Outreach to High Utilizing Patients — Basics of Care Management and Care Transitions in Camden, NJ Camden Coalition of Healthcare Providers.

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