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Camden Coalition of Healthcare Providers

Camden Coalition of Healthcare Providers. Clinical Care Coordination & Delivery Community Outreach for Complex Patients: Basics of Care Management in the Field September 5, 2012. www.camdenhealth.org. Overview. Clinical model Program goals & guiding p rinciples

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Camden Coalition of Healthcare Providers

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  1. Camden Coalition of Healthcare Providers Clinical Care Coordination & DeliveryCommunity Outreach for Complex Patients:Basics of Care Management in the FieldSeptember 5, 2012 www.camdenhealth.org

  2. Overview • Clinical model • Program goals & guiding principles • Evidence-based practice • Team composition • Daily admissions feed • Workflows • Case Presentation: “Charley” • Q & A

  3. Clinical Model “Highest risk patients” • Medically complex • 30-90 day engagement • Risk • Level 2 • Patients Flagged: • 2+ hospital admissions < 6 months • Selection Criteria: • History of chronic disease related admits • Rule out criteria • Assigned to pathway “Intermediate to high risk patients” www.camdenhealth.org

  4. 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

  5. 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/family and PCP & specialists • Equal focus of intervention on coaching www.camdenhealth.org

  6. 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

  7. Outreach Team Composition www.camdenhealth.org

  8. Daily Admissions Feed

  9. Level 1: Highest Risk • Significant hospital utilization • 2 or more chronic health conditions • Low socioeconomic status • Homeless or unstable housing • Lack of significant social supports • Low-literacy, lack of HS diploma • Behavioral health issues • Generational poverty/urban violence www.camdenhealth.org

  10. Level 1: Highest Risk Workflow www.camdenhealth.org

  11. Level 2: Intermediate to high 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

  12. Level 2: Intermediate to High risk workflow www.camdenhealth.org

  13. 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) • Individualized engagement period

  14. Case Presentation: “Charley” • 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

  15. Key Intervention:Home-Based Medication Reconciliation

  16. Patient Centered Care Coordination Transport Home PT/OT Meals Home Nursing Hospital #2 Sub-Acute Rehab Hospital #1 Durable Goods Patient Dialysis PCP Urology Nephrology Oncology Surgery Optho Transplant Cardiology Pain Mgt GI www.camdenhealth.org

  17. www.camdenhealth.org

  18. Frequently asked questions • How do you recruit and train quality staff? • What is your patient census? • How do you build relationships with outside providers? • What is your referral source? • What about HIPAA? • What are your evaluation metrics?

  19. Q & A Kelly Craig, MSW, LSW Kelly@camdenhealth.org 856-365-9510 x2004 Jason Turi, MPH, RN Jason@camdenhealth.org 856-365-9510 x2017

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