care neighborhood a model of care for high risk, high need ......6/1/2017 1 care neighborhood a...
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6/1/2017
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Care NeighborhoodA model of care for high‐risk, high‐need people
Laura M. Miller, MD
Chief Medical Officer
June 4, 2017
CPCA
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Social Determinants of Health – what is old is new
Deficiency of light is a great obstacle to cleanliness, as it prevents dirt from being seen, and it must aid very much the contamination of the food with the cholera evacuations. Now the want of light, in some of the dwellings of the poor, in large towns, is one of the circumstances that has often been commented on as increasing the prevalence of cholera.
On the Mode of Communication of Cholera, 1855
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Social Determinants of Health – what is old is new
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“We would use the principles of community‐oriented primary care and population health to deliver services and, although we didn’t use the words at the time, address the social determinants of health…In the first years of the health centers, it wasn’t rocket science to figure out that medical care alone was insufficient.
Jack Geiger, MD, circa 1964
It’s about more than clinic and meds
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Beyond Health Care: the Role of Social Determinants in Promoting Health and Health Equity. 11/4/15 Kaiser Family Foundation.
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Community Health Center Network• Founded in 1994, Community
Health Center Network (CHCN) is a managed service organization supporting 130,000 Medi‐Cal members.
• CHCN contracts on behalf of eight health centers for professional risk, giving all members access to primary care at our health centers and specialty care services
• Services provided include:– Utilization Management
– Provider Relations
– Eligibility
– Claims
– Inpatient / Concurrent Review
– Special Projects
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Health Center Organizations
Care Neighborhood – Clinic‐Based Case Management for High Risk Members
Innovative case management program for high risk members.
CHWs integrated into the medical home team.
CHCN provides technical training and support and tools.
High risk members are connected to community resources around the social
determinants.
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Community
CHCN
Clinic Interdisciplinary
Team
Best Practice Tools / Analytics / Workflows
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• Diabetes• Hypertension• Amputations
• Limited income, on GA
• Depression
• Has trouble getting to and from appointments – high no rate • High crime neighborhood
• Needs to move
• Family steps in for food, but could use assistance
44 y/o MaleRisk Score: 14.8
PCP: 9IP: 6ER: 10
Member Since: 9/14Applied for SSI and Medi‐Cal
Refer to behavioral health servicesProvided additional counseling
Got on Section 8 waitlist
Got on Paratransit, provided Uber rides to appointments, using Alliance benefit
Care Coordination and Patient Education
Apply for CalFreshShared Action Plan
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Sample Care Neighborhood Patient
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Measure Pre Post
PHQ – 9 19 12
PAM 36 50
HbA1C 14 11.7
Appointments with Medical Home
12 24
‐4
‐2
0
2
4
6
8
Jan‐14 Feb‐14 Mar‐14
Apr‐14 May‐14
Jun‐14 Jul‐14 Aug‐14
Sep‐14Oct‐14 Nov‐14
Dec‐14 Jan‐15 Feb‐15 Mar‐15
Apr‐15 May‐15
Jun‐15 Jul‐15 Aug‐15
Sep‐15Oct‐15
LOS (IP Only)
Utilization Timeline
IP ER Enrolled in CN
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Care Neighborhood History
• Pacific Business Group on Health (PBGH) funded Intensive Outpatient Care Program (IOCP) program 2013
• Launched July 2014 at LifeLong East Oakland with LCSW staffing for model development
• First CHW at Axis Community Health in Pleasanton January 2016
• Now 12 community health workers in all 8 health centers
• Financially supported by our two health plans, Alameda Alliance for Health and Anthem Blue Cross.
9Confidential – Do not distribute
CHCN Support Services for Clinic‐Based Case Management
.
10
.
