1. Alachua County Initiative to Reduce Avoidable Hospital Utilization Cathy Cook LCSW, Shands Diane Dimperio, Alachua County Health Department October 12, 2010

2. Shands at the University of Florida Discharges: ~ 40,000 ED Visits: ~ 58,500 Beds: 852 Bassinets: 20 Level 1 Trauma Burn Transplant NICU III Multispecialty academic health center UF&Shands Health System Shands Children’s Hospital at the University of Florida Shands Cancer Hospital at the University of Florida

3. SUF previous state F/U appt process in transition Unit clerks making routine appointments at Shands clinics Case managers making high risk/speciality appointments for all patients “Rejected” appointments followed up by case manager or supervisor Frequent visitors (FV’s) seen by different ED physicians, IP physicians, case managers and social workers Separate attempts at consistent follow-up unsuccessful for the most part No systematic process for identification of FV’s Barriers to success: –Inconsistent clerk education from floor to floor and turnover –FV’s admitted to different medical services and floors –Case management model changes –No new resources

4. Recent improvements Collaboration with ACHD, including monthly face to face meetings focused on high risk patients Sub-groups formed to address FV Access center committed to placing FV’s on “home floors” Hospitalist commitment to population/s Daily review of readmission by case management managers Daily review in hospitalist rounds

5. Alachua County Health Department Goal –Reduce avoidable use of hospital services –Improve access/participation in primary care –Reduce barriers to care Medical Home program –Two care coordinators –Two Medicaid out reach workers –One disease care coordinator

6. Hospital referrals Emergency room –front desk –social workers –Patient follow-up as directed In-patient –case managers/social workers

7. Medical Home Services Transitional medical care Assessment of barriers to care Refer for third party coverage –On site Medicaid eligibility Help to reduce other barriers Help patient select a PCP Patient satisfied with PCP

8. Experience: Jan 11- June 30 82 enrolled in the care coordination Most had chronic conditions 27% homeless 66% uninsured 12% Medicaid 21% needed immediate follow up

9. Services 53 closed cases 1.9 face-face contacts 6 telephone contacts 4.3 phone contacts on behalf of clients 1.5 transitional medical visits by CHD 0.5 medical visits with another provider 2.0 referrals to social services

10. Services 18 referrals for third party coverage –10 enrolled in Medicaid –1 enrolled in CHOICES –2 denied –Remainder pending or not f/u 13 referred to Medicaid by others –LIP staff follow up –6 enrolled in Mediciad –6 denied (2 enrolled in CHOICES) –1 pending Medicaid coverage was retroactive to cover hospital stay and ER visit

11. New program dimension Focus on high utilizing patients Enroll in care coordination Long term follow up –Barriers –Attitudes –Behavior modification