Our Executive Vice President of Population Health, Jennifer Drago, was on a radio show this week discussing Sun Health and our population health community efforts. Listen below!
(What is the PopHealth Week radio show? It’s all about thought leaders, entrepreneurs and disruptive companies or health systems in the emerging field of Population Health Management.)
TRANSCRIPT
Greg: We’re live from the nation’s capital, and broadcasting from 6th annual Health Data Palooza, you’re listening to Pop Health week on the Blog Talk Radio and affiliate networks. This episode is brought to you by health innovation and media, where we monitor the innovation impulse from idea to business model and emerging best practices. Welcome everyone, I’m Greg Masters, the producer and co-host of this show, and joining me in the virtual studio is my colleague and principal co-host, and co-founder of Pop Health Week – Fred Goldstein, which you’ll hear from shortly. For those of you not familiar with Fred, he’s a subject matter expert with deep roots in the hospital health plan, health, wellness and prevention space from disease management to population health. Fred is a board member of the Population Health Alliance, past chair and has most recently served as its executive director. He now captains the ship at Accountable Health LLC.
And now a few words about our special guest: Jennifer Drago, who serves as the executive vice president for Population Health at the Arizona-based 501(c)(3) organization Sun Health, whose mission is to be the leading advocate of healthy living. Jennifer Drago specializes in developing and launching innovative population health style programs, including the Sun Health Center for Health and Wellbeing, Care Transitions program, community education and Memory Care Navigator. Several of these programs have received national recognition for both quality and innovation. She has worked in healthcare for more than 20 years, including ten as an associate administrator for Boswell Memorial and Del E Webb Memorial Hospital respectively. She’s also held the position of vice president of Planning Services for the former Sun Health Hospital system. Jennifer earned her bachelor’s degree in finance as well as an MBA and masters in health services administration – all from Arizona State University. Drago volunteers for several service organizations, including chairing the board for North-West Valley Connect, a non-profit agency working to improve transportation for seniors.
With that highlight of an impressive career, Fred, over to you – help us to get to know this thought leader in the population health space.
Fred: Thank you Greg. Hello Jennifer!
Jennifer: Hi there! How are you?
Fred: I’m doing well today. Yourself?
Jennifer: Oh, fine, thank you!
Fred: Good. I’ve had the pleasure of spending some time at Sun Health’s Closer to the Population Health Alliance conference where we received the tours of your facilities. Give the audience a sense of Sun Health’s mission and wealth of services.
Jennifer: You bet. So Sun health has been in the Western Phoenix metropolitan market for almost 50 years now and the area that we have always served as a non-profit health organization includes large return communities such as Sun City, Sun City West, Sun City Grand. We have about 100,000 seniors in our immediate area, as well as family populations. But Sun Health as a hospital system, when we were a hospital system starting back in 1970, really started to serve the senior populations, as Del Webb population built their very first active retirement community here in Arizona and that was Sun City.
So Sun Health’s mission really started as a hospital system. We continued until 2008 and our two hospitals were sold to a chain here – in 7 states, Banner Health – another non-profit. We continue to do today, now that we’re NOT a hospital system, is first and foremost we have a foundation. That foundation continues to raise money for the two hospitals that we used to own, as well as a nationally recognized research institute here in the Sun City area. We also raise funds to support our community health programs, which is another leg of our three-legged stool.
The second leg of our three-legged stool is we have an impressive array of senior living campuses. We own three continuing care retirement community campuses in the West Valley and have over 700 residents that call us their senior living provider and call us a health home. So we take that responsibility very seriously. And then also as part of that senior living continuum, we have two school nursing facilities, an array of assisted living and memory care services, as well as, of course, the independent living component.
And then the third leg of our stool is community health programs. Following the sale of the hospitals, our board decided they wanted Sun Health to continue to serve the mission that they had for the past 40 years, and that was to help people in our community live healthy.
So we started a number of programs, starting in January of 2011 that really help people to learn about their health conditions that they may be facing, then to self-manage those conditions in many situations, and also providing support to help people manage those with, for example, our memory care navigator program that helps families dealing with a dementia diagnosis to access services they may not even know exist. And to prepare for later stages of the disease at a time where that preparation is a little bit easier. So that’s just an example of the things that we do.
Fred: That’s great, Jennifer. And so these programs, you’ve moved out into these community-based population health type approaches, through the division that you oversee. Can you talk a little bit about some of those programs – you mentioned the Memory Care Navigator, I think you’ve got Medication Management, the Wellness Centers, etc.
