Camden Coalition of Healthcare Providers

1. Camden Coalition of Healthcare Providers Community Outreach for Complex Patients:Basics of Care Management and Care Transitions in the FieldKelly Craig, Director of Care Management InitiativesJason Turi, Clinical Manager of Care TransitionsJuly 20, 2012 www.camdenhealth.org

2. 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

3. Clinical Model “Care Management” • 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” www.camdenhealth.org

4. 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 www.camdenhealth.org

5. 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 www.camdenhealth.org

6. Outreach Team Composition www.camdenhealth.org

7. Daily Admissions Feed

8. 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 www.camdenhealth.org

9. Care Management Workflow www.camdenhealth.org

10. 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 www.camdenhealth.org

11. 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 www.camdenhealth.org

12. www.camdenhealth.org

13. 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

14. 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

15. Care Transitions Workflow www.camdenhealth.org

16. 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 30 - 90 day engagement

17. 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 www.camdenhealth.org

18. Key Intervention:Home-Based Medication Reconciliation

19. Patient Centered Care Coordination Transport Home PT/OT Meals Home Nursing Hospital #2 Sub-Acute Rehab Hospital #1 Durable Goods Patient Dialysis PCP Urology Nephrology Oncology Surgery Optho Transplant Cardiology Pain Mgt GI www.camdenhealth.org

21. www.camdenhealth.org

22. Q & A Kelly Craig, MSW, LSW Director, Care Management Initiatives Kelly@camdenhealth.org 856-365-9510 x2004 Jason Turi, MPH, RN Manager, Care Transitions Jason@camdenhealth.org 856-365-9510 x2017