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Service Delivery Innovation Profile

Medical Home for Patients With Disabilities and Chronic Conditions Improves Access and Self-Management Skills, Leading to More Healthy Days, Fewer Hospitalizations


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Summary

The Courage Kenny Advanced Primary Care Clinic in Golden Valley, MN, provides a primary care medical home (commonly referred to as a "health care home" in Minnesota) to patients with disabilities and complex, chronic medical conditions, including a large number dealing with spinal cord or brain injuries or stroke. The clinic features a variety of physical features and services specifically designed for the population being served, including accessible exam rooms and equipment and a location shared with other services commonly used by these patients. Staff work with patients to assess their situation and needs and develop customized care plans that coordinate primary and specialty medical care along with needed social services. The program has enhanced access to primary care and improved patients' ability to manage their health, leading to more days of good health each month, fewer hospitalizations, lower costs, and high levels of patient satisfaction and engagement.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation comparisons of self-care skills, self-reported days of good health, and hospitalizations, along with post-implementation reports from patients on their satisfaction with various aspects of the program
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Developing Organizations

Courage Kenny Rehabilitation Institute
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Date First Implemented

2009
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Patient Population

The program primarily serves adults between the ages of 26 and 64 with disabilities and chronic medical conditions, including a large number dealing with the effects of a spinal cord or brain injury or stroke. Most of those served are low income.Vulnerable Populations > Disabled (physically); Medically or socially complexend pp

Problem Addressed

Many patients with disabilities also have multiple chronic medical issues. These individuals often receive inadequate primary care (including little help in managing their complex needs), leading to increased risk of hospitalizations and emergency department (ED) visits.
  • More chronic conditions among those with disabilities: People with disabilities are more likely to have chronic conditions than people without disabilities. For example, one study found that people with disabilities were more likely to be obese or extremely obese than those without disabilities. Among people in any category of obesity, people who also had disabilities were more likely to also suffer from high cholesterol, hypertension, and diabetes than those without disabilities.1 At the Courage Kenny Advanced Primary Care Clinic (which exclusively serves patients with disabilities, often resulting from a stroke or spinal cord or brain injury), the typical patient has 12 medical conditions, with the most common being pain, fatigue, sleep disorders, depression, and anxiety.
  • Unmet primary care needs: Patients with disabilities often have difficulty getting the primary medical care they need. In a survey of 501 California-based primary care physicians, nearly half (49.1 percent) reported problems with the accessibility of the exam tables for patients with disabilities, while 15.4 percent reported problems with the accessibility of the exam rooms. A majority (72 percent) expressed a desire for more training on how to care for people with disabilities.2 In focus groups, patients with disabilities and their providers highlighted the need for more specialized hospital discharge planning, more time for office visits, and better case management and doctor–patient communication.3   
  • More hospital stays and ED visits: Compared with the general population, patients with physical limitations are 14 times more likely to have been hospitalized two or more times and five times more likely to have had two or more ED visits in the past year.4

What They Did

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Description of the Innovative Activity

