Outreach to High Utilizing Patients — Basics
of Care Management and Care Transitions in
Camden, NJ
Overview
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Mission
Role
Values
Coalition Structure and Workflow
Care Management Team
Care Transitions Team
Q&A
Our Mission
The Camden Coalition of Healthcare
Providers was created with the
overarching mission to improve the
health status of all Camden residents,
by increasing the capacity, quality, and
access of care in the city
The Coalition’s Role
Unlike many service and social
organizations in the city, the Coalition
does not provide long-term services to
patients, but rather focuses on creating
solutions from the providers and health
systems side of care.
Organizational Values
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Facilitating discussion and strategy design
Collaboration among stakeholders
Creating fluid systems of communication
Data-driven initiatives
Utilizing data to evaluate projects
Sustaining programs for long-term positive
outcomes
Care Continuum Model
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Hospital
Admissions
Data
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Inclusion
Triage
Multidisciplinary care management
outreach
Patients with history of ED visits/hospital
admissions and readmissions (4 admits
w/in 6 mos.); social complexities
Average 6-8 month engagement
Medical Home
CCHP Outreach
Care Coordination
High Risk
Health Coaching
Intermediate Risk
Data driven QI
Patient Engagement
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Nurse driven care transition
Patients with history of ED visits/hospital
admissions and readmissions (2+ admits
w/in 6 mos.); socially stable
Average 6-8 week engagement
Care Transitions & Care
Management Team Program Goals
 Reduce the risk of preventable readmissions
to the hospital
 No open referrals: patients flagged from
Health Information Exchange by Care
Transitions Team
 No duplicate services: we compliment
services of existing providers
Care Management: High Risk
 Hospital utilization in the city
 Appropriate vs. inappropriate
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Two or more chronic health conditions
Low socio-economic status
Homeless or unstable housing
Lack of social supports
Low-literacy, lack of HS diploma
Behavioral health issues
Generational poverty/urban violence
Care Management Team
Purpose
 Improve the health of the patients
 Teach patients to seek services from appropriate locations,
especially their Primary Care Providers, rather than the ED
 Reduce healthcare costs
Services Offered
 Assess the individual’s needs
 Provides immediate healthcare/social services when needed
 Refers patients to their PCP and appropriate agencies for
additional services
 Outreach to homes, shelters, hospitals and even the streets to
provide services
The Role of the Social Worker
 Coordinates case management of the patient’s care
including:
 Short-term needs: temporary housing, food
 Determining insurance eligibility or level of coverage and
helps with enrollment
 Helps the patient access social/health services such as:
 Enrollment in a medical day program, applying for nursing
home care, and accessing specialty care
 Assists in applying for Supplemental Security Income,
Disability or other entitlements as needed
The Role of the RN
 Monitoring chronic conditions
 Oversight of medications/prescribing
 Communicating with other providers regarding the
patient’s care
 Patients typically have multiple social barriers to
accessing traditional healthcare-the nurse encourages
and transitions these clients into traditional primary
care
The Role of the Medical
Assistant & Health Coaches
 A bilingual outreach worker
 Works directly with the social worker and nurse in helping patients
access appropriate health/social services
 Helps patients make appointments/coordinate medical
transportation and can accompany patients to appointments, as
necessary
 Two full-time volunteers working with the Care Management
Team assisting with approximately 10-12 patients at a time
 Reinforce positive behavior changes
 Conducts social visits to monitor patient progress and provide
additional support before “graduation.”
Intake/Engagement Process
 Obtain consent
 Conduct medical and social history
 Immediately identify barriers/reasons for increased ED/hospital
visits
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Unstable housing/homeless
No/changing phone #
Lack of health insurance/benefits
Substance use/mental health issues
Transportation
 Implement immediate plan with patient to address short-term
goals, while building trust and rapport to address long-term
goals
Different Patients – Different Care
Case Study 1: Care Management
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Bedbound
Neuropathy
Obese
Diabetes
Jan 2010-Jan 2012
 24 ED visits
 23 inpatient visits
 Barrier: transportation
Case Study: Care Management
 37 year old Hispanic male
 History of schizoaffective disorder, bipolar, PTSD, history
of sexual abuse as child, unstable housing, medical day
program
 Type1DM X 19yrs, HTN, ESRD, congenital heart defect
(PMVSD/ASD), history of coma w/DKA, endocarditis
 Cognitive impairment vs. mental health
 Recent admits to crisis X 2-suicide ideation w/ means,
hospital w/DKA, GI Bleed
Lessons Learned
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Ethical considerations
Working with patients too long
Enabling vs. Helping patients help themselves
Cultural Competence
Anecdotal Reasons for Success
 Longitudinal relationship
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Build rapport/trust over time
 Proactive, holistic model of care
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Where the person is/whatever it takes
Respectful & non-judgmental care
 Community relationships
 Community problem solving
Care Transitions:
Intermediate Risk
 90-day community-based intervention to stabilize complex
patients
 Patients deemed “intermediate risk” generally have housing and
insurance coverage
 Patient determined at risk for hospital readmission through HIE
 Patient will receive bedside visit from RN/LPN while in hospital
 Home visit within 24hrs after d/c to include medication
reconciliation, health education, appointment scheduling etc.
 Care coordination with PCP & Specialist
 Accompany to 1st PCP follow-up appointment and specialists
 Weekly home/community visits with team
Care Transitions:
Evidence-Based Practices
 The Transitional Care Model: Mary D. Naylor,
PHD, RN; University of Pennsylvania School
Of Nursing
 The Care Transitions Program: Eric
Coleman, MD; Division of Health Care Policy
and Research at the University of Colorado
Denver, School of Medicine
Staffing
 Medical Home Team
 1 Full-time RN Nurse Care Manager
 1 Full-time LPN Nurse Care
Coordinator/Outreach Specialist (bilingual)
 Two “health coaches” – AmeriCorps Volunteers
 In cooperation with Camden’s Federally
Qualified Health Centers
Monitoring & Evaluation
Outcome measures:
 Reduction in ER/hospital use
 Reduction in readmission rates
 Reduction in cost
 Participant satisfaction
Key Intervention: Home–based
Medication Reconciliation
Case Study:
Care Transitions
 52 y/o female Spanish-speaking with COPD/Trach/Vent dependent,
admitted for resp. distress.
 8 readmits last year. Avg. admit every 29 days prior to intervention.
 No referral, directly outreached by team @ hospital.
 Coordinated meeting with patient/family with hospital social worker, home
care, and attending physicians at bedside.
 Transitioned at Long-term Acute Care in Philadelphia, while family
trained on vent and vent was placed at home.
 Transitioned home and f/u to PCP & Specialist appointments
 Currently at home and medically stable, will graduate May 2012
 120 days without hospital utilization, scooter delivered
to home!
Great Long-Term Solution for
Limited Mobility: Red s]Scooter!
Case Study: Care Transitions
 55y/o Male with ESRD/Dialysis, admitted for GI bleed and SOB
November 2011.
 6 admits and 3 ED visits within last 12 months, hospital visit
every 41 days
 No referral, directly outreached by team @ hospital
 Coordinated with patient and renal social worker to transition at
sub-acute facility for rehab
 Transitioned home and accompanied to PCP & Specialists
 Currently at home and medically stable, will graduate May 2012
 120 days without hospital utilization
Q&A
Thank you!
Jason Turi, MPH, RN
Manager, Care Transitions
Jason@camdenhealth.org
856-365-9510 X2017
Kelly Craig, MSW, LSW
Director, Care Management Initiatives
Kelly@camdenhealth.org
856-365-9510 x2004