camden coalition of healthcare providers
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Camden Coalition of Healthcare Providers. Clinical Care Coordination & Delivery Community Outreach for Complex Patients: Basics of Care Management in the Field September 5, 2012. www.camdenhealth.org. Overview. Clinical model Program goals & guiding p rinciples - PowerPoint PPT PresentationTRANSCRIPT
Camden Coalition of Healthcare Providers
Clinical Care Coordination & Delivery
Community Outreach for Complex Patients:Basics of Care Management in the
FieldSeptember 5, 2012
Camden Coalition of Healthcare Providers
www.camdenhealth.org
Overview• Clinical model• Program goals & guiding principles• Evidence-based practice• Team composition• Daily admissions feed• Workflows• Case Presentation: “Charley”• Q & A
Clinical Model
www.camdenhealth.org
•Lourdes•Cooper•Virtua
Data •Assessment•AssignmentTriage
•Medically complex•Socially complex•6-12 mos. engagement
Risk Level 1
•Quality improvement
•Patient engagement
•Care coordination
Medical Home
•Medically complex
•30-90 day engagement
RiskLevel 2Patients Flagged:
• 2+ hospital admissions < 6 months
Selection Criteria:• History of chronic
disease related admits
• Rule out criteria• Assigned to
pathway“Intermediate to high risk
patients”
“Highest risk patients”
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/family and PCP & specialists
• Equal focus of intervention on coaching
www.camdenhealth.org
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 Team Composition
High Utilizer Outreach Team
Program Manager & Assistant RNSocial Worker & Case Worker LPN (2)
Behavioral Health Specialist Health Coaches & Community Health Workers
www.camdenhealth.org
Daily Admissions Feed
Level 1: Highest Risk• Significant hospital utilization• 2 or more chronic health conditions • Low socioeconomic status• Homeless or unstable housing• Lack of significant social supports• Low-literacy, lack of HS diploma• Behavioral health issues• Generational poverty/urban violence
www.camdenhealth.org
Level 1: Highest Risk Workflow
www.camdenhealth.org
Level 2: Intermediate to high 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
Level 2: Intermediate to High risk workflow
www.camdenhealth.org
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)• Individualized engagement period
Case Presentation: “Charley”• 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
Key Intervention:Home-Based Medication Reconciliation
Patient Centered Care Coordination
www.camdenhealth.org
PatientHospita
l #1
Sub-Acute Rehab
Hospital #2
Home Nursin
g
HomePT/OT
Durable Goods
MealsTransport
Dialysis
Nephrology
Transplant
PCPUrolog
y OncologySurger
y
GICardiology
Optho
Pain Mgt
www.camdenhealth.org
Frequently asked questions• How do you recruit and train quality
staff?• What is your patient census?• How do you build relationships with
outside providers?• What is your referral source?• What about HIPAA?• What are your evaluation metrics?
Q & AKelly Craig, MSW, [email protected] x2004
Jason Turi, MPH, [email protected] x2017