Jennifer: Sure. So we have 6 community health programs, all together. The one that’s longstanding is community education and being that we serve an area of active retirees, they really want to learn all that they can about their health conditions, but also how to stay healthy and active. We provide between 70 and 80 different programs every month. We don’t teach all of them – we use external speakers and help experts from around the area. We also have a number of exercise classes, such as Yoga and Tai-Chi that are part of that continuum. So that is one of our community programs. I mentioned the Memory Care Navigator. Both community education and the memory care navigator are completely philanthropically supported – it’s due to the support of our Sun Health foundation that we’re able to provide those programs.
We have a care transitions program that is a 30 day post-discharge program. Helps patients that are discharging from our two partner hospitals, which are the two hospitals we used to own. We’re part of a national Medicare demonstration program where we use registered nurses and licensed practical nurses to work with patients to have a successful recovery by making sure they understand their health conditions and how to self-manage those health conditions during their recovery period.
We have a couple of programs that really help people to have their emergency medical information available at the time that it would be most needed called ‘Vial of Life and File of Life’ and the vial is simply a prescription vial that people have in their fridge. It’s the low-tech way to maintain that emergency medical information. Inside that vial is a two-sided form that holds important information in the event of an emergency, such as their health conditions, their medications, their physicians and their emergency contacts. We have a companion device they can put on their keychain and take with them when they’re outside the home, that’s a flash drive that holds the same emergency medical information, also useful when people travel. That program is also philanthropically supported through our foundation.
The fifth program is our medication management program that you’ve mentioned. Similar to Vial and File, the key with this program is really helping people to maintain an up-to-date medication list. We actually have an online profile that is free through SunHealthMeds.org. Anybody can use it to create their medication profile, including a time schedule of when they take their medications. They can also access that profile through a smartphone app, which is free. That’s pretty amazing. The nice thing about using that profile online is that it’s very easy to update medications just creating a profile, saving it with a username and password. So that’s our medication management program.
And then finally, we have the Center For Health and Wellbeing. We actually have three locations now, three locations for our Centers for Health and Wellbeing. The idea of the centers is to pick up where physicians leave off. So someone might get a diagnosis and a treatment plan, which might include medications for their health conditions, and lifestyle recommendations. Perhaps they need to exercise more, increase their physical activity, they need to lose weight, they need to eat differently than they’re eating currently, and folks leave their physician’s office with those recommendations but not a lot of information to help them figure out how to make those lifestyle changes. And so at the Center For Health and Wellbeing, we have a registered dietician, a certified diabetic education, an exercise physiologist who’s also a certified health and wellness coach, and so we can really take a personalized approach to someone’s health and wellbeing by helping them to make those lifestyle changes, helping them put those plans in place and understand what’s really needed, given their particular health conditions. Does that help?
Fred: That’s an excellent overview, Jennifer. Yeah, very helpful and there’s a ton of information. There’s a lot going on, obviously. You put a lot of expertise in the thinking through the issues of lifestyle to adherence, education, and the Care Transitions program is one that I think a lot of our audience will be interested in. This whole issue of 30 day readmits and $2.6 billion estimated in cost for that – how did that program start?
Jennifer: It’s a really good question. So, in November of 2011 we started the program, knowing that was about the time when readmissions was becoming a hot topic and hospitals were really trying to figure out what their plan was going to be to deal with readmissions. The penalties weren’t yet in place, but it was a perfect time when we, as an organization, coming off the sale of the hospitals and really trying to renew our mission in the community, together with our partner hospitals, it was a catalyst to really spur our collaboration to serve the community together.
And so, we did some research on programs that were in that readmission space. Of course, there’s a number of well-thought of evidence-based programs. We happen to use the Coleman model which we can talk about more, but there was the Nailer model, there was a couple of hospital-based care transitions models including project Boost and Project Red, so with our hospital partners, but we actually took the lead. We really did our research on the models and what would work best for our community.
We brought the program out of the ground with foundation funding and started very small, about 10 patients a month when we started, and eventually as we were able to show our outcomes and our expertise, we were able to apply to CMS through the innovation grants, and become a Medicare demonstration project for care transitions, and that program is called Community Care Transition Program – CCTP. We’ve just started our third year under that demonstration project, and the nice thing about that is that CMS pays us on a probation basis to see these patients and, of course, tracks all of our outcomes, because the thought is Medicare, I believe, was trying to evaluate the program to see if on a long-term basis they wanted to provide some reimbursement for care transitions-like programs that help people during that recovery period.
Fred: And how many patients are you monitoring now?
Jennifer: We are enrolling about 270 patients per month, and of course it varies by month. Here in Arizona, we have a pretty heavy snowbird population that really escapes the heat (and I don’t blame them by the way). But they leave in about April and come back in about October. So of course our winter months are heavier months, and our summer months are lighter months. But on average, between 250 and 270 per month.
Fred: And my understanding is that in the renewal you had with CMS, they increased your caseload.
