Camden Coalition of Healthcare Providers

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


•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


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


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


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


Level 1: Highest Risk Workflow


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


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


Key Intervention:Home-Based Medication Reconciliation

Patient Centered Care Coordination


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


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

Documents

Camden Coalition of Healthcare Providers