The Courage Kenny Advanced Primary Care Clinic provides a primary care health care home to patients with disabilities who also have complex, chronic medical conditions. The clinic features a variety of physical features and services specifically designed for this population, including being co-located with other services commonly used by these patients. Staff members work with patients to assess their situation and needs and develop customized care plans that coordinate primary and specialty medical care along with needed social services. Key program elements include the following:
  • Patient referral and screening: Providers at Courage Kenny Rehabilitation Institute typically refer patients who they think could benefit from the program to the clinic. Approximately a third of referrals come from the Institute's Transitional Rehabilitation Program, while the remainder come from other referrals at the Institute. After receiving a referral, a care coordinator at the clinic reviews the medical chart and has a telephone conversation with the patient. This information helps to determine if the prospective patient's medical needs are complex enough to warrant the intensive level of services offered in the health care home.
  • Physical features and services tailored to those with disabilities: The physical features of the medical home and the services offered within it are specifically designed with the needs of patients with disabilities in mind, as outlined below:
    • Co-location with commonly needed services: The health care home shares clinic space with psychiatry and physiatry (also known as physical and rehabilitation medicine), the two medical specialties used most frequently by this patient population. The health care home also is in the same building as inpatient and outpatient rehabilitation programs, including speech, physical, aquatic, and occupational therapy services. This physical proximity maximizes patient convenience, allowing patients to schedule appointments one after the other and get to them as easily as possible (a critical benefit for a population that often struggles with transportation issues). It also allows medical professionals to collaborate on a patient's care informally throughout the day.
    • Accessible exam rooms and equipment: Six exam rooms accommodate a motorized wheelchair and have 6- by 8-foot exam tables that can be raised and lowered, making it easy to transfer patients from wheelchair to table and to turn patients while they are on the table. The clinic also has hydraulic lifts to help with patient transfers and wheelchair-accessible scales for weighing patients.
    • Telemedicine: Software loaded on laptops allows clinic staff to conduct virtual appointments with patients who cannot travel for an appointment. A Courage Kenny volunteer brings a laptop to the patient's home for use during the appointment and helps the patient use it.
  • Customized care plans and care coordination, with emphasis on patient engagement: At the initial appointment, a nurse practitioner or physician works with a care coordinator to evaluate the patient's medical condition and degree of self-care capabilities. The staff and patient then jointly develop a care plan that emphasizes engaging patients in managing their own health, thereby fostering independence. Key components of this process are outlined below:
    • Regular assessment and self-management skills: At the initial office visit and regularly thereafter, clinic staff assess each patient's level of self-management skills by using the standardized Patient Activation Measure (PAM) assessment tool. (More information on the PAM tool is available in the Tools and Resources section.) PAM evaluates four levels of patient activation based on knowledge, skills, and self-confidence in managing one's own health. Staff then tailor the care plans based on the results of the survey.
    • Use of evidence-based pathways: Evidence-based pathways are used to manage five conditions that are the most common causes of avoidable hospitalization (diabetes, wounds, seizures, pneumonia, and urinary tract infections). Pathways specify appropriate management of the condition, including the type and timing of needed tests and treatments. The goal is to manage these conditions proactively to avoid complications and hospital stays.
    • Coordination with medical specialties: Clinic staff coordinate medical care with all relevant specialists, including in-house psychiatrists and physiatrists and external physicians who have been screened to ensure they have handicapped-accessible facilities and adequate experience in treating patients with disabilities and complex medical conditions.
    • Management of social services: The clinic's social worker ensures that patients have access to all Courage Kenny and external community-based services that could improve their quality of life, including in-home help with daily activities, recreation programs, vocational services, and life-skill classes.
    • Chronic disease self-management support (if needed): Patients with low PAM scores are referred to a chronic disease self-management workshop (developed at Stanford University School of Medicine) held at Courage Kenny Rehabilitation Institute. Co-led by a staff person and a patient with disabilities and chronic conditions (i.e., a peer), this workshop consists of six weekly meetings in which 8 to 15 participants learn strategies and set goals related to self-management, including the development of healthy behaviors.
  • Telephone and inperson followup: Care coordinators telephone patients at least quarterly to monitor compliance with care plans and answer questions. The coordinators also check-in with patients in person when they come to the Courage Kenny Rehabilitation Institute for other reasons. The number of interactions varies, depending on a patient's medical issues and his or her level of self-care knowledge and skills.
  • Round-the-clock telephone access, same-day visits as necessary: By rotating call duties, providers are available 24 hours a day by phone to respond to patients' needs. During regular office hours, a triage nurse assesses a patient's medical complaints and determines if a same-day visit is needed.

Context of the Innovation

The Courage Kenny Rehabilitation Institute was formed in June 2013 through the merger of the Courage Center in Golden Valley, MN (a community-based organization founded in 1928 that offers rehabilitation services and other resources to individuals with disabilities) and Sister Kenny Rehabilitation Institute in Minneapolis. The Courage Kenny Rehabilitation Institute operates as part of Allina Health, a nonprofit health system that includes more than 90 clinics, 12 hospitals, and 14 pharmacies. In addition to various inpatient and outpatient therapies, the Courage Kenny Rehabilitation Institute offers recreation programs, life-skills classes, support groups, vocational services, in-home help with daily activities, and other programs.

The impetus for this program came from leaders and staff at the Courage Center who noticed that their clients often tried to get their primary care medical needs met through providers at the center. In response, they decided to launch the health care home program in December 2009.

Did It Work?

