outreach to high utilizing patients — basics of care management and care transitions in camden, nj...
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Outreach to High Utilizing Patients — Basics of Care Management and Care Transitions in Camden, NJ
Camden Coalition of Healthcare Providers
Mission Role Values Coalition Structure and Workflow Care Management Team Care Transitions Team Q & A
Overview
The Camden Coalition of Healthcare Providers was created with the
overarching mission to improve the health status of all Camden residents,
by increasing the capacity, quality, and access of care in the city
Our Mission
Unlike many service and social organizations in the city, the Coalition
does not provide long-term services to patients, but rather focuses on creating solutions from the providers and health
systems side of care.
The Coalition’s Role
Facilitating discussion and strategy design Collaboration among stakeholders Creating fluid systems of communication Data-driven initiatives Utilizing data to evaluate projects Sustaining programs for long-term positive
outcomes
Organizational Values
CCHP Outreach
Hospital Admissions Data
• Nurse driven care transition• Patients with history of ED
visits/hospital admissions and readmissions (2+ admits w/in 6 mos.); socially stable
• Average 6-8 week engagement
• Multidisciplinary care management outreach
• Patients with history of ED visits/hospital admissions and readmissions (4 admits w/in 6 mos.); social complexities
• Average 6-8 month engagement
Intermediate Risk
High Risk Care Coordination
Data driven QI
Patient Engagement
Medical Home
Health Coaching
InclusionTriage
Care Continuum Model
Reduce the risk of preventable readmissions to the hospital
No open referrals: patients flagged from Health Information Exchange by Care Transitions Team
No duplicate services: we complimentservices of existing providers
Care Transitions & Care Management Team Program Goals
Care Management: High Risk
Hospital utilization in the city Appropriate vs. inappropriate
Two or more chronic health conditions Low socio-economic status Homeless or unstable housing Lack of social supports Low-literacy, lack of HS diploma Behavioral health issues Generational poverty/urban violence
Care Management Team
Purpose Improve the health of the patients Teach patients to seek services from appropriate locations,
especially their Primary Care Providers, rather than the ED Reduce healthcare costs
Services Offered Assess the individual’s needs Provides immediate healthcare/social services when needed Refers patients to their PCP and appropriate agencies for
additional services Outreach to homes, shelters, hospitals and even the streets to
provide services
The Role of the Social Worker
Coordinates case management of the patient’s care including: Short-term needs: temporary housing, food Determining insurance eligibility or level of coverage and helps
with enrollment Helps the patient access social/health services such as:
Enrollment in a medical day program, applying for nursing home care, and accessing specialty care
Assists in applying for Supplemental Security Income, Disability or other entitlements as needed
The Role of the RN
Monitoring chronic conditions Oversight of medications/prescribing Communicating with other providers regarding the
patient’s care Patients typically have multiple social barriers to
accessing traditional healthcare-the nurse encourages and transitions these clients into traditional primary care
The Role of the Medical Assistant & Health Coaches
A bilingual outreach worker Works directly with the social worker and nurse in helping
patients access appropriate health/social services Helps patients make appointments/coordinate medical
transportation and can accompany patients to appointments, as necessary
Two full-time volunteers working with the Care Management Team assisting with approximately 10-12 patients at a time Reinforce positive behavior changes Conducts social visits to monitor patient progress and provide
additional support before “graduation.”
Intake/Engagement Process
Obtain consent Conduct medical and social history Immediately identify barriers/reasons for increased ED/hospital
visits Unstable housing/homeless No/changing phone # Lack of health insurance/benefits Substance use/mental health issues Transportation
Implement immediate plan with patient to address short-term goals, while building trust and rapport to address long-term goals
Different Patients – Different Care
Case Study 1: Care Management
Bedbound Neuropathy Obese Diabetes Jan 2010-Jan 2012
24 ED visits 23 inpatient visits
Barrier: transportation
Case Study: Care Management
37 year old Hispanic male History of schizoaffective disorder, bipolar, PTSD, history of
sexual abuse as child, unstable housing, medical day program
Type1DM X 19yrs, HTN, ESRD, congenital heart defect (PMVSD/ASD), history of coma w/DKA, endocarditis Cognitive impairment vs. mental health Recent admits to crisis X 2-suicide ideation w/ means,
hospital w/DKA, GI Bleed
Lessons Learned
Ethical considerations Working with patients too long Enabling vs. Helping patients help themselves Cultural Competence
Anecdotal Reasons for Success
Longitudinal relationship Build rapport/trust over time
Proactive, holistic model of care Where the person is/whatever it takes Respectful & non-judgmental care
Community relationships Community problem solving
90-day community-based intervention to stabilize complex patients Patients deemed “intermediate risk” generally have housing and
insurance coverage Patient determined at risk for hospital readmission through HIE Patient will receive bedside visit from RN/LPN while in hospital Home visit within 24hrs after d/c to include medication
reconciliation, health education, appointment scheduling etc. Care coordination with PCP & Specialist Accompany to 1st PCP follow-up appointment and specialists Weekly home/community visits with team
Care Transitions: Intermediate Risk
The Transitional Care Model: Mary D. Naylor, PHD, RN; University of Pennsylvania School Of Nursing
The Care Transitions Program: Eric Coleman, MD; Division of Health Care Policy and Research at the University of Colorado Denver, School of Medicine
Care Transitions: Evidence-Based Practices
Medical Home Team 1 Full-time RN Nurse Care Manager 1 Full-time LPN Nurse Care
Coordinator/Outreach Specialist (bilingual) Two “health coaches” – AmeriCorps Volunteers In cooperation with Camden’s Federally
Qualified Health Centers
Staffing
Outcome measures: Reduction in ER/hospital use Reduction in readmission rates Reduction in cost Participant satisfaction
Monitoring & Evaluation
Key Intervention: Home–based Medication Reconciliation
52 y/o female Spanish-speaking with COPD/Trach/Vent dependent, admitted for resp. distress.
8 readmits last year. Avg. admit every 29 days prior to intervention. No referral, directly outreached by team @ hospital. Coordinated meeting with patient/family with hospital social worker,
home care, and attending physicians at bedside. Transitioned at Long-term Acute Care in Philadelphia, while family
trained on vent and vent was placed at home. Transitioned home and f/u to PCP & Specialist appointments Currently at home and medically stable, will graduate May 2012
120 days without hospital utilization, scooter delivered to home!
Case Study:Care Transitions
Great Long-Term Solution for Limited Mobility: Red s]Scooter!
55y/o Male with ESRD/Dialysis, admitted for GI bleed and SOB November 2011.
6 admits and 3 ED visits within last 12 months, hospital visit every 41 days
No referral, directly outreached by team @ hospital Coordinated with patient and renal social worker to transition at
sub-acute facility for rehab Transitioned home and accompanied to PCP & Specialists Currently at home and medically stable, will graduate May 2012
120 days without hospital utilization
Case Study: Care Transitions
Q & A
Thank you!
Jason Turi, MPH, RNManager, Care [email protected] X2017
Kelly Craig, MSW, LSWDirector, Care Management [email protected] x2004