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Camden Coalition of Healthcare Providers Community Outreach for Complex Patients: Basics of Care Management and Care Transitions in the Field Kelly Craig,

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Presentation on theme: "Camden Coalition of Healthcare Providers Community Outreach for Complex Patients: Basics of Care Management and Care Transitions in the Field Kelly Craig,"— Presentation transcript:

1 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

2 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

3 Clinical Model Lourdes Cooper Virtua Data Assessment Assignment Triage Medically complex Socially complex 6-12 mos. engagement High Risk Quality improvement Patient engagement Care coordination Medical Home Medically complex day engagement Interm. Risk Patients Flagged: 2+ hospital admissions < 6 months Selection Criteria: History of chronic disease related admits Rule out criteria Assigned to pathway “Care Transitions” “Care Management”

4 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

5 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

6 Outreach Team Composition High Risk Outreach TeamIntermediate Risk Outreach Team RN MALPN Health Coaches Social Worker

7 Daily Admissions Feed

8 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

9 Care Management Workflow

10 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

11 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

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13 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

14 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

15 Care Transitions Workflow

16 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 day engagement

17 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

18 Key Intervention: Home-Based Medication Reconciliation

19 Patient Centered Care Coordination Patient Hospita l #1 Sub-Acute Rehab Hospita l #2 Home Nursing Home PT/OT Durable Goods Meals Transport Dialysis Nephrology Transplant PCPUrologyOncologySurgeryGI Cardiology Optho Pain Mgt

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22 Q & A Kelly Craig, MSW, LSW Director, Care Management Initiatives x2004 Jason Turi, MPH, RN Manager, Care Transitions x2017


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