Camden Coalition of Camden Coalition Healthcare Providers

Camden Coalition of Camden Coalition Healthcare Providers 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 www.camdenhealth.org

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

Clinical Model “Care Management” Medically complex Socially complex High 6-12 mos. Risk engagement Lourdes Cooper Data Virtua Patients Flagged: 2 hospital admissions 6 months Quality improvement Medical Patient Home engagement Care coordination Assessment Triage Assignment Selection Criteria: History of chronic disease related admits Rule out criteria Assigned to pathway Interm. Risk Medically complex 30-90 day engagement www.camdenhealth.org “Care Transitions”

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 and PCP Equal focus of intervention on coaching www.camdenhealth.org

Outreach Team Composition High Risk Outreach Team Intermediate Risk Outreach Team RN RN MA LPN Health Coaches Health Coaches Social Worker www.camdenhealth.org

Daily Admissions Feed Admitted past month, 6 month summary Admit Facility Days 6 mo episodes Inp ED Name dob age sex PCP PracticeName Insurance CMC Dept of CAMcare Health Cooper Physician HORIZON NJ PPO 06/13/12 Cooper Cooper Cooper Cooper OLOL Cooper OLOL Cooper 40 44 79 35 1 5 4 27 7 3 3 2 2 2 2 2 3 2 15 18 99 13 3 3 9 43 17 27 35 46 31 2 1 34 131 54 177 3 139 9 9 5 5 5 4 3 3 3 3 2 2 2 2 2 xxxxxxxxxxxxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx 55 73 57 21 56 61 54 47 M F M M M M M M JACK GOLDSTEIN MARILYN GORDON JOHN KIRBY NO PHYSICIAN MARILYN GORDON CAMcare Health 1 2 1 xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx 22 F 55 M 64 M MIGUEL MARTINEZ NO PHYSICIAN DANIEL HYMAN Cooper Physician 5 1 5 3 1 5 2 1 1 xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx xx/xx/xxxx 48 71 66 52 70 73 52 68 73 62 35 49 91 51 87 LYNDA BASCELLI Project Hope 3 1 1 1 SELF PAY SELF PAY 06/12/12 Cooper Cooper Cooper AMERHLTH/KEYST Cooper Physician 06/11/12 Cooper OLOL OLOL Cooper OLOL OLOL OLOL Cooper OLOL Cooper Cooper OLOL OLOL Cooper OLOL Thursday, J une 14, 2012 10 6 4 2 2 Page1 of 8 M F F M F F F F F F M F F M F INTERNAL BILLING HORIZON NJ LYNDA BASCELLI Project Hope BRAVO HEALTH HORIZON NJ SELF PAY MINH HUYNH HORIZON NJ ANNA HEADLY NO PHYSICIAN NO PHYSICIAN Cooper Physician SELF PAY HORIZON NJ MEDICAID HORIZON NJ

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 www.camdenhealth.org

Care Management Workflow www.camdenhealth.org

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 www.camdenhealth.org

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 www.camdenhealth.org

1 year pre-enrollment Charges 112,664; Receipts: 22,365 Post-enrollment (10 months) Charges 64,974; Receipts 12,380 3 2.5 Length of stay 2 1.5 1 0.5 0 ED IP www.camdenhealth.org

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

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

Care Transitions 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) Planned 30 - 90 day engagement

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 www.camdenhealth.org

Key Intervention: Home-Based Medication Reconciliation

Patient Centered Care Coordination Transport Meals Durable Goods Home PT/OT Home Nursin g Sub-Acute Rehab Hospita l #1 Patient Dialysi s Hospita l #2 PCP Urolog y Nephrology Optho Transplant Pain Mgt Cardiology GI www.camdenhealth.org Oncology Surger y

www.camdenhealth.org

Q&A Kelly Craig, MSW, LSW Director, Care Management Initiatives [email protected] 856-365-9510 x2004 Jason Turi, MPH, RN Manager, Care Transitions [email protected] 856-365-9510 x2017