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Camden Coalition of Healthcare Providers Community Outreach for Complex Patients: Basics of Care Management and Care Transitions in the Field Kelly Craig, Director of Care Management Initiatives Jason Turi, Clinical Manager of Care Transitions July 20, 2012
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Overview Clinical model Program goals & guiding principles
Evidence-based practice Team composition Daily admissions feed Care management: High risk Care transitions: Intermediate risk Q & A
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Clinical Model “Care Management” “Care Transitions”
Lourdes Cooper Virtua Data Assessment Assignment Triage Medically complex Socially complex 6-12 mos. engagement High Risk Quality improvement Patient engagement Care coordination Medical Home Medically complex 30-90 day engagement Interm. Risk Patients Flagged: 2+ hospital admissions < 6 months Selection Criteria: History of chronic disease related admits Rule out criteria Assigned to pathway “Care Transitions”
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Outreach Program Goals
Reduce preventable readmissions to the hospital; reduce costs for complex patients No open referrals; patients flagged and triaged from Health Information Exchange No duplicate services; we compliment services of existing providers Facilitate clinical coordination vs. direct care
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Guiding Principles Enroll patients based on data; history of repeat admissions (high cost) and specific inclusion criteria Provide immediate and intensive follow-up coordination post discharge; connect patient to PCP as quickly as possible (target = 7 days post d/c) Dramatically improve the relationship between patient and PCP Equal focus of intervention on coaching
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Outreach Team Composition
High Risk Outreach Team Intermediate Risk Outreach Team RN MA LPN Health Coaches Social Worker
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Daily Admissions Feed
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Care Management: High Risk
Hospital utilization in the city Appropriate vs. inappropriate 2 or more chronic health conditions Low socioeconomic status Homeless or unstable housing Lack of social supports Low-literacy, lack of HS diploma Behavioral health issues Generational poverty/urban violence
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Care Management Workflow
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Case Presentation #1 62-year-old male
At time of enrollment, admitted for DKA (July 2011) History of homelessness Medicare/VA benefits Complex chronic conditions Diabetes Chronic kidney disease CHF COPD Substance use
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Outreach and Intervention
2011 hospital utilization 3 ED visits 10 inpatient stays Contributors to hospital readmissions Main interventions Coordinated care with homeless services provider Arrange long-term care placement
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Care Transitions: Intermediate Risk
History of 2 + admissions within past 6 months History of chronic disease related admits Socially stable Rule-out criteria Oncology Pregnancy-related Trauma Psych-only diagnosis
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Evidence-Based Practices
The Transitional Care Model: Mary D. Naylor, Ph.D., R.N.; University of Pennsylvania School Of Nursing The Care Transitions Program: Eric Coleman, M.D.; Division of Health Care Policy and Research at the University of Colorado Denver, School of Medicine
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Care Transitions Workflow
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Outreach & Intervention
Enrollment & begin outreach at bedside Clinical assessment and first home visit within 24 hours of d/c Care plan, resource building, goals, medical records, etc. Schedule PCP appt within 7 days (target) Schedule specialty appointments within 14 days (target) Planned day engagement
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Patient Case Presentation #1
55-year-old African-American male At time of enrollment, admitted for GI bleed and SOB (November 2011) Medicare/Medicaid coverage Lives alone in high-rise apartment 12 medications daily 6 months prior to enrollment 9 ED visits & 6 inpatient stays Hospitalized on average every 45 days Complex chronic conditions ESRD Renal Carcinoma Hepatitis B Hypertension Hyperlipidemia Peripheral vascular disease Asthma Glaucoma (blind in one eye) Sleep apnea Severe back pain
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Key Intervention: Home-Based Medication Reconciliation
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Patient Centered Care Coordination
Transport Meals Home PT/OT Home Nursing Hospital #2 Sub-Acute Rehab Durable Goods Hospital #1 Patient Dialysis PCP Urology Nephrology Oncology Surgery Optho Transplant Pain Mgt Cardiology GI
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Q & A Kelly Craig, MSW, LSW Director, Care Management Initiatives x2004 Jason Turi, MPH, RN Manager, Care Transitions x2017
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