Community Care Coordination and Case Management

1. Community Care Coordination and Case Management Kansas Public Health Association, Inc. 2006 Fall Conference

2. Central Plains Regional Health Care Foundation, Inc. • Charitable, nonprofit organization, closely affiliated with and housed within the Medical Society of Sedgwick County • Our vision is to improve the health and well being of the people of Wichita/Sedgwick County, Kansas • Program areas: • Project Access: Coordinates donated medical care for low-income, uninsured residents of Sedgwick County • Clinics Patient Index: A shared data project encompassing five safety net clinics and Project Access • Enhanced Care Management of Sedgwick County: A five-year pilot care management program for eligible Medicaid HealthConnect patients • Various special projects and studies, implemented in partnership with local providers, to assess needs and potential areas of impact • Hospital-wide utilization study/KU School of Medicine-Wichita • ED case management program through area hospitals

3. Background/Need • The need to improve the health of vulnerable, invisible patient populations • The need to increase access to health care services for the uninsured and underserved • The need for a more coordinated system of care • A coordinated system of enrollments, referrals and communication among providers related to patient needs • A more coordinated effort among providers to develop innovative models that work • The need to track data and information to share with the community about local efforts • Our projects fit within the Healthy People 2010’s Leading Health Indicator, Access to Health Care

4. Goals/Objectives • Our goals are to: • Improve the health status of our patients • By coordinating care and services • By reducing inappropriate utilization of medical services that are not in the best interest of our patients and are very costly to the community • By educating patients about how to manage their conditions and access the services they need to live healthier lives • Extend more care to more people at less cost

5. Who Is Involved? • Physicians and the Medical Society of Sedgwick County • Area hospitals • Safety-net clinics • KU School of Medicine-Wichita and related residency programs • Pharmacies • Funding partners including United Way of the Plains, City of Wichita, Sedgwick County, Sunflower Foundation, SRS Wichita Area Office, and the Kansas Health Policy Authority • Community representation on an Operations Council and many working committees • Keep our programs patient-focused and community-based • Provide important leadership and guidance • To respond to environmental changes • To make course corrections in current program areas • To consider new initiatives

6. Progress or Results • Clinics Patient Index: • Safety net system is stronger and more viable by communicating more effectively • New data will provide a unified voice across safety net • Project Access: • 6,900 Project Access patients have accessed more than $51 million in donated medical care and services • Broad range of partners convened to serve the uninsured and develop new models that work • Enhanced Care Management: • Early results are promising • More than 100 patients served • Developed care management concepts that include intensive supportive services provided by a multi-disciplinary team, patient education techniques, coordination of health care services and integrated quality standards of practice

7. Expected Impact • Project Access patients experience a clinically-significant improved health status • They are also much less likely to visit area emergency departments for primary care conditions • Local medical community saves money because care is accessed when needed rather than waiting until conditions become severe and acute • Enhanced Care Management patients are experiencing positive results early in the program • Anecdotal stories of success • A unique model has been developed and implemented • Detailed evaluation plans in place to track program outcomes • Currently working with the Kansas Health Policy Authority staff on funding issues so that we may continue this pilot project • The medical community has taken a lead in coordinating activities that serve the underserved • This leadership will drive us towards new models and approaches that will improve the health of our entire community

8. Application • Many communities have initiated similar programs, perhaps your community is ready • Visit our website and the American Project Access Network’s website for more information about volunteer-physician programs: • www.projectaccess.net • Click on evaluation reports • www.apanonline.com • Access information from many other communities • Identify potential approaches/models • Develop a leadership group to further your mission • Build the political and community will to implement your programs • Develop the key partnerships to get them off the ground • Implement programs with integrity and include objective evaluation activities to assess strengths and weaknesses • Use that information to make course corrections quickly • Report successes and failures honestly

9. Contact Information • Anne Nelson, Chief Operations Officer • Central Plains Regional Health Care Foundation • 1102 South Hillside • Wichita, KS 67211 • Phone: 316-688-0600 • Email: annenelson@projectaccess.net