1. Collaboration for Referral to Mayo Clinic Health System COMPASS Medical Home Inpatient/ ED Transitions RN January 2014

2. Austin MCHS: Site I RN Care Coordinator- 70 patients currently Co- location in office setting Medical Home RN: Kris Low, RN Transitions RN: Randi Long, RN COMPASS Float RN: Shannon Herrick, RN COMPASS RN Care Coordinator: Barb Hann, RN

3. Communication Various referral routes exist for each RN Co-location allows real time exchange of information about patients who may meet criteria of one of the programs Each coordinator understands the programs and is able to do basic screening for eligibility- Transitions RN and Medical Home use PHQ9 to assess patient status

4. Transition RN Role: Inpatient involvement with patients to help prevent re-hospitalization and contact patients upon discharge May serve as resource for connections in the community Daily Rounds inpatient which provide constant assessment of patients who may fit care coordination criteria (MH or COMPASS)

5. Risk Stratification Tool Cerner Tool Email sent daily and list used for rounds Referrals and follow up Reports given to 30 Day Readmission Team

6. Work Process: Transitions/ Care Coordination Multidisciplinary Rounds Communication to care coordinators Medical Home and COMPASS assess eligibility If patient not eligible, Transitions RN does follow up call for patient in effort to decrease readmission and assure patient is safe and following through on plan of care

7. Medical Home RN Established program at site Large census of patients and very familiar with clinic and inpatient processes Has easily adapted processes to include referral of patients who meet COMPASS criteria Currently involved in a team care project in ambulatory care so may refer through this context as well

8. COMPASS RN Care Coordinator Background in Medical Home- understanding of criteria and goals Follow up on referrals and closing the loop important Use of software to find patients has not been necessary due to referral source of Transitions and Medical Home Intakes or first contact with patient often occurs at the bedside

9. Emergency Department Referral Outreach by COMPASS Coordinator Communication with ED Care Coordinated Patients are identified by a note in the banner bar Potential patients- identifying and connecting with ED is a work in progress

10. Successes Communication among group has developed and yielded positive outcomes for COMPASS and Medical Home recruiting Communication with providers about patient status occurs in huddle with care coordinators and in pilot Team Care project in primary care increasing awareness for all on the team COMPASS Supervision Team Meetings have been a good forum for discussion of complex patients which then is communicated back to the care coordinators Rounding in clinic as a team creates a unified approach for care coordination and providers and staff are very open to feedback and information- positive presence

11. Challenges Psychosocial needs of complex patients are great- time consuming coordination Medical Home/COMPASS/Transitions collaborate to access appropriate resources but Social Work team member would add value (SW Student Intern in place at this time) Capacity is decreasing- COMPASS RN managing 70 patients at this time and Medical Home is managing 55 patients in addition to work in Team Care Project in clinic

12. Opportunities Software is developing to provide predictive indicators of who is likely to be readmitted and intervening early and often will be work of this team Awareness is still growing among providers about care coordination- referral likely to increase Increase education of inpatient nursing staff to promote referral Establishing robust Social Work/ Community Resource Guides and links will improve patient care and ability of patient to access the tools they need to be successful Demonstrate success by sharing data showing improved outcomes for patients