Outreach to High Utilizing Patients — Basics of Care Management and Care Transitions in Camden, NJ

1. Camden Coalition of Healthcare Providers Outreach to High Utilizing Patients — Basics of Care Management and Care Transitions in Camden, NJ

2. Overview Mission Role Values Coalition Structure and Workflow Care Management Team Care Transitions Team Q & A

3. Our Mission The Camden Coalition of Healthcare Providers was created with the overarching mission to improve the health status of all Camden residents, by increasing the capacity, quality, and access of care in the city

4. The Coalition’s Role Unlike many service and social organizations in the city, the Coalition does not provide long-term services to patients, but rather focuses on creating solutions from the providers and health systems side of care.

5. Organizational Values Facilitating discussion and strategy design Collaboration among stakeholders Creating fluid systems of communication Data-driven initiatives Utilizing data to evaluate projects Sustaining programs for long-term positive outcomes

6. Care Continuum Model • Multidisciplinary care management outreach • Patients with history of ED visits/hospital admissions and readmissions (4 admits w/in 6 mos.); social complexities • Average 6-8 month engagement Hospital Admissions Data Medical Home CCHP Outreach Inclusion Triage Care Coordination High Risk Health Coaching Data driven QI Intermediate Risk Patient Engagement • Nurse driven care transition • Patients with history of ED visits/hospital admissions and readmissions (2+ admits w/in 6 mos.); socially stable • Average 6-8 week engagement

7. Care Transitions & Care Management Team Program Goals Reduce the risk of preventable readmissions to the hospital No open referrals: patients flagged from Health Information Exchange by Care Transitions Team No duplicate services: we complimentservices of existing providers

8. Care Management: High Risk • Hospital utilization in the city • Appropriate vs. inappropriate • Two or more chronic health conditions • Low socio-economic status • Homeless or unstable housing • Lack of social supports • Low-literacy, lack of HS diploma • Behavioral health issues • Generational poverty/urban violence

9. Care Management Team Purpose • Improve the health of the patients • Teach patients to seek services from appropriate locations, especially their Primary Care Providers, rather than the ED • Reduce healthcare costs Services Offered • Assess the individual’s needs • Provides immediate healthcare/social services when needed • Refers patients to their PCP and appropriate agencies for additional services • Outreach to homes, shelters, hospitals and even the streets to provide services

10. The Role of the Social Worker • Coordinates case management of the patient’s care including: • Short-term needs: temporary housing, food • Determining insurance eligibility or level of coverage and helps with enrollment • Helps the patient access social/health services such as: • Enrollment in a medical day program, applying for nursing home care, and accessing specialty care • Assists in applying for Supplemental Security Income, Disability or other entitlements as needed

11. The Role of the RN • Monitoring chronic conditions • Oversight of medications/prescribing • Communicating with other providers regarding the patient’s care • Patients typically have multiple social barriers to accessing traditional healthcare-the nurse encourages and transitions these clients into traditional primary care

12. The Role of the Medical Assistant & Health Coaches • A bilingual outreach worker • Works directly with the social worker and nurse in helping patients access appropriate health/social services • Helps patients make appointments/coordinate medical transportation and can accompany patients to appointments, as necessary • Two full-time volunteers working with the Care Management Team assisting with approximately 10-12 patients at a time • Reinforce positive behavior changes • Conducts social visits to monitor patient progress and provide additional support before “graduation.”

13. Intake/Engagement Process • Obtain consent • Conduct medical and social history • Immediately identify barriers/reasons for increased ED/hospital visits • Unstable housing/homeless • No/changing phone # • Lack of health insurance/benefits • Substance use/mental health issues • Transportation • Implement immediate plan with patient to address short-term goals, while building trust and rapport to address long-term goals

14. Different Patients – Different Care

15. Case Study 1: Care Management • Bedbound • Neuropathy • Obese • Diabetes • Jan 2010-Jan 2012 • 24 ED visits • 23 inpatient visits • Barrier: transportation

16. Case Study: Care Management • 37 year old Hispanic male • History of schizoaffective disorder, bipolar, PTSD, history of sexual abuse as child, unstable housing, medical day program • Type1DM X 19yrs, HTN, ESRD, congenital heart defect (PMVSD/ASD), history of coma w/DKA, endocarditis • Cognitive impairment vs. mental health • Recent admits to crisis X 2-suicide ideation w/ means, hospital w/DKA, GI Bleed

17. Lessons Learned Ethical considerations Working with patients too long Enabling vs. Helping patients help themselves Cultural Competence

18. Anecdotal Reasons for Success • Longitudinal relationship • Build rapport/trust over time • Proactive, holistic model of care • Where the person is/whatever it takes • Respectful & non-judgmental care • Community relationships • Community problem solving

19. Care Transitions: Intermediate Risk • 90-day community-based intervention to stabilize complex patients • Patients deemed “intermediate risk” generally have housing and insurance coverage • Patient determined at risk for hospital readmission through HIE • Patient will receive bedside visit from RN/LPN while in hospital • Home visit within 24hrs after d/c to include medication reconciliation, health education, appointment scheduling etc. • Care coordination with PCP & Specialist • Accompany to 1st PCP follow-up appointment and specialists • Weekly home/community visits with team

20. Care Transitions: Evidence-Based Practices • The Transitional Care Model: Mary D. Naylor, PHD, RN; University of Pennsylvania School Of Nursing • The Care Transitions Program: Eric Coleman, MD; Division of Health Care Policy and Research at the University of Colorado Denver, School of Medicine

21. Staffing • Medical Home Team • 1 Full-time RN Nurse Care Manager • 1 Full-time LPN Nurse Care Coordinator/Outreach Specialist (bilingual) • Two “health coaches” – AmeriCorps Volunteers • In cooperation with Camden’s Federally Qualified Health Centers

22. Monitoring & Evaluation Outcome measures: • Reduction in ER/hospital use • Reduction in readmission rates • Reduction in cost • Participant satisfaction

23. Key Intervention: Home–based Medication Reconciliation

24. Case Study:Care Transitions 52 y/o female Spanish-speaking with COPD/Trach/Vent dependent, admitted for resp. distress. 8 readmits last year. Avg. admit every 29 days prior to intervention. No referral, directly outreached by team @ hospital. Coordinated meeting with patient/family with hospital social worker, home care, and attending physicians at bedside. Transitioned at Long-term Acute Care in Philadelphia, while family trained on vent and vent was placed at home. Transitioned home and f/u to PCP & Specialist appointments Currently at home and medically stable, will graduate May 2012 120 days without hospital utilization, scooter delivered to home!

25. Great Long-Term Solution for Limited Mobility: Red s]Scooter!

26. Case Study: Care Transitions 55y/o Male with ESRD/Dialysis, admitted for GI bleed and SOB November 2011. 6 admits and 3 ED visits within last 12 months, hospital visit every 41 days No referral, directly outreached by team @ hospital Coordinated with patient and renal social worker to transition at sub-acute facility for rehab Transitioned home and accompanied to PCP & Specialists Currently at home and medically stable, will graduate May 2012 120 days without hospital utilization

27. Q & A

28. Thank you! Jason Turi, MPH, RN Manager, Care Transitions Jason@camdenhealth.org 856-365-9510 X2017 Kelly Craig, MSW, LSW Director, Care Management Initiatives Kelly@camdenhealth.org 856-365-9510 x2004