In-Reach Hospital Program In-Reach Hospital Program Coordinating Multiple Service Providers Rare Presentation Partnership between: South Central Human Relations Center Steele County Human Services South Country Health Alliance Owatonna Hospital-Allina Health SystemsNovember 5 th 2014

Objectives of the Program To encourage health care providers to coordinate their efforts to assure the most vulnerable patient populations seek and obtain primary care. To increase preventive services including screening and counseling, to those who would otherwise not receive such screening to improve health, reduce complications, and cost. To provide a mechanism for improving both quality and efficiency of care for vulnerable individuals with an emphasis on those most likely to remain uninsured or underinsured. To manage chronic conditions to reduce their severity, negative health outcomes, and expense.

Program Value Patient Access to the full spectrum of needed provider services through access assistance and advocacy for correct health care program enrollment resulting in optimal care. Providers Efficient patient encounters assisted by unique treatment plans easily accessed in Excellian and system care coordinator in attendance at clinic visits. Cost Savings

Process for Identifying and Engaging Patients List of patients is generated 5 more visits in in quarter (BOE Report) Phone Call, Letter, and note in chart to page social worker when they arrive List is reviewed with Medical Director of ED and Nurse Manager of ED Patient consents to system care coordination.

How is Health Care Coordination different from typical hospital social worker role? Health Care Coordinator Community Provider- connecting to resources Patient is not admitted to hospital. 60 days of interventions. Attends follow up health care appointments with patient. Hospital Social Worker Discharge Planning Patient is admitted to hospital or in ED Once patient is discharged Social Worker does not follow up.

Health Care Coordinator Tasks Functional Assessment Completed Goal Development Releases are Signed Screening Tools: PHQ-9, GAD-7, Physical Exam, Pre Questions Unique Treatment Plan Developed

Key Interventions Health care coaching; accessing health care at the correct location Health care coordinator; social worker housed at the hospital with other key medical staff versus human services or community mental health center Care plan development for emergency department staff for future emergency department visits Attending appointments with patients; ensuring they are talking with physician about symptoms, treatments, and concerns; modeling how to interact with their care providers

Key Interventions Health care coordinator walks with the patient through a variety of service delivery systems. Attention is given to simple barriers to health care that are generally not addressed in discharge plans. Educating patients on the language they may want to sue with their physicians

The Program Data

Managed Care Data 39 Patients Reviewed Emergency Department, Overall Primary Care Physician Cost $51,951 reduction in paid health care claims 22 Patients Prior ED Visits = 139 Post ED Visits = 91 Difference = -47 Hospitalizations: Prior – 17 Post –

Patient Satisfaction 1.Patient Survey upon closure of case. 2.Pre and Post Questions Survey

Contact Information Elizabeth Keck, MSW, LGSW