1. In-Reach Hospital Program In-Reach Hospital Program Coordinating Multiple Service Providers Rare Presentation Partnership between: South Central Human Relations Center Steele County Human Services South Country Health Alliance Allina Health Owatonna HospitalOctober 2 nd 2012

2. Program Value Patient Access to the full spectrum of needed provider services through access assistance and advocacy for correct health care program enrollment resulting in optimal care. Providers Efficient patient encounters assisted by unique treatment plans easily accessed in Excellian and system care coordinator in attendance at clinic visits Cost Savings

3. Objectives of the Program To encourage health care providers to coordinate their efforts to assure the most vulnerable patient populations seek and obtain primary care. To increase preventive services including screening and counseling, to those who would otherwise not receive such screening to improve health, reduce complications, and cost. To provide a mechanism for improving both quality and efficiency of care for vulnerable individuals with an emphasis on those most likely to remain uninsured or underinsured. To manage chronic conditions to reduce their severity, negative health outcomes, and expense.

4. Process for Identifying and Engaging Patients List of patients is generated 5 more visits in in quarter (Crystal Report) Phone Call, Letter, and note in chart to page social worker when they arrive List is reviewed with Medical Director of ED and Nurse Manager of ED Patient consents to system care coordination.

5. How is Systems Care Coordination different from typical hospital social worker role? Social worker walks with the patient rather than makes referrals from the hospital environment. Social worker walks with the patient rather than makes referrals from the hospital environment. Functional Assessment and Community support plan is developed with the patient to stabilize their mental and physical health. Functional Assessment and Community support plan is developed with the patient to stabilize their mental and physical health. Sixty days of case management with a goal of the patients transitioning to community based support services. Sixty days of case management with a goal of the patients transitioning to community based support services. Collaborative to get all of the service providers working together with the patient. Collaborative to get all of the service providers working together with the patient.

7. Common Patient Profile Patients are between the ages of 20 and 40 years of age. Diagnosed or undiagnosed anxiety, depression, or substance abuse Chief complaint related to physical symptoms related to depression or anxiety (i.e. HA, SOB, palpitations, etc) Majority are on public assistance (but not ALL) Majority either have or have had a mental health adult case worker Often are disconnected with case worker and primary care physician Need assistance before qualifying for the Human or Mental Health Services recommended in their discharge instructions/plan from ED Many have issues with transportation, housing, food, and medications which is often not addressed in their ED stay

8. The Program Data

12. Managed Care Data January 2012 to July 2012 39 clients Reviewed Emergency Department, Overall Primary Care Physician Cost $51,951 reduction in paid health care claims

13. Billable Service 2011-Successful legislative effort-payment guidelines imbedded in the HS Omnibus Bill (Sec. 45. Minnesota Statutes 2010, section 256B.0625) Currently in final process of approval from CMS with MNDHS Billing expected to be in 15 minute increments at community health worker hourly salary.

15. Contact Information Elizabeth Keck, MSW, LGSW elizabeth.keck@allina.com