Building a Learning Collaborative for High Utilizer Interventions

1. Building a Learning Collaborative for High Utilizer Interventions Andrea Hallowell MillerProgram Manager, Cross-Site Learning

2. John’s Story 44 year old former Pro Wrestler “The Black Scorpion” Suicide Attempt Homeless Lack of Family Support Poor Medication Adherence Drug Use Seizures & Hypertension Anxiety & Depression Insulin Dependent 2012 Hospital Utilization: 9 inpatient admissions 3 Emergency Department visits

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

4. Clinical Interventions The Carry The Catch The Push

5. The Carry: Community Based Care Coordination Outreach Triage Graduation Data • Discharge • Deceased • Moved • Lost contact • Disengaged

6. Cross-Site Learning Program • Began in July 2012 to address the need for teaching and collaboration around care for high needs, high cost patients • Fosters technical assistance and other resources for sites across the country • Moving toward a “hub” model for collaboration, with sites serving as regional centers of excellence for other communities

7. Project Goals

8. CSL Project Sites Robert Wood Johnson Foundation Centers for Medicare and Medicaid Innovations • Boston, MA • Cincinnati, OH • Cleveland, OH • Grand Rapids, MI • Humboldt County, CA • Kennebec County, ME • Allentown, PA • Aurora, CO • Kansas City, MO • San Diego, CA Independently Funded • Howard County, MD • New Orleans, LA • Pittsburgh, PA

9. National Governors’ Association State Projects • Alaska • Colorado • Kentucky • New Mexico • Puerto Rico • West Virginia • Wisconsin

10. Known Super-Utilizer Interventions

11. 2014 and Beyond • Manual: Developing a Super-Utilizer Intervention • Interactive web resources • Expanded “boot camp” open house program • Recruiting new CSL sites • National Governors Association Super-Utilizer Policy Academy

12. Theory of Change

13. Clinical Readiness • Do you have staff members in your organization who will take on this work, or is hiring necessary? • Have you developed a workflow for care transitions? • Have you begun seeing patients?

14. Data Readiness • Have you used data to define the problem in your community (hotspotting)? • Have you established patient enrollment criteria? • Have you determined a strategy for these patients?

15. Engagement Readiness • Have you assessed existing community resources for this patient population? • Do you already have connections with these resources? • Which organizations do you plan to target for partnership?

16. Resources • andrea@camdenhealth.org • www.camdenhealth.org • Twitter: @camdenhealth