1.  Reducing Re-hospitalizations Using Non-Medical Personnel Kelly Craig, Camden Coalition of Healthcare Providers Rachel Wolf, Salud Family Health Centers October 10, 2013

2. CARE TRANSITIONS 101

3. “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.asphttp://www.caretransitions.org/definitions.asp

4. 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

5. 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

6. “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.Improving the Quality of Transitional Care for Persons with Complex Care Needs.

7. Coleman, EA. (2008) The Care Transitions Program®. Retrieved from http://www.caretransitions.org 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 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 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/RecognitionTraini ng/PatientCenteredMedicalHomePCMH2011Standard.aspx http://www.ncqa.org/Programs/Recognition/RelevanttoAllRecognition/RecognitionTraini ng/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 http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=76 PRESENTATION SOURCES

8. Camden Coalition of Healthcare Providers Community-Based Care Management for Vulnerable Populations Kelly Craig, MSW, LSW Camden Coalition of Healthcare Providers www.camdenhealth.org

9. 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

10. Patient Centered Care Coordination Hospital #1 Streets Hospital #2 Transport Behavior Day Program Wiley Christian Day PCPNeuro Physical Therapy Occup Therapy Podiatry Endocrine Ortho- Pedics Nephro Shelter Apart- ment Cherry Hill Partial Day Tempus Pharmacy Collab. Support Program Accomp animent SSD Legal Aid Child Support

11. 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

12. 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

13. Hospital Discharge Framework The Push The Carry The Catch

14. The Carry: Community Based Care Coordination Data Triage Outreach Graduation

15. 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

16. Key Intervention: Home-Based Medication Reconciliation www.camdenhealth.org

17.  Registered Nurse  Social Worker  Behavioral Specialist  Intervention Specialist  Licensed Practical Nurse  Community Health Worker  Health Coach  Program Director  Associate Clinical Director  Licensed Practical Nurse  Community Health Worker  Health Coach It takes a team Team Awesome Team Dynomite

18. 2012-2013 NACHC AmeriCorps Health Navigators

19. Division of Work (0-30 days) NursingHealth Coaches Clinical assessmentMake appointments Medication reconciliationTransportation 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

20. Division of Work (30 days and beyond) NursingHealth Coaches Medication reconciliationLogistics: make own appointments, arrange own transportation, access specialty care Chronic disease maintenanceDisease self management: awareness of chronic disease maintenance, can communicate with provider(s) and navigate an agenda Handle readmissionsSocial skills: can find resources, life management skills Schedule hand-off appointment; graduation to PCP Ongoing social support

21. 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

22. Expansion to Primary Care Incorporating Community HealthCorps Navigators in 4 Primary Care Practices/FQHCs Maternal/Child Health programming

23. 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.”

24. Thank you for your time Questions/comments please contact Kelly Craig - kelly@camdenhealth.orgkelly@camdenhealth.org www.camdenhealth.org