Transcript Welcome to the Camden Coalition of Healthcare Providers

Reducing Re-hospitalizations
Using Non-Medical Personnel
Kelly Craig, Camden Coalition of Healthcare Providers
Rachel Wolf, Salud Family Health Centers
October 10, 2013
S
CARE TRANSITIONS 101
“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
The Care Transitions Program®. (2008) Transitional Care: Definitions.
Retrieved: http://www.caretransitions.org/definitions.asp
1
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
KEY BARRIERS TO PROPER CARE
TRANSITIONS
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)
“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
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.
2
PRESENTATION SOURCES
Coleman, EA. (2008) The Care Transitions Program®. Retrieved from
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
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
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
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
Camden Coalition of
Camden Coalition of
Healthcare Providers
Healthcare Providers
Community-Based Care
Management for Vulnerable
Populations
Kelly Craig, MSW, LSW
www.camdenhealth.org
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
Patient Centered Care Coordination
SSD
Child
Support
Transport
Accomp
animent
Legal
Aid
Hospital
#1
Tempus
Pharmacy
PCP
Neuro
OrthoPedics
Occup
Therapy
Shelter
Collab.
Support
Program
Behavior
Day
Program
Wiley
Christian
Day
Cherry Hill
Partial
Day
Streets
Hospital
#2
Apartment
Nephro
Endocrine
Podiatry
Physical
Therapy
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
Camden Cost Curve, 2011
10% of patients accounted
for 73% of all charges
5% of patients accounted for
58% of all charges
1% of patients accounted for
26 % of all charges
www.camdenhealth.org
Hospital Discharge Framework
The Push
The Carry
The Catch
The Carry: Community Based Care
Coordination
Data
Triage
Outreach
Graduation
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
Key Intervention:
Home-Based Medication Reconciliation
www.camdenhealth.org
It takes a team





Team
Awesome
Licensed Practical
Nurse
Licensed Practical
Nurse
Community
Health Worker
Health Coach
Health Coach
 Registered Nurse
 Social Worker
 Behavioral
Specialist
 Intervention
Specialist
 Program Director
 Associate Clinical Director
Team
Dynomite
 Licensed Practical
Nurse
 Licensed Practical
Nurse
 Community Health
Worker
 Health Coach
 Health Coach
2012-2013 NACHC AmeriCorps
Health Navigators
Division of Work (0-30 days)
Nursing
Health Coaches
Clinical assessment
Make appointments
Medication reconciliation
Transportation 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
Division of Work (30 days and beyond)
Nursing
Health Coaches
Medication reconciliation
Logistics: make own
appointments, arrange own
transportation, access specialty
care
Chronic disease maintenance
Disease self management:
awareness of chronic disease
maintenance, can communicate
with provider(s) and navigate an
agenda
Handle readmissions
Social skills: can find resources, life
management skills
Schedule hand-off appointment;
graduation to PCP
Ongoing social support
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
Engagement
•Patient registries
•Team meetings
•Protocols
•Provider/staff Education
•EMR Meaningful Use
assistance
•Data collection/analysis
•Chronic Disease selfmanagement education
•Group medical visits
•Mental health assessment &
counseling
•Peer support groups
•Wellness programs
Expansion to Primary Care
• Incorporating Community HealthCorps
Navigators in 4 Primary Care
Practices/FQHCs
• Maternal/Child Health programming
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.”
Thank you for your time
Questions/comments please contact
Kelly Craig - [email protected]
www.camdenhealth.org