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 Inclusion Triage 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 compliment services 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 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 1 st 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 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  6 admits and 3 ED visits within last 12 months, hospital visit every 41 days  No referral, directly outreached by 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, RN Manager, Care Transitions X2017 Kelly Craig, MSW, LSW Director, Care Management Initiatives x2004