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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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Presentation Transcript
slide1

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

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

outreach program goals
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
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

evidence based practices
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
outreach team composition
Outreach Team Composition

www.camdenhealth.org

level 1 highest risk
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

level 1 highest risk workflow
Level 1: Highest Risk Workflow

www.camdenhealth.org

level 2 intermediate to high r isk
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
outreach intervention
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
case presentation charley
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

patient centered care coordination
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

frequently asked questions
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?
slide20
Q & A

Kelly Craig, MSW, LSW

Kelly@camdenhealth.org

856-365-9510 x2004

Jason Turi, MPH, RN

Jason@camdenhealth.org

856-365-9510 x2017