1. Coordinating Care with People with Multiple Health and Social Needs
Catherine Craig, MSW, MPA
September 12, 2011
The presenter has nothing to disclose.

2. The Reality Note: Figures in parentheses are expenses per person.
Source: Conwell LJ, Cohen JW. Characteristics of people with high medical expenses in the U.S. civilian noninstitutionalized population, 2002. Statistical Brief #73. March Agency for Healthcare Research and Quality, Rockville, MD. Web site:

3. Highest Cost Conditions
How many of our patients have more than 1 chronic condition? A behavioral health condition? Social needs?
Source: Olin GL, Rhoades JA. The five most costly medical conditions, 1997 and 2002: estimates for the U.S. civilian noninstitutionalized population. Statistical Brief #80. Agency for Healthcare Research and Quality, Rockville, MD.

4. The Triple AimTM

5. Virtual Ward Croydon Primary Care Trust Coordinating Complex Care
Began in May 2006
Predictive model to identify highest-risk patients
Use systems, staffing of inpatient ward to deliver home-based care
Goal: Discharge patients to general practitioner in community
Coordinating Complex Care
Team is responsible for holistic care
Communication is Key! Emphasis on transferring information between multidisciplinary providers, GP, and patient
Daily staff meetings to coordinate & calibrate care to meet current needs
Build relationships with community resources

6. Care Coordination Model

7. Hospital Provider to patient:
“Go home,
take care of yourself,
get lots of sleep,
take your medications,
make sure to stay dry
GO SEE YOUR DOCTOR
and come back and see me in a couple weeks…”
Patient to discharge planner:
“I don’t have a home,
I’d love to take care of myself,
but I can’t sleep all night went where I camp,
my medications were just stolen,
my sleeping bag is soaked and lost
I DON’T HAVE A DOCTOR
and I don’t have a phone or a way to get back up to the hospital…”
Created by Nic Granum, Central City Concern Recuperative Care Program, 2010.

8. COMMUNITY& PROGRAM INTEGRATOR & ORIENTATION MEDICAL HOME HOUSING
PROGRAM FUNDING
CCC’s Recuperative Care Program
Portland OR
Integrated Team: Lead case mgr = SW/EMT, plus MD, housing, logistics & FT volunteer
* SW or EMT
Old Town Clinic FQHC
~30-day respite w/connection to Permanent Supportive Housing (PSH)
Local Hospitals, CareOregon & City of Portland Housing Bureau
Pathways to Housing
Philadelphia PA
Multi-disciplinary Assertive Community Treatment (ACT)
* RN
On-site physician from TJU
Permanent Supportive Housing
ACT: Medicaid MD: Grant
BronxWorks Homeless Outreach Team
Bronx NY
Hospital Homeless Coordinator
* LMSW
Locating FQHCs in community
Transitional & PSH
Local Department of Homeless Services
Hospital to Home
New York NY
Community-Based Care Manager
* Community health worker or BSW
Integrated care team
Link to transitional & PSH
New York State Department of Health grant
* Denotes background of person in the Integrator role: identifying goals and coordinating care

9. Macro-Integration Local, State & Federal Government Agencies
Housing Health Mental Substance
Health Abuse
Local, State & Federal
Government Agencies

10. Integration2 Local State & Federal Government Agencies Informs
Housing Health Mental Substance
Health Abuse
Local State & Federal
Government Agencies
Informs
Supports

11. Making the Business Case
Hospitalizations
Fragmentation of care
Total spend
Health
Experience of care
Challenge: Cost savings vs. cost avoidance

12. ROI Data Points
What is the per member per month (PMPM) cost of the intervention?
e.g. an RNP with a FTE caseload of 40 = $300 PMPM additional cost.
What are the key utilization and cost metrics that are expected to change with the intervention?
 ED visits/K/Yr.
 ED PMPM expenses
 Hospital Admits/K
 Hospital Days/K
 Hospital PMPM expenses
 Pharmacy PMPM expenses
 BH PMPM expenses
What is the change in total PMPM expenditures for the target population from a predetermined baseline?
A+ROI occurs when the “sustained” cost of the intervention is more than offset by reductions in total PMPM expenditures due to “expected utilization changes”. eg
© 2010 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information

13. Why partner? Decreasing Medicaid reimbursement rates
It’s “the right thing” to do
Focus on preventive care
Efficient consumption of services
Alleviates the burden on Emergency Departments
Redistributes consumption of services:
Primary and specialty care
Mental Health
Chemical Dependency
Health Home, Accountable Care Organization incentives
Community partners can help you manage some of the most challenging patients
Hospitals are an entrance point and potential point of intervention for the homeless population
Need to have a mechanism for knowing when they enter the system
“Captive audience”
Potential for treating physical, behavioral, and substance use needs in one location
Poor discharge planning often leads to re-admissions
Coordinating with community partners can reduce this
Reduces fragmentation of care

16. Action Items Identify:
- 5 people with complex needs to target for care coordination services this month
- Track what you learn, intervene with a PDSA
- Who coordinates care?
- How do you fund coordination services?
- At least 2 community partners
Define:
- 3 impact measures to track progress
- Health - Cost - Experience of care