reducing re-hospitalizations using non-medical personnel kelly craig, camden coalition of healthcare...
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Reducing Re-hospitalizations Using Non-Medical Personnel
Kelly Craig, Camden Coalition of Healthcare ProvidersRachel Wolf, Salud Family Health Centers
October 10, 2013
CARE TRANSITIONS 101
“Care transitions refers to the MOVEMENT patients make
BETWEEN health care practitioners & settings as their
condition and care needs CHANGE during the course of
chronic or acute illness.”1
1 The Care Transitions Program®. (2008) Transitional Care: Definitions. Retrieved: http://www.caretransitions.org/definitions.asp
Inadequate care transitions contributed to [an estimate of] $25-$45 million in wasteful spending in 2011
Nearly 1/5 of hospitalized [fee for service Medicare] patients are re-admitted within 30 days of discharge
3/4 of those readmissions ($12 billion annual cost) are preventable through proper care transitions
Lack of consistent care post hospitalization
Complete hospital records often not accessible to Primary Care Physicians
Limited information given to patient upon discharge (e.g. self-care, medication management, who to contact with questions)
KEY BARRIERS TO PROPER CARE TRANSITIONS
“Transitional care is a set of actions designed to ENSURE the
COORDINATION and CONTINUITY of health care as
patients transfer between different LOCATIONS or different LEVELS
of care.”2
2 Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):556-557.
Coleman, EA. (2008) The Care Transitions Program®. Retrieved from http://www.caretransitions.org
Health Workforce Solutions LLC, Robert Wood Johnson Foundation. (2008). Care Transitions Intervention. Innovative Care Models. Retrieved from http://www.innovativecaremodels.com/care_models/12/overview
Health Workforce Solutions LLC, Robert Wood Johnson Foundation. (2008). Transitions Care Model. Innovative Care Models. Retrieved from http://www.innovativecaremodels.com/care_models/21/overview
National Committee for Quality Assurance. (2011) Patient Centered Medical Home (PCMH 2011 Standards. Recognition Training. Retrieved from http://www.ncqa.org/Programs/Recognition/RelevanttoAllRecognition/RecognitionTraining/PatientCenteredMedicalHomePCMH2011Standard.aspx
Robert Wood Johnson Foundation. (2012, September 13). Health Policy Brief: Care Transitions. Health Affairs. Retrieved from http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=76
PRESENTATION SOURCES
Camden Coalition of Healthcare Providers
Community-Based Care Management for Vulnerable
PopulationsKelly Craig, MSW, LSW
Camden Coalition of Healthcare Providers
www.camdenhealth.org
John’s Story•44 year old former Pro Wrestler “The Black Scorpion”•Suicide Attempt by hanging•Homeless•Lack of Family Support•Poor Medication Adherence•Drug Use•Seizures & Hypertension•Anxiety & Depression• Insulin Dependent
Patient Centered Care Coordination
Hospital #1
Streets
Hospital #2
Transport
BehaviorDay
Program
WileyChristian
Day
PCP
Neuro PhysicalTherapy
OccupTherapy
PodiatryEndocrine
Ortho-Pedics
Nephro
Shelter
Apart-ment
Cherry HillPartialDay
Tempus Pharmacy
Collab.Support Program
Accompaniment
SSD
LegalAid
ChildSupport
What is the Camden Coalition of Healthcare Providers?
Mission: “…to improve the health status of all Camden
residents by increasing capacity, quality, coordination, and accessibility of care in the City”
Vision:“To be the first community in the country to
dramatically bend the cost curve while improving quality outcomes”
www.camdenhealth.org
Camden Cost Curve, 2011
www.camdenhealth.org
1% of patients accounted for 26 % of all charges
5% of patients accounted for 58% of all charges
10% of patients accounted for 73% of all charges
Hospital Discharge Framework
The Push
The Carry
The Catch
The Carry: Community Based Care Coordination
Data Triage Outreach Graduation
Tenets of Good Care
• Enroll patients based on data; history of repeat admissions (high cost) and specific inclusion criteria
• Provide immediate and intensive follow-up coordination post discharge (<72 hours)
• Connect patient to PCP as quickly as possible (target = 7 days post d/c)
• Improve the relationship between patient/family and PCP/specialists
• Equal focus of intervention on coaching
www.camdenhealth.org
Key Intervention:Home-Based Medication Reconciliation
www.camdenhealth.org
Registered Nurse Social Worker Behavioral
Specialist Intervention
Specialist Licensed Practical Nurse
Licensed Practical Nurse
Community Health Worker
Health Coach Health Coach
Program Director Associate Clinical Director
Licensed Practical Nurse
Licensed Practical Nurse
Community Health Worker
Health Coach Health Coach
It takes a team
Team Awesome Team
Dynomite
2012-2013 NACHC AmeriCorps Health Navigators
Division of Work (0-30 days)
Nursing Health Coaches
Clinical assessment Make appointments
Medication reconciliation Transportation enrollment & training
Establish care plan; identify patient goals
Nutritional support AND food security
Accompanied PCP and specialty care follow up appointments
Mobility assistance
Follow-up home visits; care provider reinforcement
Accompaniment
Establish Health Coach plan for second phase
Division of Work (30 days and beyond)
Nursing Health Coaches
Medication reconciliation Logistics: make own appointments, arrange own transportation, access specialty care
Chronic disease maintenance Disease self management: awareness of chronic disease maintenance, can communicate with provider(s) and navigate an agenda
Handle readmissions Social skills: can find resources, life management skills
Schedule hand-off appointment; graduation to PCP
Ongoing social support
The Catch: Primary Care Capacity Building
Care Coordination
•Nurse Care Transitions•Accompanied PCP visit•Weekly care coordination rounds•Accompanied specialty visit•HIE training•Social work assistance
Quality
Improvement
•Patient registries•Team meetings•Protocols•Provider/staff Education•EMR Meaningful Use assistance•Data collection/analysis
Patient
Engagement
•Chronic Disease self-management education•Group medical visits•Mental health assessment & counseling•Peer support groups•Wellness programs
Expansion to Primary Care
• Incorporating Community HealthCorps Navigators in 4 Primary Care Practices/FQHCs
• Maternal/Child Health programming
The Black Scorpion Speaks…“At first I was reluctant, but the communication and the relationship with the team is wonderful and very supportive. They are always in touch with me and assist me in meeting my goals. For example, guiding me to my new apartment and MICA program. I feel security with the team. I was not just left, put out in the middle of nowhere. They actually did what they said they were going to do and that made all the difference.”
Thank you for your timeQuestions/comments please contact Kelly Craig - [email protected]
www.camdenhealth.org