healthy lives: communitybased care - coordination for complex … › files › documents › 2018...
TRANSCRIPT
![Page 1: HEALTHY LIVES: CommunityBased Care - Coordination for Complex … › files › documents › 2018 › 09 › 12 › BCMHC - … · HEALTHY LIVES: CommunityBased Care - Coordination](https://reader036.vdocuments.net/reader036/viewer/2022081404/5f040e1a7e708231d40c1883/html5/thumbnails/1.jpg)
HEALTHY LIVES: Community-Based Care Coordination for Complex Patients
Photo: David Binder
H e n r y W h i t e , M D
H a n n a h S c o t t , P M H N P -B C
![Page 2: HEALTHY LIVES: CommunityBased Care - Coordination for Complex … › files › documents › 2018 › 09 › 12 › BCMHC - … · HEALTHY LIVES: CommunityBased Care - Coordination](https://reader036.vdocuments.net/reader036/viewer/2022081404/5f040e1a7e708231d40c1883/html5/thumbnails/2.jpg)
SOCIAL DETERMINANTS
OF HEALTH MEDICAL
BEHAVIORAL HEALTH
The CHALLENGE
*
The patient population lies at the intersection of those with high medical needs, complicated behavioral health needs, and multiple needs related to the social determinants of health.
![Page 3: HEALTHY LIVES: CommunityBased Care - Coordination for Complex … › files › documents › 2018 › 09 › 12 › BCMHC - … · HEALTHY LIVES: CommunityBased Care - Coordination](https://reader036.vdocuments.net/reader036/viewer/2022081404/5f040e1a7e708231d40c1883/html5/thumbnails/3.jpg)
SOCIAL DETERMINANTS
OF HEALTH MEDICAL
BEHAVIORAL HEALTH
The SYSTEM
*
Most care for complex patients is delivered in segregated systems. Providers in each system work in isolated settings without inter-disciplinary communication or integrated care planning.
![Page 4: HEALTHY LIVES: CommunityBased Care - Coordination for Complex … › files › documents › 2018 › 09 › 12 › BCMHC - … · HEALTHY LIVES: CommunityBased Care - Coordination](https://reader036.vdocuments.net/reader036/viewer/2022081404/5f040e1a7e708231d40c1883/html5/thumbnails/4.jpg)
Healthy Lives
Community Mental Health Center Based
Community Based w/Hospital Integration
Community Health Center Integration 2010
2012
2014
2017
ACO Co-location
(TCCI)
• Started in response to patient needs • Provides integrated, community based care • Tested in varying healthcare settings
![Page 5: HEALTHY LIVES: CommunityBased Care - Coordination for Complex … › files › documents › 2018 › 09 › 12 › BCMHC - … · HEALTHY LIVES: CommunityBased Care - Coordination](https://reader036.vdocuments.net/reader036/viewer/2022081404/5f040e1a7e708231d40c1883/html5/thumbnails/5.jpg)
The TEAM • Managed by a Nurse Care Manager or LICSW • Consists of Bachelor’s Level Community Health Workers • Share proficiency in medical, mental health, and social
service expertise
![Page 6: HEALTHY LIVES: CommunityBased Care - Coordination for Complex … › files › documents › 2018 › 09 › 12 › BCMHC - … · HEALTHY LIVES: CommunityBased Care - Coordination](https://reader036.vdocuments.net/reader036/viewer/2022081404/5f040e1a7e708231d40c1883/html5/thumbnails/6.jpg)
The APPROACH • Begin with patients in their home environments • Goal: build a comprehensive understanding of the patient’s
environment including family, friends, agencies, and providers
patient
@ HOME
FAMILY
HEALTHCARE
COMMUNITY
![Page 7: HEALTHY LIVES: CommunityBased Care - Coordination for Complex … › files › documents › 2018 › 09 › 12 › BCMHC - … · HEALTHY LIVES: CommunityBased Care - Coordination](https://reader036.vdocuments.net/reader036/viewer/2022081404/5f040e1a7e708231d40c1883/html5/thumbnails/7.jpg)
The INTERVENTION
• Form a team around the patient for long-term support
• Address all domains of health
• Connect providers and supports
• Create an integrated, shared understanding of the patient for all team members
patient patient
Utilization
Access Basic Needs
Activation
Functioning
![Page 8: HEALTHY LIVES: CommunityBased Care - Coordination for Complex … › files › documents › 2018 › 09 › 12 › BCMHC - … · HEALTHY LIVES: CommunityBased Care - Coordination](https://reader036.vdocuments.net/reader036/viewer/2022081404/5f040e1a7e708231d40c1883/html5/thumbnails/8.jpg)
The EXPERIENCE
patient
“SUSAN”
• Low fixed income • In danger of eviction • Isolated/No social supports
• Diabetes • Obesity • Congestive Heart Failure • Heavy Smoker
• Bipolar 1 Disorder • Distrustful • Poor executive functioning
SOCIAL DETERMINANTS
OF HEALTH
MEDICAL
BEHAVIORAL HEALTH
