Community Care Teams Carl Schiessl, Director, Regulatory Advocacy Connecticut Hospital Association Eileen Kardos, LMSW, High Risk Navigator Western Connecticut Health Network

Scope of the Problem + + Fragmented system Limited definition of health Homelessness, lack of substance abuse treatment, other social stressors Poor coordination of services Disconnect between the hospital and outpatient care Social determinants impact the health and well being of patients and how frequently they come to the hospital Overuse of acute services Worsening medical conditions + +

Consequences Poor Outcomes Wasted Resources Unsustainable Finances Overworked Providers

Frequent Visitors In 2013, in the United States, 1 of every 8 ED visits was related to a mental health or substance use disorder Connecticut emergency departments treated more than 8,400 patients at least 7 times in 6 months, totaling approximately 58,000 visits

Who are the Frequent Visitors? Seven or more visits in a six-month period Disproportionate rates of mental health and/or substance misuse diagnoses Medicaid or no insurance Homeless or housing unstable Alcohol misuse diagnosis Seeking controlled substances or pain management Chronic disease or other complex medical conditions

One Solution: Community Care Teams A Community Care Team (CCT) is a team of local medical, behavioral health, and social service providers utilizing a wraparound approach to provide patient-centered care, requiring multi-agency partnership and care planning, and the use of traditional and non-traditional supports and services.

CCT Structure and Function Broad coalition of service providers Meet regularly to review patient outcomes Identify frequent visitors to EDs Obtain a Release of Information form (ROI) Develop an Intensive Case Management (ICM) plan for each patient Connect the patient to services

Potential Benefits Improve patient health Reduce overcrowding in EDs Relieve pressure on community providers Save millions of dollars by reducing ED visits Demonstrate regional cooperation

CCT Challenges Recruit and maintain essential community providers Obtain support from senior management of all community providers, and local and state agencies Dedicate sufficient personnel and resources to manage CCTs Obtain and manage patient information in accordance with privacy laws

Characteristics of the NH CCT Population Current Census is 195 Patients 36% female; 64% Male 50% White; 30 % Black; 20% Hispanic or Other 20% Homeless; (85%+ have had unstable housing or been homeless at one time) 60% have substance misuse dx; 37% alcohol misuse dx 55% have a mental health DX 65% have at least one chronic disease dx in the chart 25%+ have no PCP; 73% have no behavioral health provider 95% are Medicaid, Medicare or self-pay

Who are the Greater Norwalk CCT Stakeholders? Americares Open Door Shelter Mid Fairfield Child Guidance NCHC Norwalk Hospital Connecticut Counseling Family and Children’s Agency Gillespie Center Day Street Clinic Norwalk Police Department Connecticut Renaissance Homes with Hope Liberation Programs Connecticut Counseling Norwalk Probation DuBois Center Person to Person

High-Risk Navigators—Scope of Practice Execute plans developed in CCT meetings Liaisons between the hospital, the community and the patient Follow patients and partner with other agencies as patients engage in systems and services outside of the hospital Follow Patients and communicate with appropriate hospital staff about community work when patients are in the ED or admitted to the floor Connect Patients to Medical care/Behavioral Health Supports in the outpatient setting Connect patients to supports and resources surrounding the social determinants of health Work to remove barriers to patients accessing referrals Follow-up accordingly Data Collection and Analysis Represent the hospital in the community Build Community Relationships

CCT Client Case Example: ST Before CCT -Homeless/living in the park -Undocumented -Not connected to primary care -No case mgmt services -Never engaged in substance abuse tx - Ed visits one year prior to being housed(FY15=75) After CCT -Housed in own apt > 1 yr -Documented -Connected to NCHC/medical/therapy -Has housing case mgmt -Has a recovery assistant -Completed detox - Visits Reduced (FY16=50; FY 17=5)

CCT Outcomes

CCT Outcomes Average Visits Per Patient 3.1.15-8.31.15 N=121   3.1.15-8.31.15 N=121 9.1.15-2.28.16 N=141 3.1.16-8.31.16 N=166 9.1.16-2.28.17 N=174 3.1.17-8.31.17 N=196 Average ED visit per patient (Total Number Of Visits/N) 3.76 2.46 3.09 2.30 1.80 Average number of inpatient days per patient (Total Number Of Days/N) 2.88 1.53 1.95 1.71 1.64 Change Two and a Half Years -39.6% -41.7% Average Inpatient Days -52.0% Average ED Visit -43.0% Average Inpatient days

CCT Outcomes—Data Pulls Hospital Usage Analysis CCT Data Pull 3.1.17- 8.31.17: N=174 patients (Same Cohort of People for a Year in the Program) *297 includes 21 days of observation visits **226 includes one day of observation visits Hospital Usage Analysis CCT Data Pull 3.1.16-2.28.17: N=164 patients (Same Cohort of People for a Year in the Program) *223 includes 13 days of observation visits    ED Visits  Inpatient Days  Average ED Visit per PT  Average #inpatient days per PT 9.1.16-2.28.17 400 297* 2.29 1.71  3.1.17- 8.31.17 284 226** 1.63 1.30  Change -29% -24%    ED Visits  Inpatient Days  Average ED Visit per PT  Average #inpatient days per PT  3.1.16-8.31.16  510 316   3.12 1.92  9.1.16- 2.28.17  289 223* 1.76   1.36  Change  -43.3% -29.4%   -43.6%  -29.2%

Carl Schiessl, CHA Schiessl@chime.org 203-294-7341 Eileen Kardos, WCHN Eileen.Kardos@wchn.org 203-855-3722