# Presentation: 852616

## Community Care for Complex Illness (3CI)

*An EPICnet Project*
- Eastern Pennsylvania Inquiry Collaborative Network
- PI: Lou Lukas, MD & Abby Letcher, MD

## EPICnet

- 25 active 115 affiliate Practices
- Current projects include ULTRA, Practice Vitality
- Family Medicine and General Internal Medicine practices
- Julie Dostal, MD director
- Melanie Johnson, coordinator

## Goals of Presentation

- Overview of a significant EPICnet initiative
- Translating organizational research into practice

## Chronic Illness- practice perspective

- Practices identified Chronic Illness a as top concern for PBRN
- Evaluating reorganization suggestions
- Chronic Care Model- Wagner/IHI
- New Model Practice- Future of Family Medicine
- Medical Home- Pediatrics/FFM
- Disease management – 3rd Party Payers
- Pay for Performance- CMS

## Chronic Illness in America

- 20% of people over age 65 have four of more chronic illnesses
- Primary care doctors provide care to most of these people.
- 1-3% have Advanced Complex Illness
- They account for more than 30% of health care expenditures

## Community Care for Complex Illness (3CI)

- Prospective, Population-based, Primary care focused systems change to improve care of people with ACI
- Practice- Hospital Network collaboration (perverse incentives)
- Initial funding by Pool Trust

## Advanced Complex Illness

- “Frequent Flyers”
- End-stage CHF, COPD, etc
- High but uncertain mortality
- Very sick, but not eligible or ready for hospice
- Palliative care perspective
- Multi-dimensional care
- Goals of Care

## Community Care for Complex Illness

- Phase I- understanding the population
- Phase II- understanding the systems
- Phase III- piloting intervention
- Phase IV- testing intervention

## Phase I-population identification and baseline data

- Inclusion criteria- CHF, COPD and/or PVD;55 years of age; or more admissions for above DX in last 18 months.
- 3000 Patients
- age 77, 51% female, 93% white
- 8379 Admissions
- 42,278 hospital days, avg LOS 5.8
- 2.5 admission/pt- rage 2-12
- Exclusion- primary cancer diagnosis, nursing home residence

## Phase I- next steps and challenges

- Next Steps
- Map patients back to PCP
- Continue descriptive statistics
- Select Pilot practices
- Challenges
- IRB/HIPPA- delay
- Accuracy of administrative data in identification of PCP/Group

## Phase II- Understanding Network

- Mixed-method study of patient and provider understanding of the “medical/social network”
- Social Network Analysis
- Qualitative interviews
- Patients
- Family members
- Physicians
- Staff

## Phase III-The Intervention

- Changing practices using insights from complexity science, CCM, Palliative care.
- Practices are complex, adaptive systems (CAS)
- They change through reflective adaptation-
- Multi Method Assessment of Practice
- Facilitated Change Model
- Relationships are key- Team building and expansion
- Chronic Illness team
- APN “consultant” in practices.
- Social/community support

## Phase IV- Evaluation & Measurement

- Practice level-MAP
-  ACIC, number of visits, qualitative assessment
- Patient/family outcomes
- Satisfaction with care (PACIC)
- Caregiver burnout
- Quality of life (FACIT-P)
- Mortality
- Systems level outcomes
- Hosp admissions, ED use, length of stay, referral to hospice
- Change in SNA patterns

## Phase IV- Challenges

- Sampling- clustered by practice, stratified by?
- Inevitable mortality and uniform severity of illness may inhibit responsiveness of instruments
- Would like to measure halo effect
- Measuring emergent properties prospectively