![Page 9: HEALTHY LIVES: CommunityBased Care - Coordination for Complex … › files › documents › 2018 › 09 › 12 › BCMHC - … · HEALTHY LIVES: CommunityBased Care - Coordination](https://reader036.vdocuments.net/reader036/viewer/2022081404/5f040e1a7e708231d40c1883/html5/thumbnails/9.jpg)
The EXPERIENCE
patient
SOCIAL DETERMINANTS
OF HEALTH
MEDICAL
BEHAVIORAL HEALTH
INTERVENTIONS
• Consolidate debts • Collaborate with housing • Connect to service providers
• Meal Planning & Delivery • Daily Weights • Appointment Attendance • Smoking Cessation
• Integration of Care Team • Focus on Relationship Building • Concrete Assistance w/Tasks
![Page 10: HEALTHY LIVES: CommunityBased Care - Coordination for Complex … › files › documents › 2018 › 09 › 12 › BCMHC - … · HEALTHY LIVES: CommunityBased Care - Coordination](https://reader036.vdocuments.net/reader036/viewer/2022081404/5f040e1a7e708231d40c1883/html5/thumbnails/10.jpg)
Inpatient Utilization (per patient/year)
Health Outcomes
68% of patients showed improvement
in relevant outcome selected at enrollment
e.g A1c, BP, BMI, pain
Homelessness
18% of patients reported homelessness or housing instability at engagement
2% reported after 9
months of enrollment
*Data annualized and based on 12 months pre-enrollment and
annualization of 9 months post-enrollment for all measures; n=41
2.5 1.6
before after
3.8 2.5
before after
9 Month Interim Outcomes ED Utilization (per patient/year)
30-Day Readmissions (per patient/year)
0.37
before after
0.88
![Page 11: HEALTHY LIVES: CommunityBased Care - Coordination for Complex … › files › documents › 2018 › 09 › 12 › BCMHC - … · HEALTHY LIVES: CommunityBased Care - Coordination](https://reader036.vdocuments.net/reader036/viewer/2022081404/5f040e1a7e708231d40c1883/html5/thumbnails/11.jpg)
The CONTEXT A hierarchy of care coordination/care management services has been developed by healthcare systems.
“USUAL CARE”
+ RESOURCE SPECIALIST SUPPORT
+ CARE MANAGEMENT
* 1:1000
1:300
1:25
HEALTHY LIVES
![Page 12: HEALTHY LIVES: CommunityBased Care - Coordination for Complex … › files › documents › 2018 › 09 › 12 › BCMHC - … · HEALTHY LIVES: CommunityBased Care - Coordination](https://reader036.vdocuments.net/reader036/viewer/2022081404/5f040e1a7e708231d40c1883/html5/thumbnails/12.jpg)
NEXT STEPS
Community Mental Health Center Based
Community Based w/Hospital Integration
Community Health Center Integration 2010
2012
2014
2017
ACO Co-location
(TCCI) ACO Consultation
(SHIFT-Care)
2018
![Page 13: HEALTHY LIVES: CommunityBased Care - Coordination for Complex … › files › documents › 2018 › 09 › 12 › BCMHC - … · HEALTHY LIVES: CommunityBased Care - Coordination](https://reader036.vdocuments.net/reader036/viewer/2022081404/5f040e1a7e708231d40c1883/html5/thumbnails/13.jpg)
SOCIAL DETERMINANTS
OF HEALTH MEDICAL
BEHAVIORAL HEALTH
In CONCLUSION By creating a shared, integrated understanding of the patient and assembling a long-term care team for a patient’s comprehensive needs, health care costs are significantly decreased and patient health outcomes are improved.
patient
![Page 14: HEALTHY LIVES: CommunityBased Care - Coordination for Complex … › files › documents › 2018 › 09 › 12 › BCMHC - … · HEALTHY LIVES: CommunityBased Care - Coordination](https://reader036.vdocuments.net/reader036/viewer/2022081404/5f040e1a7e708231d40c1883/html5/thumbnails/14.jpg)
POLICY IMPLICATIONS • Recognition of the impact of complex, multidimensional
systems on health
• Targeting high-cost, high-need patients with flexible, intensive, community-based interventions
• Provide integrated training opportunities for healthcare professionals
• Necessity of integrated electronic health records and information exchange between providers
![Page 15: HEALTHY LIVES: CommunityBased Care - Coordination for Complex … › files › documents › 2018 › 09 › 12 › BCMHC - … · HEALTHY LIVES: CommunityBased Care - Coordination](https://reader036.vdocuments.net/reader036/viewer/2022081404/5f040e1a7e708231d40c1883/html5/thumbnails/15.jpg)
c o n t a c t u s H e n r y W h i t e , M D
C l i n i c a l D i r e c t o r
h e n r y w h i t e @ b r o o k l i n e c e n t e r . o r g
H a n n a h S c o t t , P M H N P - B C
D i r e c t o r o f C a r e S t r a t e g y & N e w B u s i n e s s D e v e l o p m e n t
h a n n a h s c o t t @ b r o o k l i n e c e n t e r . o r g