Care Transitions - Camden Coalition of Healthcare Providers
Download
Report
Transcript Care Transitions - Camden Coalition of Healthcare Providers
Outreach to High Utilizing Patients — Basics
of Care Management and Care Transitions in
Camden, NJ
Overview
Mission
Role
Values
Coalition Structure and Workflow
Care Management Team
Care Transitions Team
Q&A
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
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.
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
Care Continuum Model
•
Hospital
Admissions
Data
•
•
Inclusion
Triage
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
Medical Home
CCHP Outreach
Care Coordination
High Risk
Health Coaching
Intermediate Risk
Data driven QI
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
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 compliment
services of existing providers
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
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
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
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
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.”
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
Different Patients – Different Care
Case Study 1: Care Management
Bedbound
Neuropathy
Obese
Diabetes
Jan 2010-Jan 2012
24 ED visits
23 inpatient visits
Barrier: transportation
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
Lessons Learned
Ethical considerations
Working with patients too long
Enabling vs. Helping patients help themselves
Cultural Competence
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
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
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
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
Monitoring & Evaluation
Outcome measures:
Reduction in ER/hospital use
Reduction in readmission rates
Reduction in cost
Participant satisfaction
Key Intervention: Home–based
Medication Reconciliation
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!
Great Long-Term Solution for
Limited Mobility: Red s]Scooter!
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
Q&A
Thank you!
Jason Turi, MPH, RN
Manager, Care Transitions
[email protected]
856-365-9510 X2017
Kelly Craig, MSW, LSW
Director, Care Management Initiatives
[email protected]
856-365-9510 x2004