Jennifer: Correct. We went from 150 enrollees under contract in years 1 and 2, to 270. So that was about a 71% increase. Part of it was reflective of the fact that we had good program outcomes in terms of readmissions. It also reflected CMS’s desire that CCTP programs have the ability to touch about 30% of the Medicare fee for service population in the partner hospitals. So at the 150 mark, we weren’t able to get to that 30%, the most we could see was about 16%-17% of the Medicare beneficiaries of the hospital. And CMS believes that in order to move the needle on all cause readmissions, programs like ours need to touch about 30% of the beneficiary population.
Fred: Are there specific focuses on who gets admitted or selected for the program?
Jennifer: Yes, and we really focus on patients that have an underlying chronic condition. So their admission may be related to a chronic condition, for example diabetes, heart failure, COPD, or they may have a history of chronic diseases – there’s about 15 of them that we cover. And the hospitalization may have been related to something else. So, for example, a joint replacement, but they have underlying chronic conditions that during the sedentary period with changes in medications and that recovery period – it may be more easy for that chronic condition to be exacerbated. So we want to monitor them during that recovery period and make sure that everything stays within control.
Fred: So between the patients who were high risk and may be coming back often, and those that have conditions and tend to come back more often, those are the ones you are targeting for your enrolment in the program. Is that correct?
Jennifer: Correct. We believe that where we can have the most success with our patients is wanting to teach them, educating them on their chronic disease, which by the way, it’s sometimes scary to understand the true lack of knowledge that patients have about, can have about their health conditions. So if they have heart failure, they may have been told a number of things, but may not understand in basic layman’s terms what’s going on with their body. And likewise, may not understand that because their heart doesn’t function at the same capacity it may have before damaged or when they were younger that they really have to watch their weight, because the body may not be removing, the heart pumping may not be able to remove the water. And therefore, when the water builds up in the system, it makes the heart harder to beat, it makes it harder for the heart to beat, harder to breathe as well.
And so we explain kind of those body functions, our registered nurses explain in layman’s terms what’s going on with their body and why certain things are important – why it’s important to take their medications, what different pills do for them, why it’s important to monitor their weight or their blood pressure. Just as important is understanding when it’s appropriate to call your physician. Sometimes with COPD or health failure, they may take a wait-and-see attitude: I’m just gonna wait and see if my breathing gets a little bit better, I’m gonna rest here. And the reality with some of these conditions is without intervention, they’re not going to get better, they’re going to get worse. We give patients parameters of when they should call their doctor and assure them their doctor does want to hear from them in those conditions or situations, and almost give them permission, at times, to call their doctor.
Fred: And I understand that with the Coleman model, there are a number of touch points you have. How does that work?
Jennifer: The Coleman model is focused on four pillars of care and I’ll go through those pillars in just a second – but it also focuses on an initial home visit and follow-up phone calls, weekly after that initial home visit.
So we’ve actually taken the program and modified it just a bit in that, the initial Coleman model was focused on having well-trained lay health leaders be the health coaches that did the home visits, and the follow-up calls. In our model, knowing our population as well as we do, we thought that it would be more appropriate to have an RN or LPN team work with the patients. When the patient is still in the hospital we’re trying to enroll them in the program. We make sure that they meet the program criteria. We have a liaison in the hospital that goes in and introduces the program and gains acceptance at the bedside. And when the patient is discharged from the hospital, we have an LPN that calls them the first day that they go home, and actually starts the intervention right there. So they are doing a couple things with them: they are making sure that if they had new medications prescribed at discharge, that they had a chance to have those prescriptions filled, and if there’s any barriers to getting those prescription filled, then they help patients through that. That’s one pillar of Coleman, by the way: medications.
Second is physician visits. Physician follow-ups. We make sure that the patient, at the time that they’ve already been discharged from the hospital, have their follow-up appointments made, and if not, we help them understand the importance of calling right then to get that appointment – the goal is really for them to see their physician within a 7 day period. That’s the second pillar of Coleman.
Another pillar of Coleman is understanding red flags or warning signs to look for. At the time that we’re talking to them on the phone, we have not started chronic disease education yet. So we really focus on the discharge instructions and warning flags related to their admission. But we review their discharge instructions and red flags with them, and tell them when to call their physician, even before we get out to see them. That’s the third pillar of Coleman.
And then the fourth pillar of Coleman is a personal health record, and that we have interpreted that for our program to include a binder of information that we’ve put together for the patient that includes not only health education specific for that patient, but a place to keep their medication list, to keep their advanced directives, to make note of their physician appointments and questions that they have for the physician to make note of their health goals. We really want to talk to them about what their goal is for their health, and then we have a whole resource section including a list of urgent care centers in our area. That’s really important for reducing readmissions, by the way, when they can’t get into their physician, if they know there’s other available service that might be able to help them with their urgent issue, we provide that information as well.
