Date post: | 29-Jan-2018 |
Category: |
Health & Medicine |
Upload: | andreacamden |
View: | 2,234 times |
Download: | 0 times |
Camden Coalition of
Healthcare Providers
Community Outreach for Complex Patients:
Basics of Care Management and
Care Transitions in the Field
Kelly Craig, Director of Care Management Initiatives
Jason Turi, Clinical Manager of Care Transitions
July 20, 2012
Camden Coalition of
Healthcare Providers
www.camdenhealth.org
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
Clinical Model
www.camdenhealth.org
•Lourdes
•Cooper
•Virtua
Data•Assessment
•AssignmentTriage
•Medically complex
•Socially complex
•6-12 mos. engagement
High Risk
•Quality improvement
•Patient engagement
•Care coordination
Medical Home
•Medically complex
•30-90 day engagement
Interm.
RiskPatients Flagged:
• 2+ hospital
admissions < 6
months
Selection Criteria:
• History of chronic
disease related
admits
• Rule out criteria
• Assigned to pathway
“Care Transitions”
“Care Management”
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
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
Outreach Team Composition
High Risk Outreach Team Intermediate Risk Outreach Team
RN RN
MA LPN
Health Coaches Health Coaches
Social Worker
www.camdenhealth.org
Admitted past month, 6 month summary Days 6 mo episodes Admit Facility Inp ED Name dob age sex PCP PracticeName Insurance
06/13/12 Cooper 40 7 3 xxxxxxxxxxxxxx xx/xx/xxxx 55 M JACK GOLDSTEIN CMC Dept of Cooper 44 3 2 xx/xx/xxxx 73 F MARILYN GORDON CAMcare Health Cooper 79 3 xx/xx/xxxx 57 M JOHN KIRBY Cooper Physician HORIZON NJ PPO Cooper 35 2 3 xx/xx/xxxx 21 M NO PHYSICIAN OLOL 1 2 1 xx/xx/xxxx 56 M SELF PAY - Cooper 5 2 1 xx/xx/xxxx 61 M OLOL 4 2 1 xx/xx/xxxx 54 M SELF PAY Cooper 27 2 xx/xx/xxxx 47 M MARILYN GORDON CAMcare Health
06/12/12 Cooper 15 13 1 xx/xx/xxxx 22 F MIGUEL MARTINEZ Cooper Physician Cooper 18 3 2 xx/xx/xxxx 55 M NO PHYSICIAN AMERHLTH/KEYST Cooper 99 3 1 xx/xx/xxxx 64 M DANIEL HYMAN Cooper Physician
06/11/12 Cooper 9 9 5 xx/xx/xxxx 48 M LYNDA BASCELLI Project Hope OLOL 43 9 1 xx/xx/xxxx 71 F INTERNAL BILLING OLOL 17 5 5 xx/xx/xxxx 66 F HORIZON NJ Cooper 27 5 3 xx/xx/xxxx 52 M LYNDA BASCELLI Project Hope OLOL 35 5 1 xx/xx/xxxx 70 F BRAVO HEALTH OLOL 46 4 5 - xx/xx/xxxx 73 F HORIZON NJ OLOL 31 3 2 xx/xx/xxxx 52 F SELF PAY Cooper 2 3 1 xx/xx/xxxx 68 F MINH HUYNH OLOL 1 3 1 xx/xx/xxxx 73 F HORIZON NJ Cooper 34 3 xx/xx/xxxx 62 F ANNA HEADLY Cooper Physician Cooper 131 2 10 xx/xx/xxxx 35 M NO PHYSICIAN OLOL 54 2 6 xx/xx/xxxx 49 F SELF PAY - OLOL 177 2 4 xx/xx/xxxx 91 F HORIZON NJ Cooper 3 2 2 xx/xx/xxxx 51 M NO PHYSICIAN MEDICAID OLOL 139 2 2 xx/xx/xxxx 87 F HORIZON NJ
Thursday, June 14, 2012 Page 1 of 8
Daily Admissions Feed
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
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
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
1 year pre-enrollment Charges = $112,664; Receipts: $22,365
Post-enrollment (10 months)Charges = $64,974; Receipts= $12,380
0
0.5
1
1.5
2
2.5
3
Len
gth
of s
tay
ED IP
www.camdenhealth.org
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
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
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
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
Patient Centered Care Coordination
www.camdenhealth.org
Patient
Hospita
l #1
Sub-Acute Rehab
Hospita
l #2
Home
Nursing
Home
PT/OT
Durable Goods
Meals
Transport
Dialysis
Nephrology
Transplant
PCP
UrologyOncology
Surgery
GI
Cardiology
Optho
Pain
Mgt
Q & A
Kelly Craig, MSW, LSW
Director, Care Management Initiatives
856-365-9510 x2004
Jason Turi, MPH, RN
Manager, Care Transitions
856-365-9510 x2017