1. Community Care Teams Carl Schiessl, Director, Regulatory Advocacy
Connecticut Hospital Association
Eileen Kardos, LMSW, High Risk Navigator
Western Connecticut Health Network

2. Scope of the Problem + + Fragmented system
Limited definition of health
Homelessness, lack of substance abuse treatment, other social stressors
Poor coordination of services
Disconnect between the hospital and outpatient care
Social determinants impact the health and well being of patients and how frequently they come to the hospital
Overuse of acute services
Worsening medical conditions + +

3. Consequences Poor Outcomes Wasted Resources Unsustainable Finances
Overworked Providers

4. Frequent Visitors
In 2013, in the United States, 1 of every 8 ED visits was related to a mental health or substance use disorder
Connecticut emergency departments treated more than 8,400 patients at least 7 times in 6 months, totaling approximately 58,000 visits

5. Who are the Frequent Visitors?
Seven or more visits in a six-month period
Disproportionate rates of mental health and/or substance misuse diagnoses
Medicaid or no insurance
Homeless or housing unstable
Alcohol misuse diagnosis
Seeking controlled substances or pain management
Chronic disease or other complex medical conditions

6. One Solution: Community Care Teams
A Community Care Team (CCT) is a team of local medical, behavioral health, and social service providers utilizing a wraparound approach to provide patient-centered care, requiring multi-agency partnership and care planning, and the use of traditional and non-traditional supports and services.

7. CCT Structure and Function
Broad coalition of service providers
Meet regularly to review patient outcomes
Identify frequent visitors to EDs
Obtain a Release of Information form (ROI)
Develop an Intensive Case Management (ICM) plan for each patient
Connect the patient to services

8. Potential Benefits Improve patient health Reduce overcrowding in EDs
Relieve pressure on community providers
Save millions of dollars by reducing ED visits
Demonstrate regional cooperation

9. CCT Challenges Recruit and maintain essential community providers
Obtain support from senior management of all community providers, and local and state agencies
Dedicate sufficient personnel and resources to manage CCTs
Obtain and manage patient information in accordance with privacy laws

10. Characteristics of the NH CCT Population
Current Census is 195 Patients
36% female; 64% Male
50% White; 30 % Black; 20% Hispanic or Other
20% Homeless; (85%+ have had unstable housing or been homeless at one time)
60% have substance misuse dx; 37% alcohol misuse dx
55% have a mental health DX
65% have at least one chronic disease dx in the chart
25%+ have no PCP; 73% have no behavioral health provider
95% are Medicaid, Medicare or self-pay

11. Who are the Greater Norwalk CCT Stakeholders?
Americares Open Door Shelter Mid Fairfield Child Guidance NCHC Norwalk Hospital Connecticut Counseling Family and Children’s Agency Gillespie Center Day Street Clinic
Norwalk Police Department Connecticut Renaissance Homes with Hope Liberation Programs Connecticut Counseling Norwalk Probation DuBois Center Person to Person

12. High-Risk Navigators—Scope of Practice
Execute plans developed in CCT meetings
Liaisons between the hospital, the community and the patient
Follow patients and partner with other agencies as patients engage in systems and services outside of the hospital
Follow Patients and communicate with appropriate hospital staff about community work when patients are in the ED or admitted to the floor
Connect Patients to Medical care/Behavioral Health Supports in the outpatient setting
Connect patients to supports and resources surrounding the social determinants of health
Work to remove barriers to patients accessing referrals
Follow-up accordingly
Data Collection and Analysis
Represent the hospital in the community
Build Community Relationships

13. CCT Client Case Example: ST
Before CCT -Homeless/living in the park -Undocumented -Not connected to primary care -No case mgmt services -Never engaged in substance abuse tx - Ed visits one year prior to being housed(FY15=75)
After CCT -Housed in own apt > 1 yr -Documented -Connected to NCHC/medical/therapy -Has housing case mgmt -Has a recovery assistant -Completed detox - Visits Reduced (FY16=50; FY 17=5)

14. CCT Outcomes

15. CCT Outcomes Average Visits Per Patient 3.1.15-8.31.15 N=121
N=121
N=141
N=166
N=174
N=196
Average ED visit per patient
(Total Number Of Visits/N)
3.76
2.46
3.09
2.30
1.80
Average number of inpatient days per patient
(Total Number Of Days/N)
2.88
1.53
1.95
1.71
1.64
Change Two and a Half Years
-39.6% -41.7% Average Inpatient Days
-52.0% Average ED Visit
-43.0% Average Inpatient days

16. CCT Outcomes—Data Pulls
Hospital Usage Analysis CCT Data Pull :
N=174 patients (Same Cohort of People for a Year in the Program)
*297 includes 21 days of observation visits **226 includes one day of observation visits
Hospital Usage Analysis CCT Data Pull :
N=164 patients (Same Cohort of People for a Year in the Program)
*223 includes 13 days of observation visits
 ED Visits
 Inpatient
Days
 Average ED Visit per PT
 Average #inpatient days per PT
400
297*
2.29
1.71  
284
226**
1.63
1.30
 Change
-29%
-24%
 ED Visits
 Inpatient
Days
 Average ED Visit per PT
 Average #inpatient days per PT  
 510
316 
 3.12
1.92  
 289
223*
1.76  
1.36
 Change
 -43.3%
-29.4% 
 -43.6%
 -29.2%

17. Carl Schiessl, CHA
Eileen Kardos, WCHN