients at Maury. Program staff randomly selected participants who they knew
had interacted with a TCC or an OCC, although many participants did not recognize that either of them
was part of a special program. Only those who regularly engaged with a care coordinator (eight of 26
participants) could comment on the program.
Conclusion and Policy Implications
Vanderbilt’s award program used OCCs and TCCs in an attempt to provide better care and improve
patient health through smarter spending. They implemented programs across three sites that differed in
size, geographic setting, and technological capacity. VUMC, the largest and most urban site, invested
heavily in its HIT to create an electronic surveillance system and a care coordinator dashboard. Its OCCs
Page 398
NORC | HCIA Disease-Specific Evaluation
THIRD ANNUAL REPORT | 386
Exhibit B.4: Main Code Families Used for Patient and Caregiver Interviews
Page 399
NORC | HCIA Disease-Specific Evaluation
THIRD ANNUAL REPORT | 387
Exhibit B.5: Subcodes Used in Patient and Caregiver Interview Coding
T H I R D A N N U A L R E P O R T
HCIA Disease-Specific Evaluation
FEBRUARY 2016 PRESENTED TO:
Caitlin Cross-Barnet &
Erin Murphy Colligan
Center for Medicare & Medicaid
Innovation
7500 Security Blvd Mail Stop:
WB-06-05
Baltimore, MD 21244
(410) 786-0263
PRESENTED BY:
NORC at the University of Chicago
Adil Moiduddin
Vice President, Health Care Research
4350 East-West Hwy, Suite 800
Bethesda, MD 20814
(301) 634-9419
Contract No. HSSM-500-2011-00002I,
Order No. HHSM-500-T00009
Page 2
NORC | HCIA Disease-Specific Evaluation
THIRD ANNUAL REPORT | I
Disease-Specific Awardees
Awardee Name Abbreviation
Christiana Care Health Services, Inc. Christiana
Duke University’s South Eastern Diabetes Initiative SEDI
FirstVitals Health and Wellness, Inc. FirstVitals
The George Washington University GWU
Health Resources in Action, Inc. HRiA
Trustees of Indiana University Indiana
Innovative Oncology Business Solutions, Inc. IOBS
Joslin Diabetes Center, Inc. Joslin
Le Bonheur Community Health and Well-Being Le Bonheur
Mountain Area Health Education Center, Inc. MAHEC
Nemours Children’s Health System of the Nemours Foundation Nemours
Ochsner Clinic Foundation Ochsner
University of Alabama at Birmingham UAB
Regents of the University of California, Los Angeles UCLA
The Trustees of the University of Pennsylvania UPenn
Upper San Juan Health Service District USJHSD
The Rector and Visitors of the University of Virginia UVA
Vanderbilt University Medical Center Vanderbilt
Page 199
NORC | HCIA Disease-Specific Evaluation—Third Annual Report Vanderbilt University Medical Center
THIRD ANNUAL REPORT | 187
with high socioeconomic status, and most focus group participants from that site reported little need for
assistance following discharge. Maury served a more rural and lower-income population and included a
social worker on its team to help address social needs following discharge. VUMC’s patients had access
to an array of resources in the large academic medical center and in the urban setting of Nashville.
The three sites targeted different conditions, and the target conditions changed over time. As
described in the quantitative analysis section, the sites varied in the number and type of conditions they
targeted. For their TCC programs, VUMC and Maury targeted congestive heart failure (CHF), chronic
obstructive pulmonary disease (COPD), acute myocardial infarction (AMI), and pneumonia; Williamson
targeted only CHF. Over the course of the intervention, the OCCs at all three sites expanded their
inclusion criteria from hypertension (HTN), CHF, and diabetes mellitus to include active smokers and
individuals with multiple or complex health conditions.
Workforce
OCCs reported high satisfaction with their
work. High satisfaction was reflected in the low
turnover among OCC staff.
Maury’s single TCC was well integrated into
the hospital’s workflow, whereas multiple
TCCs at the other two sites were not. Maury’s
TCC reported having good communication with
inpatient nurses and discharge social workers, as well as support from the hospital administration. She
managed the disease-specific portion of the patient’s transition to home from the inpatient stay and
conducted follow-up, whereas social workers handled all other aspects of the discharge process. In
contrast, there was turnover among TCCs at VUMC and Williamson. Williamson’s TCCs experienced
difficulty integrating into the inpatient team’s workflow, and VUMC’s TCCs reported being asked to take
on more case management and discharge planning than expected. Over time, VUMC and Williamson did
not replace the TCCs who left, and only Maury sustained the TCC role as developed through the program.
