Outreach to High Utilizing Patients — Basics of Care Management and Care Transitions in Camden, NJ
Overview
Mission Role Values Coalition Structure and Workflow Care Management Team Care Transitions Team Q&A
Our Mission
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
The Coalition’s Role 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.
Organizational Values
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
Care Continuum Model •
Hospital Admissions Data
• •
Inclusion Triage
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
Medical Home
CCHP Outreach
Care Coordination
High Risk Health Coaching
Intermediate Risk
Data driven QI Patient Engagement
• • •
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
Care Transitions & Care Management Team Program Goals 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 compliment services of existing providers
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
Care Transitions: Intermediate Risk 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: Evidence-Based Practices 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
Staffing
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
Monitoring & Evaluation
Outcome measures: Reduction in ER/hospital use Reduction in readmission rates Reduction in cost Participant satisfaction
Key Intervention: Home–based Medication Reconciliation
Case Study: Care Transitions 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!
Great Long-Term Solution for Limited Mobility: Red s]Scooter!
Case Study: Care Transitions 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
Q&A
Thank you!
Jason Turi, MPH, RN Manager, Care Transitions
[email protected] 856-365-9510 X2017
Kelly Craig, MSW, LSW Director, Care Management Initiatives
[email protected] 856-365-9510 x2004
