Cmmi oct final

Camden Coalition of

Healthcare Providers

Clinical Care Coordination & Delivery

Community Outreach for Complex Patients:

Basics of Care Management in the Field

Camden Coalition of

Healthcare Providers

www.camdenhealth.org

Overview

• Problem & Goals

• Tenets of Good Care

• Patient Variation & Team Composition

• Workflows & Enrollment

• Patient Engagement

• Case Study

• Key Intervention: Medication Reconciliation

• Q & A


Problem


Charley

Hospital

#1

Sub-Acute Rehab

Hospital

#2

Home

Nursing

Home

PT/OT

Durable Goods

Meals

Transport

Dialysis

Nephrology

Transplant

PCP

UrologyOncology

Surgery

GI

Cardiology

Eye

Pain

MgtPulm.

Goals

• Stabilize

• Coordinate

• Improve Health

• Reduce Cost


Tenets of Good Care

• It takes a team

• Enroll based on specific triage data r/t preventable readmissions

• Engage patient at hospital

• Build/maintain rapport with patients/families

• Assess medical/social complexity

• Provide immediate post d/c(<72 hours) inperson intake

assessment

• Accompany to PCP < 7 days post d/c

• Build the relationship between patient/family and PCP/specialists

• Individualized care plan with specific graduation timeline

• Collect information at each step to evaluate/improve program

• Helping patients help themselves to find long-term sustainable

resources


Variations of Patient Complexity


So

cia

l Co

mp

lexity

• 42 y.o. male

• Hx Asthma Exacerbation

• Homeless

• Mental health illness

• No social support

• Crack cocaine addiction

Medical Complexity

• 67 y.o. female

• Hx CHF, HTN, COPD

• Depression, anxiety

• 17 meds daily

• Work history

• D/C to LTAC

• Daughter is primary caregiver

• 23 y.o. male

• Hx of Type 1 Diabetes

• Lives with grandmother

• Works as day laborer

• Learning disability

High

Higher

Higher


So

cia

l Co

mp

lexity

Medical ComplexityHigh

Higher

Higher

Staffing pairs to meet complexity

SW/HC

LPN/HC RN/LPN

RN/SW

SW

CW

Staff Composition

RN LPN

LPN

CHW

HC

HC

Pr. Dir.


Care Management Workflow


•Admissions data

•Current day

•Access to patient chart

Data•Assessment

•AssignmentTriage

•Blend of medical & social complexity

Outreach

•Completion of care plan

•Transition to PCP

Graduation

Admitted past month, 6 month summary Days 6 mo episodes Admit Facility Inp ED Name dob age sex PCP PracticeName Insurance

06/13/12 Cooper 40 7 3 xxxxxxxxxxxxxx xx/xx/xxxx 55 M JACK GOLDSTEIN CMC Dept of Cooper 44 3 2 xx/xx/xxxx 73 F MARILYN GORDON CAMcare Health Cooper 79 3 xx/xx/xxxx 57 M JOHN KIRBY Cooper Physician HORIZON NJ PPO Cooper 35 2 3 xx/xx/xxxx 21 M NO PHYSICIAN OLOL 1 2 1 xx/xx/xxxx 56 M SELF PAY - Cooper 5 2 1 xx/xx/xxxx 61 M OLOL 4 2 1 xx/xx/xxxx 54 M SELF PAY Cooper 27 2 xx/xx/xxxx 47 M MARILYN GORDON CAMcare Health

06/12/12 Cooper 15 13 1 xx/xx/xxxx 22 F MIGUEL MARTINEZ Cooper Physician Cooper 18 3 2 xx/xx/xxxx 55 M NO PHYSICIAN AMERHLTH/KEYST Cooper 99 3 1 xx/xx/xxxx 64 M DANIEL HYMAN Cooper Physician

06/11/12 Cooper 9 9 5 xx/xx/xxxx 48 M LYNDA BASCELLI Project Hope OLOL 43 9 1 xx/xx/xxxx 71 F INTERNAL BILLING OLOL 17 5 5 xx/xx/xxxx 66 F HORIZON NJ Cooper 27 5 3 xx/xx/xxxx 52 M LYNDA BASCELLI Project Hope OLOL 35 5 1 xx/xx/xxxx 70 F BRAVO HEALTH OLOL 46 4 5 - xx/xx/xxxx 73 F HORIZON NJ OLOL 31 3 2 xx/xx/xxxx 52 F SELF PAY Cooper 2 3 1 xx/xx/xxxx 68 F MINH HUYNH OLOL 1 3 1 xx/xx/xxxx 73 F HORIZON NJ Cooper 34 3 xx/xx/xxxx 62 F ANNA HEADLY Cooper Physician Cooper 131 2 10 xx/xx/xxxx 35 M NO PHYSICIAN OLOL 54 2 6 xx/xx/xxxx 49 F SELF PAY - OLOL 177 2 4 xx/xx/xxxx 91 F HORIZON NJ Cooper 3 2 2 xx/xx/xxxx 51 M NO PHYSICIAN MEDICAID OLOL 139 2 2 xx/xx/xxxx 87 F HORIZON NJ

Thursday, June 14, 2012 Page 1 of 8

Enrollment Data


Patient Engagement


Patient Level Timeline:Clinical Phase (0-30 days)

Start

(d/c date)

Week 1 Week 2 Week 3 Week 4

HomeVisit #1

(24-48 hrs)

HomeVisit #2

PCP Visit(w/in

7 days)

RN, SW, LPN

LPN, SW RN

Specialty Visits(w/in 14 days)

HomeVisit #3

LPN, SW

HomeVisit #4

LPN, CHW


Patient Level Timeline:Social Phase (30-60 days)

Week 4 Week 5 Week 6 Week 7 Week 8

HomeVisit #5

HomeVisit #6

HomeVisit #7

HomeVisit #8

CHW, HC• Chronic disease self mgt. skills• Health care navigation skills• Care plan development• Coaching

Case Study “Charley”

• 55-year-old African-American male

• At time of enrollment, admitted for GI bleed and SOB (November 2011)

• Medicare/Medicaid coverage

• Lives alone in high-rise apartment

• 12 medications daily

6 months prior to enrollment• 9 ED visits & 6 inpatient stays

• Hospitalized on average every 45 days

Complex chronic conditions• ESRD

• Renal Carcinoma• Hepatitis B

• Hypertension

• Hyperlipidemia

• Peripheral vascular disease

• Asthma• Glaucoma (blind in one

eye)

• Sleep apnea

• Severe back pain

Key Intervention:Home-Based Medication Reconciliation



Q & A

THANK YOU!

Cmmi oct final

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