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					                                                       Benefits of Aggressive Patient Management on Radiation Therapy in Socio-Economically
                                                                                      Disadvantaged Populations
                                                                               M.C.Baird, MD, T Shirley, MPH, SM Baird, RN, L Smithhart, LMSW, N Mayronne, LCSW, D Green, RD, S. Vijayakumar MD
                                                                                             Department of Radiation Oncology, University of Mississippi Medical Center, Jackson, MS




                                   Introduction                                                   Materials & Methods                                                              Results                                                               Financial Analysis
            • Studies have shown poorer outcomes when                             • Aggressive patient management program consists of a                                        Interim Analysis
                                                                                                                                                                                                                                       Revenue Gain from Daily Operations
              minority patients are treated for cancer, despite                     coordinated patient intake assessment and plan, and a          The first quarters of 2008 and 2009 had similar physician and
              the fact that it has been shown that race, per                        volunteer based patient management team that monitors          departmental staffing. The only major change was the implementation                 •5% of treatment appointments moved from lost productivity to
              say, is not usually a factor in treatment results.                    and facilitates all aspects of the program. The program is     of the patient management program in 2009. This gave us the                         income generating (representing 98.6 „units‟ of productivity)
              This leaves the socio-economic factors that                           structured as follows:                                         opportunity to explore the global effects of this program by comparing              •Our costs over this period are $68.08 per unit and our
              influence treatment outcome as the most likely                                                                                       both time periods.                                                                  realized income is $446.26 per unit
                                                                                  • Initial contact by volunteer to facilitate initial consult
              cause of poor treatment results in minority                                                                                          Goals of the analysis were to monitor the overall effects of the program            •Therefore a loss of $6,712.69 was converted into a gain of
                                                                                    exam                                                           on patient compliance and department efficiency and to see what the
              patients.                                                                                                                                                                                                                $37,288.55
                                                                                  • At initial consult, evaluation by social worker and            financial effects of the program were on a global basis. The grant
            • The Radiation Oncology Department at the                                                                                                                                                                                 •This represents an improvement of $44,001
                                                                                    dietitian to determine needs. All patients are eligible for    covered driver, gas, food, and some housing costs. Van use was
              University of Mississippi Medical Center treats                                                                                                                                                                          •Costs of the program were $ 23,443
                                                                                    support under the program, but those who meet criteria of      donated by Jackson Medical Mall Foundation. Since we were
              a large number of rural, minority and                                                                                                                                                                                    •This calculates to a revenue gain of almost $2 for each $1
                                                                                    ” rural or disadvantaged minority patients” will be eligible   interested in the sustainability of the project, in the financial analysis all
              disadvantaged patients. We have observed                                                                                             services were priced at market rate despite actual costs to the
                                                                                                                                                                                                                                       expended
                                                                                    for financial assistance under the grant. Others will be
              within this patient population a high incidence                       billed for the actual costs of provided support on a sliding   program.
              of failure to show for initial treatment                              scale “means testing” formula (below). Patents who                                               Costs                                                 Revenue Gain from New Consults
              consultation, as well as a high rate of non-                          qualify for grant support meet the follow criteria:            Services provided to patients during program period ( Q1 2009)                     Twenty-one new consults represent a significant new
              compliance with our multi-week treatment                                                                                             included the following:
                                                                                  • Patients whose daily drive to the                                                                                                                 revenue source. If half of the consults are treated and
              programs.                                                                                                                                                      707 days of housing
                                                                                    Jackson Medical Mall is in excess of 45                                                                                                           assuming an average of a three week treatment course, a
            • This study was undertaken in an attempt to                                                                                                                     241 supplementary meals
                                                                                    minutes one way                                                                                                                                   potential of 189 “revenue units” could be realized. At our
              quantify the health effect of this non-                                                                                                                        130 social services consults
                                                                                  • Patients whose income is at or below                                                     130 dietary consults                                     rate of $446.26 per unit, this represents approximately
              compliance and to see if aggressive attempts
                                                                                    200% of the Federal Poverty Guideline                                                    631 Van trips                                            $85,000 in potential new revenue.
