1. In-Reach Program Elizabeth Keck, MSW, LGSW Allina Health - Owatonna Hospital May 19, 2014 Participants:1-866-639-0744, no code needed

2. In-Reach Program In-Reach Program Coordinating Multiple Service Providers Rare Presentation Partnership between: South Central Human Relations Center Steele County Human Services South Country Health Alliance Owatonna Hospital-Allina Health SystemsMay 19 th 2014

3. Program Value Patient Access to the full spectrum of needed provider services through access assistance and advocacy for correct health care program enrollment resulting in optimal care. Providers Efficient patient encounters assisted by unique treatment plans easily accessed in Excellian and system care coordinator in attendance at clinic visits. Cost Savings

4. Objectives of the Program To encourage health care providers to coordinate their efforts to assure the most vulnerable patient populations seek and obtain primary care. To increase preventive services including screening and counseling, to those who would otherwise not receive such screening to improve health, reduce complications, and cost. To provide a mechanism for improving both quality and efficiency of care for vulnerable individuals with an emphasis on those most likely to remain uninsured or underinsured. To manage chronic conditions to reduce their severity, negative health outcomes, and expense.

5. Process for Identifying and Engaging Patients List of patients is generated 5 more visits in in quarter (BOE Report) Phone Call, Letter, and note in chart to page social worker when they arrive List is reviewed with Medical Director of ED and Nurse Manager of ED Patient consents to system care coordination.

6. Common Patient Profile Patients are generally between the ages of 20 and 40 years of age. Diagnosed or undiagnosed anxiety, depression, or substance abuse. Chief complaint related to physical symptoms related to depression or anxiety (i.e. HA, SOB, palpitations, etc) Majority are on public assistance (but not ALL) Majority either have or have had a mental health adult case worker Often are disconnected primary care physician Need assistance before qualifying for the Human Service or Mental Health Services as recommended in their discharge instructions/plan from ED Many have issues with transportation, housing, food, and medications which is often not addressed in their ED stay Often times patients mental health treatment providers are not aware of their emergency department visits that relate to their mental health symptoms.

7. How is Health Care Coordination different from typical hospital social worker role? Health Care Coordinator Community Provider- connecting to resources Patient is not admitted to hospital. 60 days of interventions. Attends follow up health care appointments with patient. Hospital Social Worker Discharge Planning Patient is admitted to hospital or in ED Once patient is discharged Social Worker does not follow up.

8. Health Care Coordinator Tasks Functional Assessment Completed Goal Development Releases are Signed Screening Tools: PHQ-9, GAD-7, Physical Exam, Pre Questions Unique Treatment Plan Developed

10. The Program Data

15. Managed Care Data 39 Patients Reviewed Emergency Department, Overall Primary Care Physician Cost $51,951 reduction in paid health care claims 22 Patients Prior ED Visits = 139 Post ED Visits = 91 Difference = -47 Hospitalizations: Prior – 17 Post – 13 2013 2012

16. Patient Satisfaction 1.Patient Survey upon closure of case. 2.Pre and Post Questions Survey

17. Pre and Post Questions

18. Billable Service 2011-Successful legislative effort-payment guidelines imbedded in the HS Omnibus Bill (Sec. 45. Minnesota Statutes 2010, section 256B.0625) Billing expected to be in 15 minute increments at community health worker hourly salary. MS 256B.0625 subd, Covered Services; Medical Service Coordination. Bill 80 hours within a calendar year. Can not have two overlapping 60 day occurrences Criteria is 4 visits in 3 months.

20. Contact Information Elizabeth Keck, MSW, LGSW elizabeth.keck@allina.com

21. Upcoming RARE Events…. Stay tuned for the next RARE Mental Health Webinar: New York Office of Mental Health Dr. Molly Finnertry June 26, 2014 (Noon-1pm)

22. Future webinars… To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact: Kathy Cummings, kcummings@icsi.orgkcummings@icsi.org Jill Kemper, jkemper@icsi.orgjkemper@icsi.org