Downtown Coordinated Care Center (DC3)

Mission Statement

Humanizing Health Care

Location

Close to Pacific Alliance Medical Center

Downtown Coordinated Care Center711 W. College Street, #540

Los Angeles, CA 90012Phone (213) 437-4216Fax (213) 621-0430

Opened Doors on May 7th, 2012

Current Goals

• Develop and implement a Complex Care Center model of care• Identification & Enrollment of High Risk, High Cost Members and those

members predicted to be high risk from our 200,000 plus Dual risk members

• Improve Care Coordination and Transitions Leading to Better Outcome• Patient Center Member Care and Disease Focused Approach • Breaking Down Barriers to Health• Assist PCP & Provide Resources to Manage Complex Cases• Increase Member Self-Management Practices• Decrease Total Cost of Care • Encourage Development of Innovative and “Out of the Box” Solutions• Changes the lives of our patient's for the better

Support – Internal

• Open-access patient scheduling with after hours on-call staffing

• Same Day Radiology & Other Diagnostic Services• Chronic wound assessment, treatment & in-office

debridement• Prescription Medication Orders and Refills • Follow-up calls to members depending on case• Once a week Psychiatry Services

Support – External

• Daily PAMC Hospital Rounds• Direct Communication with Hospitalists & Case Managers

• Non-PAMC Hospital Rounds• Assurety Nurse D/C Planner to do on-site member

identification for potential DC3 referral• Warm Hand Off to the DC3

• Member Assigned to a Complex Care Manager • Specialty Referrals Fast Tracked & Coordinated with

PCP and IPA/MG

Support – Technology

• AthenaHealth Electronic Health Records (EHR)• Linked to LabCorp for real-time test results

• MEDITECH Access (PAMCs EMR)• SynerMed SHARE• SynerMed CONNECT• HIE (Health Information Exchange) – Future

Integration IEHIE.ORG• Access to SynerMed’s proprietary analytics

AthenaHealth (EHR)

Meditech – PAMC CPOE

SHARE

CONNECT

Support – Transportation

• Free Transportation to and from Home/DC3

• PAMC Van and Med-Life Ambulette

• Ambulatory, Wheelchair or Gurney

Support – Misc

• In-house Licensed Social Worker• Behavioral Intervention• Community Resource Referrals (IHSS, housing, etc)

• “Meals-on-Wheels” program for non-compliant members on specific diet

• Transition of Care Coordination for inactive DC3 members

Target - PAMC

• PAMC capitated members under EHS Medical Group and Angeles IPA within 15 miles of PAMC• Will accommodate members who are outside of 15 miles on

a case by case basis

Target - ER

• Frequent ER Flyers• Readmissions within 30 Days• History of Non-Compliance, Drug-Seeking Behavior• Polypharmacy – Meds Galore

Target - COMPLEX

• Complex and/or Chronic Medical Conditions leads to high cost• Diabetes with Complications• Cardiovascular Disease• Psychiatric or Psychosocial Needs

Uncontrolled Diabetes Mellitus

Cardiovascular Disease

Target - ESRD

Chronic Kidney Disease /

End Stage Renal Disease

Target - COPD

Target – Chronic Infections & Wounds

Skeletal or Connective Tissue

Infections

Target - PAIN

Chronic Pain

Syndrome

Target – InflammatoryInflammatory / Autoimmune Disease

Target – HIV/AIDS

HIV / AIDS Related Complications

Target – SPD’s/SNP’s

HomelessAddiction

Limited ResourcesChronic Conditions

Case Study – A - Before

Prior to DC3 Ms. J. LoDemographics 45 years old African American SPD Female

EHS Effective 05/01/2012Condition Uncontrolled Diabetes - HgbA1c 16

Cellulitis/Abscess Formation on Right Leg – 18.5 x 8.5 x 1cmHistory Recent Inpatient Visit for Surgical Drainage of Abscess

Sent Home with Home Health Nursing for Wound CareIssues Behavioral Issues leading to 5 Nurse Changes in First Week

