Urban Medical: Overview

1
Urban Medical Overview

• Primary care practice founded in 1977, serving
  all adults and specializing in the elderly,
  chronically ill, and complex patients
• Team based care provided across settings
  office, home, nursing home, and hospital
• Track record of designing and incubating
  innovations in primary care for target
  populations

2
Urban Medical House Calls Program Structure

• NP-directed program (73 of visits) with
  significant non-clinician coordinator roles
• Enhanced primary care with care coordination
  including regular team meetings
• Frequent, proactive visits to manage chronic
  conditions
• 24/7 on-call with EMR support as alternative to ED

3
Urban Medical House CallsProgram Staffing

• 550 Patients, 7000 Annual Visits
• 5 FTE NPs
• 1.5 FTE MDs
• .25 FTE Social Worker
• 1.4 Care Coordinator
• 1.4 Operating/Admin

4
Urban Medical House Calls Population Served

• Mean Age 81.5
• Gender 69.6 Female
• Race 85 White 12 AA
• Urban (Greater Boston)
• 90 in congregate housing
• 24 on Medicaid
• Medicare patient profile 2005

5
Urban Medical House Calls Population Served
(contd)

• Chronically Medically Ill
• 57 CHD
• 35 CHF
• 32 Diabetes
• 35 with 3-4 chronic diseases
• Chronically Mentally Ill
• 64 with mental health diagnoses
• Medicare FFS patient profile 2005

6
Urban Medical House Calls Population Growth
7
Urban Medical House Calls Internal Evaluation
(2004)

• Analyzed "home hospital admissions for 70
  patients
• Compared period in House Calls and equivalent
  period prior to joining House Calls
• Results
• Hospital admission rates reduced 29
• Hospital days reduced 34
• While patients aged with progressing disease

8
Urban Medical House Calls Payor Analysis
(2006-2007)

• Data from Senior Care Organization
• 90 dual eligible, nursing home certifiable
  patients cared for in the community
• Mean age of 77
• Average risk score 2.40
• 40 with congestive heart failure

9
Urban Medical House Calls Payor Analysis
(contd)

• NO hospitalizations for CHF (versus benchmark of
  21.1 hospitalizations/1000 for the population
  over 65 as a whole in Massachusetts)
• Medical expense ratio 59.53 of premium
• ED expenses 20/pmpm -- 50 of expected

10
Why does House Calls work? Some Best Practices

• Team-based care
• Proactive, frequent patient visits
• Focus on patient and family/caregiver
• Teaching patients and caregivers to watch for
  ominous symptoms
• Easy availability of clinicians 24/7 as
  alternative to ER
• Giving patients thoughtful control of
  hospitalization and end of life decisions and
  making this a recurrent theme of care

11
Best Practices - continued

• Partnership with housing providers to support
  aging in place
• Care coordination by non-clinical team member to
  make sure that tests, prescriptions and referrals
  actually happen and to provide links to social
  services
• Transition coaching of patients and families
  after discharge from hospital and rehab
• Linking or integrating mental health care