Inpatient Support
Technical Training and Support
Program Management
Data AnalyticsCase Management System
Network Meetings and Calls
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Community Health Worker• Embedded and part of clinic• From Local Community• Trained• Culture and Language Concordant• Former CN Enrollee
Care Neighborhood Workbook
• High Risk members List
• Action Lists• Metrics• Track Activity and
Impact
Care Plan Development• Interdisciplinary• Documented in CN
Workbook
SuperVisit• Member Relationship• Connecting to Eligible
Resources• Shared Action Plan• Standard Checklists and
Assessments
Connecting to Community Resources• POH – Medically tailored meals, Dietician• Food Bank – Access to food pantries
Network Collaborative
Member
CN WorkbookChecklists /
Tools
CHW
Clinic SW
Clinic RN
CN Interdisciplinary Team• SW ‐ Follow up for
Advanced Issues –Behavioral Health, Care Plan Development
• RN – Medication management, Education
Clinic Resources
Case Calls / Network Meetings / Ongoing
Trainings
Protocol for Follow Up
Connecting to Clinic Resources
• Medi‐Cal‐Renewal • CalFresh Support• Behavioral Health
Appointments• PCP Appointments
CHCN Support• Eligibility/Insurance• Prior Auth• IP Support• Discharge Planning• Acute Care Coordination• DME• Training• Data/Analytics
How Care Neighborhood Works
Member Advocacy / Peer Support Group
• Community Resource Sharing
• Mutual Aid
Confidential – Please do not distribute
Identifying Care Neighborhood Eligible Members
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Ideal Characteristics: Risk + Impactability
Inpatient Admission OR ACG Probability IP in 6 mos in top 8%
OR 2*CHF/2*CAD/8*COPD/4DM+2HTN claims in 15 months
AND
ACG Risk Score >2.0 OR Chronic Conditions >= 4
Exclusions: ESRD, ESLD, cancer, hospice
Exclude: Existing case management, Violence
Evaluate for impactability and fit for intervention: Active Substance Use, “End stage of disease,” SMI, dementia, homelessness
Look for: Not connected to PCP, social determinant issues
Predictive Risk Data Model Clinic Care Team Reviewand Referral
Eligible Members
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Heart of the Model ‐ Community Health Workers who build trusting relationships
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Nick TomLifeLong East Oakland
June 2016
Melinda LyallLifeLong AshbyOctober 2016
Yvonne FungAxis Community Health
January 2016
Queenie NgAsian Health Services
July 2016
Kelsey EntrekinLifeLong West Berkeley
October 2016
Ana MirandaNative American Health Center
December 2016
Shanay ConawayWest Oakland Health Council
December 2016
Betty SanchezTiburcio Vasquez – Union City
January 2017
Jing MaiLifeLong‐Downtown Oakland
April 2017
Olivia PalaciosTiburcio Vasquez
March 2017
Cecelia SchonholtzTri‐City
April 2017
CHW Workforce Development and Support
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Assigned Social Work Lead at
CHCN
Interdisciplinary Team Support
at the
clinic
Training /
Weekly Case Meetings
Empowering CHWs with tools and data to support workflow
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Person‐Centered Approach
Person‐Centered Approach
Motivational Interviewing
Trauma Informed Care
Cultural Humility
Comprehensive Biopsychosocial assessment
Harm Reduction
Care Plan and Shared Action
Plan
Root Cause and Social Justice Framing
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Longitudinal CHW training is key
• Weekly meetings• Case Review• Mutual support and self care• Training topics:
– Medical topics • COPD• DM• CKD• CHF
– Motivational interviewing– Community Resources– Trauma‐informed care
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Partnering with Welkin Health to develop case management platform for CHWs
Case Management
System
IP/ER Claims
NextGen Appointment / Demographics
Eligible Patient Lists Tailored to
Clinic
Real Time Inpatient
Authorizations and RN Notes
CHW Notes and Assessments
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CHCN developed a prototype case management
to drive CHW workflow
CHCN received “Technology for Healthy Community” grant to create case
management platform with Welkin Health
IMPACT
‐ Provider, LifeLong Medical Care
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Control = 80 propensity score matched membersN = 41 members enrolled in Care Neighborhood at least 7 monthsPre = 1‐180 days before enrollment; Post = 31‐210 days after enrollment
‐ Care Neighborhood Member
“Having more staff besides medical providers serving our members has been helpful. We appreciate support from others. Members appreciate the attention they receive.”
“My experience with Care Neighborhood has been very impressive. My case manager empowered me to take on a more active role in my rehabilitation. She allowed me to realize the importance of taking charge of my own health, while at the same time, offering guidance in avenues where I may need
some extra support.”
ControlCare
Neighborhood
Change from expected utilization without
treatment
Inpatient Admission
+2% ‐41% 43% less utilization
ER visits ‐20% ‐41% 21% fewer ER visits
SpecialtyVisits
‐17% +11% 28% more specialty visits
PCP appts. ‐34% ‐2% 32% more PCP visits
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Lessons Learned
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Focus human relationships.
CHW integrated into pr
Co‐Creation /
Continuous Improvement
Health Plan / Provider
Collaboration Key
Standard Tools / Workflows Key
to Spread
Questions
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Intensive Outpatient Case Management in the
Safety NetJim Austin, RN MSN NP
The desired outcome
• Robert Wood Johnson Foundation
• “People actively involved in their health and health care tend to have better outcomes‐and some evidence suggests, lower costs.”
• Health Policy Brief, 02/14/2013
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Culture of Quality
• “Triple Aim” Institute for Healthcare Improvement
• Focus on improvement from an integrated system:
– Improve individual experience
– Improve health of your defined population
– Control random inflation of Per Capita Costs
Case Management
• Implies management of organizational resources to support the patients needs.
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How can we help?
• The complexity of today’s health care is daunting to those who are perplexed by hurdles, blockades and speed bumps. Hence the assistance of the skilled case manager to help navigate, negotiate and help train for future challenges.
• The impact of social determinants will remain as long as the challenge of change is not met.
“I never thought….”
• One case I will always remember! Seeing two young ones during the cold and flu season. Mom seems distracted and distant. Of course I ask ‘Are you Ok? Is there something I can do for you?’.
• “I never thought I would ever be in a county clinic. My husband left me and the children after clearing out our bank accounts.”
• Let me help you with our resources. The journey began!