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Results

The program has enhanced access to primary care and improved patients' ability to manage their health, leading to more days of good health, fewer hospitalizations, lower costs, and high levels of patient satisfaction.
  • Enhanced access to care: Overall, 270 patients enrolled in the health care home between December 2009 and October 2013, allowing them to receive a variety of services and support that would have been very difficult to get elsewhere.
  • Better independent-living skills: Between December 2009 and October 2011, the average (median) PAM score for patients enrolled in the program increased by 17 points. According to published research, a 1-point increase is considered a statistically significant change in patient behavior.5
  • More days of good health: Patients reported an increase in the number of self-reported "healthy" days each month (as defined by the Centers for Disease Control and Prevention Healthy Days measure), from an average of 11.3 at enrollment to 16.8 after 16 months in the program.
  • Fewer hospitalizations, lower costs: For 147 Medicaid patients enrolled in the clinic, the average number of days spent in the hospital each year fell from 10.9 in the 3 years prior to enrollment in the medical home to 3.7 days in the year after enrollment, according to an analysis completed at the end of 2012. Based on Minnesota Department of Human Services' cost data from 2007, program leaders estimate that this decline translates into savings of $1,343 per patient per month.
  • Highly satisfied patients: In standardized surveys, patients express high levels of satisfaction with the health care home, with 97 percent reporting that their primary care provider took a personal interest in them and their problems, 97 percent also reporting that reception staff were courteous, and 94 percent indicating that they would recommend the health care home to others.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation comparisons of self-care skills, self-reported days of good health, and hospitalizations, along with post-implementation reports from patients on their satisfaction with various aspects of the program

How They Did It

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Planning and Development Process

Key steps included the following:
  • Securing initial grant funds: Staff at the Courage Center applied for and received two grants (one for planning and a second for implementation) from the Minnesota Department of Human Services.
  • Becoming certified as health care home: After reviewing a detailed application and conducting a site visit to the clinic, the Minnesota Department of Health certified the Courage Kenny Advanced Primary Care Clinic as a health care home in 2011.
  • Analyzing data to inform service design: Staff analyzed information on prospective patients, mined from a database maintained by a "sister" service. This analysis revealed that hospital charges accounted for the bulk of medical costs. It also identified several medical conditions that create a very high risk of complications and avoidable hospitalizations, including diabetes and urinary tract infections. Seeing this data, staff then developed evidence-based care pathways to reduce the risk of complications through routine treatments and preventive steps.
  • Modifying physical space and equipment: Staff at the Courage Center remodeled the existing clinic space (which already housed psychiatry and physiatry) to create exam rooms large enough to accommodate the radius of a motorized wheelchair. The center also purchased the specialized equipment described earlier.
  • Negotiating with payers to augment payments: Because the traditional fee-for-service reimbursement structure does not cover the cost of time-intensive care coordination, the staff negotiated alternative payment arrangements with some insurers. The contracts with two private insurers and Minnesota's Medical Assistance program (which administers Medicaid and other State programs) were revised to include separate payments for care coordination. Another private insurer agreed to add incentive payments tied to specific patient care goals, such as reducing hospitalizations.

Resources Used and Skills Needed

  • Staffing: The health care home employs an administrator and two schedulers (who also work for other programs and services), a part-time physician, two nurse practitioners, three care coordinators, a triage nurse, four certified nursing assistants, and a social worker.
  • Costs: The annual budget for the program is not available, although the bulk of expenses consists of staff salaries and benefits.
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Funding Sources

Centers for Medicare and Medicaid Services; Minnesota Department of Human Services
Public and private insurers partly cover the cost of medical services and care coordination for most patients. Nearly half of patients (46 percent) have coverage through Minnesota's Medical Assistance program, and another 30 percent are dually eligible for both Medicare and Medicaid. Roughly 15 percent have commercial insurance, and 8 percent are covered only by Medicare. To date, however, the medical home has not been able to break even on its operations.

In May 2012, the Centers for Medicare and Medicaid Services awarded a 3-year, $1.8 million innovation grant to the Courage Kenny Advanced Primary Care Clinic. The money from the award funds numerous services for a 3-year period, which began in July 2012. The funded services include telemedicine, a full-time social worker, the chronic disease self-management program, and the provision of in-home assistance with independent-living skills (such as money management) to patients who do not qualify for such help through Minnesota's Medical Assistance program.end fs

Tools and Other Resources

Manuals and other information on Stanford University School of Medicine's Chronic Disease Self-Management Program are available at: http://patienteducation.stanford.edu/programs/cdsmp.html

Information on the Healthy Days measure is available at: http://www.cdc.gov/hrqol/hrqol14_measure.htm.

