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Reducing Re-hospitalizations Using Non-Medical Personnel. Kelly Craig, Camden Coalition of Healthcare Providers Rachel Wolf, Salud Family Health Centers October 10, 2013. CARE TRANSITIONS 101.

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Reducing re hospitalizations using non medical personnel

Reducing Re-hospitalizations Using Non-Medical Personnel

Kelly Craig, Camden Coalition of Healthcare Providers

Rachel Wolf, Salud Family Health Centers

October 10, 2013


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

1 The Care Transitions Program®. (2008) Transitional Care: Definitions. Retrieved: http://www.caretransitions.org/definitions.asp


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

2Coleman 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.


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/RecognitionTraining/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


Community based care management for vulnerable populations kelly craig msw lsw

Camden Coalition of

Healthcare Providers

Community-Based Care Management for Vulnerable PopulationsKelly Craig, MSW, LSW

www.camdenhealth.org


John s story
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

Accompaniment

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


What is the camden coalition of healthcare providers
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
Hospital Discharge Framework

The Carry

The Catch

The Push


The carry community based care coordination
The Carry: Community Based Care Coordination

Outreach

Triage

Graduation

Data


Tenets of good care
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 m edication r econciliation
Key Intervention:Home-Based Medication Reconciliation

www.camdenhealth.org


It takes a team

  • Registered Nurse

  • Social Worker

  • Behavioral Specialist

  • Intervention Specialist

Team Awesome

Team Dynomite

  • Licensed Practical Nurse

  • Licensed Practical Nurse

  • Community Health Worker

  • Health Coach

  • Health Coach

  • Licensed Practical Nurse

  • Licensed Practical Nurse

  • Community Health Worker

  • Health Coach

  • Health Coach

  • Program Director

  • Associate Clinical Director




Division of work 30 days and beyond
Division of Work (30 days and beyond)



Expansion to primary care
Expansion to Primary Care

  • Incorporating Community HealthCorps Navigators in 4 Primary Care Practices/FQHCs

  • Maternal/Child Health programming


The black scorpion speaks
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


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