Faculty Bibliography

Statement of Problem Or Question (One Sentence): Can a home visit complex care management program successfully identify and engage high risk patients in a FQHC? Objectives of Program/Intervention (No More Than Three Objectives): 1. Identify patients at an FQHC who are at risk for preventable hospitalization 2. Enroll and engage patients in a home visit based complex care management program. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): The Primary Care Plus program (PCP+) is a home visit based program established to address the needs of patients at risk for preventable hospitalizations within the Family Health Centers at NYU Langone. The program staff-a physician, a nurse practitioner, a social worker and 2 community health workers-coordinate as a team to identify and address the biopsychosocial needs of high risk patients. A key intervention is the home visit lead by a physician or nurse practitioner to perform the medical assessment, medication reconciliation, and identification of both medical and social impediments to optimal health. The program is not intended to replace the patient's primary care provider, but to function as an addition to the patient's care team, identifying and mitigating risk drivers, and handing off to the primary team and care management resources once the risk drivers have been addressed. Patients are referred into the program by either their primary care doctors or care management. The program is restricted to those patients who have a continuity relationship in the Federally Qualified Health Center, and who are identified as being at risk for a preventable hospitalization. Latitude is given to the referral source in how patients are identified; guidance is given to focus on patients with a history of preventable hospitalizations (as defined by PQI) or patients with advanced disease and potential palliative care needs. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): The primary measure of success is patient engagement. Patient engagement is defined by both consent to the program and successful home visit by the medical provider. Other outcome metrics are patient characteristics, number of emergency department visits and number of inpatient hospitalizations in the 12 months before program enrollment. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): Since program inception in August 2018 through December 31, 2018, 75 patients have been identified by care management or primary care providers as potential candidates for the program and who met criteria as defined above. Of the 75 patients, 6 (8%) declined the program, and another 10 (13.3%) could not be found. The remaining 59 patients were seen at home and assessed. Total engagement was 78.7%. Patients identified represent a cohort of patients with an average of 2.0 inpatient admissions and 3.2 emergency department visits in the preceding 12 months prior to enrollment. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): Identification of a high-risk patient population in a federally qualified health center and referral into a home visit based care management program is associated with high acceptance and engagement. Future study will determine if patients enrolled in the program have an impact on risk drivers and preventable hospitalizations

Background: The Hitech Act of 2009 led to Federal funding on EHR incentives such as Advancing Care Information within MIPs and Meaningful Use. EPIC currently has a MyChart application which allows a patient to interface with their medical records and provider. The Family Health Centers (FHC) at NYU Langone is a network of 8 Federally Qualified Health Centers (FQHC) located in Brooklyn New York. The primary service area has a large immigrant population with 47% of the population reported as being foreign born, and a diverse payor mix with 12% of patients being self-pay/uninsured.
Method(s): Retrospective analysis was performed regarding 78,168 unique patients seen within the Family Health Center Network from January 2018 to December 3rd, 2018. Patient were identified by payor class and by utilization of MyChart. Given the diversity of healthcare plans afforded within New York State, payor classes were grouped into 7 broad categories: Medicaid/Managed Medicaid, commercial, Medicare/Managed Medicare, self-pay, no insurance, Child Health Plus and Med-icaid Expansion (Affordable Care Act). Patient MyChart data abstraction within the EPIC Clarity database included whether the patient was enrolled and when the last date of activity occurred. Enrollment with activity versus enrollment without activity within the last calendar year was used to gauge whether the patient would be considered an active subject in this retrospective review.
Result(s): Regarding percentage of patient enrolled in MyChart, the patient population most likely to enroll was found to be those who have commercial health plans at 41%, with Medicaid expansion plans at 37%, followed by Medicaid tied with self-pay coverage (23%) and Medicare at 18%. Utilization tells a different story with the highest utilizers found in the Medicare enrollees at 79%, followed by Medicaid expansion at 78%, then commercial plans at 77%. The next tier of active users was found to be no coverage (67%), self-pay (66%) and Medicaid (61%). Retrospective review with enrollment data was somewhat expected; high enrollment in patients with commercial plans and lower enrollment amongst Medicare beneficiaries. What was surprising was the utilization/activity data revealed an entirely different picture. Activity usage reflected two tiers. Patients who have Medicare utilize the application as much as patients who have commercial plans and Medicaid expansion. Despite connotations on patients who are self-pay or who have no coverage at all, these patients still use the application, with greater than 50% of those enrolled, actively using MyChartwithin the last calendar year.
Conclusion(s): As medical care becomes more immersed in web-based technologies, attention and opportunities exist for patients who traditionally were viewed as not having access nor inclination to use such technologies. Continued efforts should be maintained regarding enrollment regardless of the payor class or age