For more information on the Patient Activation Measure, see the following article: Hibbard JH, Stockard J, Mahoney ER, et al. Development of the patient activation measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res. 2004;39(4):1005-26. [PubMed]

Adoption Considerations

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Getting Started with This Innovation

  • Involve leadership in program conceptualization: Senior leadership at the Courage Center developed the concept of the health care home initially, and their ongoing support has been crucial because the program does not break even. The leadership also has encouraged the staff to experiment with new services, even though some initiatives may not work out. 
  • Analyze data to identify and address potential problems: Program planners should analyze data on prospective patients' likely health problems and develop clinical pathways and/or other programs to address these issues proactively, with the goal of avoiding unnecessary hospitalizations.
  • Hire experienced staff: Planners should hire individuals who have experience treating patients with disabilities and are comfortable working as part of a care team that includes the patient. Care coordinators should be registered nurses, to ensure they have the clinical knowledge to manage medically complex patients effectively.

Sustaining This Innovation

  • Continually seek funding, including new payment structures: Even with augmented payments, the program may not break even. Hence there will be a need for additional funds to cover operating costs. Because patients with disabilities and complex medical conditions are more expensive to manage than other patients, reimbursement models need to reflect the true cost of managing this population.
  • Develop and maintain relationships with outside providers: Patients will need services from community-based specialists and other providers who have handicapped-accessible offices and experience treating patients with disabilities, including mobile providers offering mammography or x-ray services.
  • Offer 24-hour phone availability, same-day access (including via telemedicine): Patients with disabilities tend to be medically fragile and often need immediate attention when medical issues arise. Without such attention, their health can deteriorate quickly and result in the need for an expensive hospital stay. Because patients with disabilities often struggle to leave their homes, telemedicine can be a good way to provide immediate access to providers when serious health problems emerge.

More Information

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Contact the Innovator

Nancy A. Flinn, PhD
Senior Scientific Advisor
Public Affairs
Allina Health
3915 Golden Valley Road
Minneapolis, MN 55422
Phone: (763) 520-0210
Fax: (763) 520-0562
E-mail: nancy.flinn@couragecenter.org

Innovator Disclosures

Ms. Flinn reported having no financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Courage Kenny Rehabilitation Institute. Courage Center Primary Care Clinic—Health Care Home [Web site]. Includes information on services and outcomes. Available at: http://www.couragecenter.org/ContentPages/primarycareclinic.aspx

Flinn N, Simunds E, Parker K, et al. Primary care: a health care home for persons with disabilities and complex health conditions. Courage Kenny Rehabilitation Institute, 2011. Available at http://www.couragecenter.org/images/documents/ACRM%20poster%20final.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)

Courage Center Primary Care Clinic. Health Care Home final report to DHS. January 2012. Available at: http://www.couragecenter.org/images/documents/FINAL%20report%20DHS%20medical%20home.pdf

Footnotes

1 Froehlich-Grobe K, Lee J, Washburn RA. Disparities in obesity and related conditions among Americans with disabilities. Am J Prev Med. 2013; 45(1):83-90. [PubMed]
2 McNeal M, Carrothers L, Premo B. Providing primary care for people with disabilities: a survey of California physicians. Center for Disability Issues and the Health Professions, Western University of Health Sciences. 2002. Available at: http://webhost.westernu.edu/hfcdhp/wp-content/uploads/ProvPrimeCare.pdf
3 Morrison E, George V, Mosqueda L. Primary care for adults with disabilities: perceptions from consumer and provider focus groups." Fam Med. 2008;40(9):645-51. [PubMed] 
4 National Center for Health Statistics. Health, United States, 2010: with special feature on death and dying. Available at: http://www.cdc.gov/nchs/data/hus/hus10.pdf.
5 Remmers C, Hibbard J, Mosen D, et al. Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes? J Ambul Care Manage. 2009;32(4):320-7. [PubMed] 
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 09, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

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