Coordinating Care with People with Multiple Health and Social Needs Catherine Craig, MSW, MPA September 12, 2011 The presenter has nothing to disclose.

The Reality Note: Figures in parentheses are expenses per person. Source: Conwell LJ, Cohen JW. Characteristics of people with high medical expenses in the U.S. civilian noninstitutionalized population, 2002. Statistical Brief #73. March 2005. Agency for Healthcare Research and Quality, Rockville, MD. Web site: http://www.meps.ahrq.gov/mepsweb/data_files/publications/st73/stat73.pdf.

Highest Cost Conditions How many of our patients have more than 1 chronic condition? A behavioral health condition? Social needs? Source: Olin GL, Rhoades JA. The five most costly medical conditions, 1997 and 2002: estimates for the U.S. civilian noninstitutionalized population. Statistical Brief #80. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st80/stat80.pdf.

The Triple AimTM

Virtual Ward Croydon Primary Care Trust Coordinating Complex Care Began in May 2006 Predictive model to identify highest-risk patients Use systems, staffing of inpatient ward to deliver home-based care Goal: Discharge patients to general practitioner in community Coordinating Complex Care Team is responsible for holistic care Communication is Key! Emphasis on transferring information between multidisciplinary providers, GP, and patient Daily staff meetings to coordinate & calibrate care to meet current needs Build relationships with community resources

Care Coordination Model

Hospital Provider to patient: “Go home, take care of yourself, get lots of sleep, take your medications, make sure to stay dry GO SEE YOUR DOCTOR and come back and see me in a couple weeks…” Patient to discharge planner: “I don’t have a home, I’d love to take care of myself, but I can’t sleep all night went where I camp, my medications were just stolen, my sleeping bag is soaked and lost I DON’T HAVE A DOCTOR and I don’t have a phone or a way to get back up to the hospital…” Created by Nic Granum, Central City Concern Recuperative Care Program, 2010.

COMMUNITY& PROGRAM INTEGRATOR & ORIENTATION MEDICAL HOME HOUSING PROGRAM FUNDING CCC’s Recuperative Care Program Portland OR Integrated Team: Lead case mgr = SW/EMT, plus MD, housing, logistics & FT volunteer * SW or EMT Old Town Clinic FQHC ~30-day respite w/connection to Permanent Supportive Housing (PSH) Local Hospitals, CareOregon & City of Portland Housing Bureau Pathways to Housing Philadelphia PA Multi-disciplinary Assertive Community Treatment (ACT) * RN On-site physician from TJU Permanent Supportive Housing ACT: Medicaid MD: Grant BronxWorks Homeless Outreach Team Bronx NY Hospital Homeless Coordinator * LMSW Locating FQHCs in community Transitional & PSH Local Department of Homeless Services Hospital to Home New York NY Community-Based Care Manager * Community health worker or BSW Integrated care team Link to transitional & PSH New York State Department of Health grant * Denotes background of person in the Integrator role: identifying goals and coordinating care

Macro-Integration Local, State & Federal Government Agencies Housing Health Mental Substance Health Abuse Local, State & Federal Government Agencies

Integration2 Local State & Federal Government Agencies Informs Housing Health Mental Substance Health Abuse Local State & Federal Government Agencies Informs Supports

Making the Business Case Hospitalizations Fragmentation of care Total spend Health Experience of care Challenge: Cost savings vs. cost avoidance

ROI Data Points What is the per member per month (PMPM) cost of the intervention? e.g. an RNP with a FTE caseload of 40 = $300 PMPM additional cost. What are the key utilization and cost metrics that are expected to change with the intervention?  ED visits/K/Yr.  ED PMPM expenses  Hospital Admits/K  Hospital Days/K  Hospital PMPM expenses  Pharmacy PMPM expenses  BH PMPM expenses What is the change in total PMPM expenditures for the target population from a predetermined baseline? A+ROI occurs when the “sustained” cost of the intervention is more than offset by reductions in total PMPM expenditures due to “expected utilization changes”. eg © 2010 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information

Why partner? Decreasing Medicaid reimbursement rates It’s “the right thing” to do Focus on preventive care Efficient consumption of services Alleviates the burden on Emergency Departments Redistributes consumption of services: Primary and specialty care Mental Health Chemical Dependency Health Home, Accountable Care Organization incentives Community partners can help you manage some of the most challenging patients Hospitals are an entrance point and potential point of intervention for the homeless population Need to have a mechanism for knowing when they enter the system “Captive audience” Potential for treating physical, behavioral, and substance use needs in one location Poor discharge planning often leads to re-admissions Coordinating with community partners can reduce this Reduces fragmentation of care

http://100khomes.org/resources/downloadable-documents-and-tools

Action Items Identify: - 5 people with complex needs to target for care coordination services this month - Track what you learn, intervene with a PDSA - Who coordinates care? - How do you fund coordination services? - At least 2 community partners Define: - 3 impact measures to track progress - Health - Cost - Experience of care