1. Group Visits for Superutilizers: Focusing on Well-being Rather than Disease Jenny Kuo D.O. Devida S. Crawford, MSW Toni Crespo, Program Coordinator Leanne Chrisman-Khawam, MD, MEd Partially sponsored by the MEDTAPP Healthcare Access Initiative

2. Healthcare Access Initiative The HCA Initiative was designed to align with established, successful programs and leverage existing resources to attract, train and retain healthcare practitioners to serve Medicaid beneficiaries in the following areas: Child and Adolescent Psychiatry, Community Psychiatry with a Geriatric and/or Integrated Behavioral Health/ Primary Care Focus, Pediatrics, Family Practice, Advanced Practice Nursing, and Dentistry.

3. A Patient’s Story Deirdre

4. DG971

9. General Data Points Number of hospitalizations Number of emergency room visits Number of no show visits without prior cancellation

10. Extra Care Group Clinics COPD 8 patients ED visits decreased by 88% Hospitalization decreased by 85% No show rate decreased by 81% Diabetes 10 patients ED visits decreased by 80% Hospitalization decreased by 78% No show rate decreased by 77%

11. Extra Care Group Clinics Chronic Pain 7 patients ED visits decreased by 75% Hospitalization decreased by 100% No show rate decreased by 72%

12. Measurement Tools Intake Form (IPC) Patient Self-intake form Stanford: Self-Efficacy for Managing Chronic Disease 6-Item Scale Patient Health Questionnaire (PHQ-9) Generalized Anxiety Disorder (GAD-7)

13. Shared Medical Visits/Focus on Patient-centered, Goal-centered Care PHQ-9 GAD-7 Stanford Self-Efficacy Content and Goal of Visits Patient Goals Patient Ground Rules Patient Accountability Self-Efficacy and Communications

14. Intensive Primary Care Evaluation IPCE Negative Affects on Quality of LifeBarriers to Treatment Functionality Hx Abuse/Trauma Substance Abuse Difficulty with ADLs Length of Illness Pain Disease symptoms/prognosis Social function Housing instability Transportation Passivity Poor decision- making/understanding/coping skills Mental Health Symptoms Access to healthcare Resistance to change

15. Action Plans Goal Setting Goal setting must be realistic and very specific Weekly goal setting Patients answer the what, how much, when, and how many days Scale with a 7 or above for confidence level Overall Goals Patients discuss their “DREAM” (long-term goal) Patients then set an Action Plan that is short- term to meet that “DREAM”

16. Goal Setting DREAM: What would you like to accomplish? BRAINSTORM: What are different ways that will help you accomplish your dream? ACTION PLAN: What is a short-term action that will let you accomplish your dream? JUST DO IT: Carry out your action plan. REVIEW: Check your results ADJUST: Make changes as needed. KUDOS: Remember to reward yourself. Some people want it to happen, some wish it would happen, others make it happen” - Michael Jordan

17. System Navigation in a Large Hospital Setting

18. Barriers to Care that we have Found in our System ♦Call Centers ♦Do not know the patient personally ♦Make Decisions based off of Algorithm's ♦Center is reviewed based on Quantity not Quality ♦Phone Trees in Hospital Departments ♦Confusion with Options ♦Long Hold Times ♦Patient’s hang up ♦Follow Up Care does not happen

19. Barriers to Care that we have Found in our System ♦Access to Care ♦Urgent Access with Patient’s PCP ♦Scheduling Blocks in Templates ♦Scheduling Routine Follow Up appointments before the Patient leaves ♦Social and Economic Barriers ♦Transportation ♦Telephone Service ♦Literacy ♦Medication Knowledge

20. How the MEDTAPP HCA Initiative is Helping to Decrease Barriers COMMUNICATION One Central Phone Number Answered by our Team ♦Patient’s know who they are talking to, they can put a face with the name ♦Schedule/ Cancel Appointments ♦Medication Refills ♦Health Questions can be quickly answered because of co-location of Inter-professional Team ♦No Phone Trees or confusing options to choose ♦Simple voicemail system ♦Long Hold Times Eliminated

21. SOCIAL AND ECONOMIC ♦Working with the Patient as a Team ♦Building Trust ♦Continuity of Care ♦Direct Contact ♦Weekly Education ♦Creating Access by Increasing Workforce Capacity ♦24 hour urgent Access ♦Decreasing Unnecessary ER visits ♦Create a Bridge between the Patient and their PCP How the MEDTAPP HCA Initiative is Helping to Decrease Barriers Disclaimer: The MEDTAPP HCA Initiative does not provide funding for healthcare service delivery.