DC3 Enrollment Hesitant to go to DC3 due to DistanceFree Transportation Changed Her Mind

Case Study – A - After

In DC3 Ms. J. LoDiabetes HgbA1c improved from 16 to 12.1

(24.375% reduction)Cellulitis Reduction in Size & Granulation -

9.3 x 5.3 x 0.1 cm (69% reduction)Appt. No Missed Clinic Appointments

Behavior Improved Attitude Toward StaffImproved Compliance to Treatment Regiment & Disease Mgmt

DC3 Enrollment

June 11, 2012

Member “That’s the best it’s ever been!” Taken on July 13, 2012

Case Study – B - Before

Prior to DC3 Mr. Jay ZDemographics 40 year old Hispanic HN Mcal (non-SPD) Male

Angeles IPA Effective 01/01/2012Condition Uncontrolled Diabetes - HgbA1c 14.4

Left Foot Ulcer - 5 x 2.6 cmRight Foot Ulcer – 4.2 x 2.5 cm

History 10 Prior HospitalizationsDaily Home Health Services for Wound

Treatment since April 2012Issues Non-Compliant to Treatment Regimen

DC3 Enrollment May 16th, 2012

Taken May 16th, 2012

Case Study – B - After

In DC3 Mr. Jay ZDiabetes Improved treatment compliance

Blood Glucose & Blood Pressure monitoredHbA1c on July 7th – 13.4 (7% improvement)Medication adjusted

Ulcer Left Foot Ulcer – 1.7 x 0.6 cm (92% improvement)Right Foot Ulcer – 0 x 0 (100% improvement)

Appt. 3 times a week for 22 appointments

DC3 Enrollment

May 16, 2012 to present

Member Via the driver, says nothing but great things about DC3Taken July 27, 2012

Case Study – C - Before

Prior to DC3 Mr. A.P. Demographics 62 year old Native American Male SPD Angeles member

Effective 05/01/2012Condition Orthostatic Hypertension – severely low BP 92/62, 77/55

Uncontrolled Diabetes: Blood Sugar: 371-452-536 | HbA1c: 11.4History 3 ER Visits (that we know about) from May to June

1 Admission – DC3 picked upNot Seen by PCP

DC3 Enrollment Hesitant to go to DC3 due to missing the local Senior Center’s activitiesEnrolled on 06/20/2012

Case Study – C - After

In DC3 Mr. A.P. Treatment Patient started on IV in DC3 with insulin administration

Up to 4 hours at a time in officeFed PAMC food for breakfast and lunch

Condition Improved BP to 118/78, 115/81Managed hypertension preventing patient dizziness, light headedness and fall

Hospitalization since Enrollment

One Urgent Care Visit in the first week of enrollmentNo ER or Urgent Care visits since

Appt 3 times a week to monitor | 9 appointments in 1.5 months

DC3 Enrollment Currently enrolled

Member Response

Will call DC3 first when feeling signs of troubleMr. A.P. doesn’t mind missing Senior Center’s activities to attend DC3 and hang out with his new friends

Case Study – D - BeforeTaken on June 18th, 2012

Case Study – D - After

Taken on July 27th, 2012

Future Goals

• Develop a Pain Management Program• Develop Palliative Care and Hospice Programs• Psychiatric and Psychotherapy Services• Telemedicine Participation in SynerMed eCONSULT

platform• Streamline & Partner with HDO’s• Free Disease-Specific Educational Sessions• Group Therapy Classes• Incorporate HEDIS and CMS Stars measures• Provide Recuperative Care Services• Mobile Medical Van• In-Home Assessments

Staff

Yvonne Quezada, LVN Assurety Nurse Lizet Gonzalez, MA, Clinic ManagerLindie Kuzmich, LVN Case ManagerLing Le, NPRoy Kaufmann, LCSWDr. Pedro Lopez I.M. (not pictured)

Eric Campos, MANicole Michery, MA

Q & A