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In-Reach Hospital Program

In-Reach Hospital Program . Coordinating Multiple Service Providers Rare Presentation Partnership between: South Central Human Relations Center Steele County Human Services South Country Health Alliance Allina Health Owatonna Hospital October 2 nd 2012. Program Value.

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In-Reach Hospital Program

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  1. In-Reach Hospital Program Coordinating Multiple Service Providers Rare Presentation Partnership between: • South Central Human Relations Center • Steele County Human Services • South Country Health Alliance • Allina Health Owatonna Hospital October 2nd 2012

  2. Program Value

  3. Objectives of the Program

  4. Process for Identifying and Engaging Patients

  5. How is Systems Care Coordination different from typical hospital social worker role? • Social worker walks with the patient rather than makes referrals from the hospital environment. • Functional Assessment and Community support plan is developed with the patient to stabilize their mental and physical health. • Sixty days of case management with a goal of the patients transitioning to community based support services. • Collaborative to get all of the service providers working together with the patient.

  6. Common Patient Profile • Patients are 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 with case worker and primary care physician • Need assistance before qualifying for the Human or Mental Health Services 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

  7. Owatonna Hospital The Program Data

  8. Managed Care Data • January 2012 to July 2012 • 39 clients • Reviewed Emergency Department, Overall Primary Care Physician Cost • $51,951 reduction in paid health care claims

  9. Billable Service • 2011-Successful legislative effort-payment guidelines imbedded in the HS Omnibus Bill (Sec. 45. Minnesota Statutes 2010, section 256B.0625) • Currently in final process of approval from CMS with MNDHS • Billing expected to be in 15 minute increments at community health worker hourly salary.

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

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