              at patient management could reverse the
              negative effects of low socio-economic status,                      • Means Testing: Based on patient‟s financial condition                                    29 Taxi vouchers
              and improve treatment outcomes.                                       level of grant support will be determined                                                168 volunteer hours                                                               Discussion
            • If a positive effect was observed, we wanted to                        – 100% of poverty level full support;                         • Housing and meals:                                            $16,984
                                                                                                                                                                                                                                    The implementation of a comprehensive, aggressive patient
              see if a program such as this would be                                 – 100-200%                 sliding scale of support;          • Social Worker and                                                              management program for socio-economically disadvantaged
              financially viable.                                                                                                                       Dietary consults:                                              2,924        patients has shown dramatic results in its first full quarter of
                                                                                     – over 200% of poverty patient pays full share of direct
            • A grant from the Mississippi Institute for                                                        expenses                           •    Travel costs                                                                operation. Patient consult volumes have increased by 12% while
              Improvement of Geographic Minority Health                           • Types of Support Offered                                       •          (driver, gas, taxi)                                    3,535          treatment volume grew by 21%. More important, patients
              was obtained which covered approx 25% of the                                                                                         •    Total costs                                                $23,443          dramatically improved in their compliance both for initial consult
              projected program costs of $100,000 per                                                                                                                                                                               (30% no show rate dropped to 15%) and with attendance for daily
              annum.                                                                     • Housing accommodations                                  Given our projected budget of $100,000 per year, the $23,443 was on              therapy (11 % no show reduced to 6%). This improved
                                                                                            – for those who live too far to commute                target for the first quarter of the year.
            • The remainder was underwritten by the                                                                                                                                                                                 compliance with therapy will almost certainly lead to improved
                                                                                         • Van and driver services
              University of Mississippi Health Care, as in-                                 – for those who need transportation assistance                             Patient Compliance                                           outcomes, which will be studied in future analyses. The positive
              kind services.                                                             • Nutritional evaluation                                          Daily treatment patients           Failed   Scheduled   %                effect of this program on the financial side was unexpected.
            • A cost accounting of all expenses has been                                    – by a dietitian weekly and when weight loss noted             Control period                     180 1629             11%              Given the marked improvement in compliance with daily treatment
              performed to aid in the financial analysis.                                • Two meals per day                                               Program period                     121 1972             6%               schedules, our departmental efficiency improved by 5% and this
                                                                                            – for patients who are provided housing                        New Patient Consults                                                     represented a dramatic improvement in our financial performance.
            • The program began in January 2009, and this                                                                                                                                                                           This increased revenue more than covered the expenses of the
              is the report of the first interim analysis-                        • Volunteer patient managers headed by a volunteer                       Control period                     37       122         30%
                                                                                                                                                                                                                                    project, and makes this program revenue generating. The
              comparing first quarter 2008 (when no                                 coordinator, a cadre of 4 volunteer managers contact                   Program period                     21       137         15%
                                                                                                                                                                                                                                    improved capture of initial consults further represents a significant
              aggressive management program existed),                               every new patient prior to consult and determine barriers                                  Table 1                                              departmental growth engine and would be expected to provide
              with the first quarter of 2009 (initial quarter of                    to coming to the consults (i.e. lack of rides, other
                                                                                                                                                   Daily Treatment Patients                                                         even more revenue in the future.
              the program). 101                                                     appointments, etc.). They then ensure that the patient
                                                                                    actually was seen, and arrange a new appointment if the
                      Poverty Related Socio-Economic Factors                        patient missed. They maintain phone contact with patient
                                                                                                                                                   The no show rate fell from 11 % to 6% despite a 21%                                                        Conclusion
                                                                                                                                                   increase in activity. (Table 1)
                                                                                    during the simulation and treatment planning times, until                                                                                       An organized, multidisciplinary approach to the
            • Co morbidity (unhealthy life style)                                   the patient actually begins therapy. They then actively        This 5% improvement in efficiency equates to 197 cancellations                   management of socio-economically disadvantaged
                                                                                    monitor follow up appointments and notify staff if medical     being avoided in the program period and represents 98.6 „units‟ of               patients can :
               – Smoking, drinking, drugs, obesity, HIV/AIDS
            • Fear of organized medicine leading to late                            problems occur post therapy. The goal is to notify social      productivity on the department budget.
              diagnosis                                                             services, residents, fellows or staff of potential social                                                                                           1. Be effective at getting patients seen and
                                                                                    issues before they become a crisis                             New Patient Consults
            • Poor access to medical care and therapy                                                                                                                                                                                      evaluated in a timely manner
                                                                                  • Bi weekly Multidisciplinary Conferences are held to            Again, despite a 12 % increase in the number of
            • Limited skills to follow through complex
                                                                                    coordinate housing, transportation, department treatment       scheduled consults, the no show rate was halved from
              medical therapy programs                                                                                                                                                                                                  2. Markedly improve patient compliance with daily
                                                                                    schedules and other issues.                                    30% to 15% in the program period. (Table 1)                                             therapy
                                                                                  • A specialized patient waiting area for van patients was
            Some of these socioeconomic issues are beyond our direct
              ability to influence, but some are not. In the list above, the        developed.                                                     This 50% reduction in consultation failures was calculated to result
              issues noted in red are clearly under our control to intervene      • Emergency fund for medicines under direction of Social                                                                                              3. Be cost effective for the Department in that it
                                                                                                                                                   in 21 additional patients being seen for therapy in the program
              and improve.                                                          Workers was established for patients who lack share of         period as a consequence of patient management.                                          generates more revenue by increased efficiency
                                                                                    costs for medicines.                                                                                                                                   than it costs

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