Identification and Connecting with High Risk and Transitions of Care Patients March 2017.

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Presentation transcript:

Identification and Connecting with High Risk and Transitions of Care Patients March 2017

THUNDERMIST HEALTH CENTER A Federally Qualified Community Health Center established in 1969 with sites in three Rhode Island communities Woonsocket West Warwick South County

Identifying High Risk Patients

THUNDERMIST HIGH RISK ALGORITHM CTC Category #1 high cost/utilization CTC Category #2 poorly controlled complex patients CTC Category #3 payer defined and practice confirmed patient group Thundermist high risk defined

THUNDERMIST HIGH RISK ALGORITHM Thundermist High Risk Includes (not complete listing) Out of Control Diabetics 65 Years or Older Diagnosis Code sets Social Determinants of Health Homeless, 100% FPL or <,Uninsured

“IMPACTABLE” RISK ALGORITHM Description Points 3+ ED or IP Visits 3 ED or IP Visits for BH 2+ No Shows 2 Homeless Uninsured HbA1C > 9 1 Poorly Controlled Asthma Active Addiction Diagnosis 10+ Active Medications Incomplete Referrals > 6 Months BMI > 35 Active Smoker Total Possible Points 19 Recognizes cumulative impact of health, utilization, behavior, and social factors that we can measure and supports structured allocation of resources to maximize impact.

CONNECTING TO HIGH RISK PATIENTS August 12, 2013

NOTIFICATION AND ALERTS Enhanced Care Previsit Planning Report

NOTIFICATION AND ALERTS Enhanced Care Previsit Planning Report

NOTIFICATION AND ALERTS Enhanced Care Previsit Planning Report

NOTIFICATION AND ALERTS Enhanced Care Previsit Planning Report

ED NOTIFCIATIONS AND WORKFLOWS MA 1 ED Notice in 6 mo Document Management Merges MA ED/UC Template Assign Telephone encounter to PCP’s MA MA receives Telephone encounter and completes follow-up per site protocol RN 2 ED Notice in 6 mo Document Management Merges RN ED/UC Template Assign Telephone encounter to Team RN RN receives telephone encounter and completes follow-up per site protocol NCM 3 ED Notice in 6 mo Document Management Merges NCM ED/UC Template Assign Telephone encounter to PCP’s NCM NCM receives Telephone encounter and schedules Post hospital visit with NCM and PCP

INPATIENT NOTIFICATION AND WORKFLOWS NCM receives notification of admission Monitor for discharge Current Care Dashboard Telephone encounters - Discharge Summary Hospital Case Management (Varies by Hospital) Patient discharged Scheduling guidelines NCM schedules with PCP w/i 7-14 days of d/c Visit is in conjunction w/ NCM visit scheduled for 40 minutes prior to PCP visit Post Hosptial Visit Visit documentation Medication Reconciliation Contributing factors to utilization Coordination of home health/DME as needed

IDENTIFYING AND CONNECTING

HIGH RISK ALGORITHM Planning Z codes for Social determinants of health Additional high cost high risk diagnosis Liver Disease Fall Risk Others Pediatrics

CARE TRANSITIONS Current Care Care team workflows Hospital and ED notifications -content Care team workflows Evaluation of team roles Right patient, right role, right size Pharmacist for post hospitalization

HOW DO WE MEASURE? Outcome measures Access Improved medication adherence Improved patient engagement Reduction in admissions ??????