With the addition of patients with complex concerns to the target conditions, some OCCs worried
that they may not have the skills to support patients remotely. They reported that knowledge about
CHF, COPD, and diabetes was a fundamental part of their training and practice as nurses. However,
patients with complex conditions—including those who had more than two admissions in the past year
and sought care from multiple specialists—presented challenges beyond their knowledge and expertise.
“I used to work as a PCP nurse. You would see
[patients] in clinic, send them home, and not know
outcomes. We are the resource between visits, so we
see the A1c going down because the patient is on-
board with counting carbs [so we can] help them
educate their families. You know, they see you as
someone they can call on as a resource to them. That
is the most satisfying for me.”
—Outpatient Nurse Coordinator
Context
As a large teaching and research center, Vanderbilt engaged in many other complementary
research projects; this situation might have interfered with our ability to assess the impacts of the
HCIA program. For example, Vanderbilt was the recipient of another HCIA grant aimed at reducing
hospitalizations among Medicare beneficiaries through a collaboration between VUMC and one of 23
partnering skilled nursing facilities (SNFs) in Tennessee and Kentucky. This essentially removed from the
TCC target population all of the patients who were being discharged to a SNF.
Page 200
NORC | HCIA Disease-Specific Evaluation—Third Annual Report Vanderbilt University Medical Center
THIRD ANNUAL REPORT | 188
Trends in health care toward value-based payments put pressure on Vanderbilt to develop a care
coordination program. Health care financing is shifting from fee-for-service to value-based payment
models. Although Vanderbilt was not an accountable care organization (ACO), there were two ACOs in
the Nashville area and six others throughout the state.
Sustainability, Scalability, and Spread
Vanderbilt sustained its OCC program beyond
the award period through internal institutional
support. In light of the environmental pressure to
move toward value-based care, program
leadership committed to sustaining the program
beyond the award period despite limited evidence of effectiveness.
Maury sustained its TCC program through internal institutional support and sought to expand it,
whereas the other two sites did not. VUMC reported that it was considering how to integrate the TCC
program into its general case management program; Williamson disbanded its TCC program altogether.
Hospital staffs at VUMC and Williamson were generally unclear regarding the role of the TCCs and
therefore had difficulty integrating the TCC role into the existing case management structure.
Working with a private payer, Vanderbilt began testing a remote model of care coordination using
claims data rather than providers’ patient panels. OCCs began to recruit patients based on their claims
records by calling and sending letters to high-risk patients. They found that many patients at first were
skeptical, so they modified their approach by offering face-to-face office visits.
“Society has demanded improved value, and the
payers are demanding it and all the consultants tell the
leadership here that care coordination has to be a part
of it. So it is sustained.”
—Program Leader
Limitations
For our quantitative analysis of the OCC program, we excluded patients with conditions other than
hypertension and/or diabetes mellitus, as those were the only enrollment criteria identifiable in claims.
Our analyses, therefore, may not capture the overall impact of the Vanderbilt OCC program. Our OCC
analysis only focused on Medicare beneficiaries in part because of the availability of claims and
Vanderbilt’s policy of not serving Medicaid patients in outpatient settings.
We developed our findings from site visits and telephone interviews with program leaders and staff
members and four focus groups with participants at VUMC and Williamson. We also conducted three
telephone interviews with patients at Maury. Program staff randomly selected participants who they knew
had interacted with a TCC or an OCC, although many participants did not recognize that either of them
was part of a special program. Only those who regularly engaged with a care coordinator (eight of 26
participants) could comment on the program.
Conclusion and Policy Implications
Vanderbilt’s award program used OCCs and TCCs in an attempt to provide better care and improve
patient health through smarter spending. They implemented programs across three sites that differed in
size, geographic setting, and technological capacity. VUMC, the largest and most urban site, invested
heavily in its HIT to create an electronic surveillance system and a care coordinator dashboard. Its OCCs
Page 398
NORC | HCIA Disease-Specific Evaluation
THIRD ANNUAL REPORT | 386
Exhibit B.4: Main Code Families Used for Patient and Caregiver Interviews
Page 399
NORC | HCIA Disease-Specific Evaluation
THIRD ANNUAL REPORT | 387
Exhibit B.5: Subcodes Used in Patient and Caregiver Interview Coding