We don’t provide the physician or the personal health record during the call, obviously, but during that first call in the 24 hour window following discharge, we set the appointment for the nurse to go out. We want the nurse to be in the home within 48 to 72 hours following discharge. The RN goes out and does a full health assessment of the patient, so we’re not there to provide any hands-on care. We’re not there to dress wounds, to change dressings, to give meds – we’re actually there as an education and self-monitoring program, but the one hands-on thing we do at the beginning of the visit to make sure the patient is still stable following their discharge is a health assessment. They take a set of vital signs, they listen to lungs; if they’ve had a surgery, they’ll actually take a look at the wound and make sure that it’s clean, dry, intact and that there’s no warning signs around it that would impact their recovery. Then the nurses in the home do a full medication reconciliation, so the beauty of having someone actually go into the home vs. over the phone or trying to do this while they’re still in the hospital is we have the patient bring all their medications to the kitchen table. We have their discharge instructions, so we know what the hospital thought they were on at home, any new meds that they’ve been prescribed and then we actually get to see what they were actually taking, what was refilled and are there other over-the-counters, and we help them create an up-to-date medication list. In the course of doing that, our nurses can identify potential duplications of drugs that were unintended, or interactions, and take action to engage the primary care physician to rectify those issues.
Also, the home visit includes education around the health condition, around self-monitoring. If the patient needs to weigh themselves and doesn’t have a scale, we give them a scale. We give them a weight log. We teach them the importance of taking those measurements every day. If they haven’t taken their blood pressure, we give them the blood pressure log. If they’re diabetic and really aren’t doing all of the things that they need to do to self-monitor, we teach them and get them on the right road to recovery. We reinforce the physician visits, we give the personal binder.
And then the last thing that we’re able to do in the home, again, another beauty of people allowing you into their home is you get to find out a lot more about the patient. Are there financial issues that are challenging this person’s healthcare and recovery? Are there psycho-social issues? Is there a lack of support? Is nutrition really an issue? And then, based on that information, we’ve added our own fifth pillar to the Coleman model to refer patients to other community services they might benefit from, that relate to some of those challenges that I just spoke of. We even have our own social worker who, for the more challenging cases, can go out and meet with the patient separately and help to address some of those issues.
Fred: Holistic approach to the monitoring and the education and assistance for that individual, trying to look at all of the various factors that might cause a readmission, and then seek to find solutions to each of those problems.
Jennifer: Exactly. And that’s one thing in health, you know, I worked in healthcare, you worked in healthcare for a number of years and I feel like we’re really good at addressing the immediate healthcare condition, but we’re not always able to take into account all the other factors that surround the individual, that impact their health. Part of that is being able to get into the home in a more relaxed environment, when the patients are starting to feel a little bit better and might be more receptive to that input. I think we’re able to do that a little bit easier.
And then just to follow up your question, the other, the last thing that we do to finish the Coleman model for that patient is following the home visit, we do three weekly follow-up calls with the client. We focus on the same five pillars and use a common documentation platform, so that challenges the RNs note in the home are followed-up on during those follow-up calls with the LPNs. It’s a very nice program and we’re having fantastic results.
Fred: Yeah, the results really have been excellent. I’ve seen some of those, and I know Jennifer, I believe you’re looking now at the possibility of expanding this program out into other service areas, potentially. If people are interested in learning more or talking to you about that, how might they get in touch with you?
Jennifer: Well, the best way is email or phone. The phone number is 623-832-5563 and my email is [email protected]. Our website is SunHealth.org as well, so we’d love to hear from anybody who’s interested in working on a program like this. We reduced readmissions in our program to about 8% and the national average for Medicare readmissions today is about 17.8%, so literally about half of the average, and I think it’s just due to some of the extra attention on some of those issues that we’ve talked about today.
Fred: Fantastic results, it’s excellent, Jennifer. Well, I think we’re coming on the end, and I just want to say it’s been a pleasure to have you this week on Pop Health Week. We probably should get you back on to talk about some of the other innovative things that Sun Health is doing, and with that, I’ll turn it back over to you, Greg. Thank you, Jennifer.
Greg: And that will have to be the last word for today’s broadcast. I want to thank our guest, Jennifer Drago for time and insights today. Do follow her and Sun Health on Twitter via @sunhealthaz and on the web at SunHealth.org. We do this weekly at 9 AM Pacific, 12 PM Eastern on Wednesdays. Join us next week for our special guest, Cave Suvave MD, JD, the managing director for Global Health Care Business at Accenture. Until then, for Fred Goldstein, this is Greg Masters saying bye.
