In-Reach Program
Elizabeth Keck, MSW, LGSW
Allina Health - Owatonna Hospital
May 19, 2014
Participants:1-866-639-0744, no code needed
In-Reach Program
Coordinating Multiple Service Providers
Rare Presentation
Partnership between:
 South Central Human Relations Center
 Steele County Human Services
 South Country Health Alliance
 Owatonna Hospital-Allina Health Systems
May 19th 2014
Program Value
Patient
Access to the full spectrum of needed provider services through access assistance
and advocacy for correct health care program enrollment resulting in optimal care.
Providers
Efficient patient encounters assisted by unique treatment plans easily accessed in
Excellian and system care coordinator in attendance at clinic visits.
Cost Savings
Objectives of the Program
To encourage health care providers to coordinate their efforts to assure
the most vulnerable patient populations seek and obtain primary care.
To increase preventive services including screening and counseling, to
those who would otherwise not receive such screening to improve health,
reduce complications, and cost.
To provide a mechanism for improving both quality and efficiency of care
for vulnerable individuals with an emphasis on those most likely to remain
uninsured or underinsured.
To manage chronic conditions to reduce their severity, negative health
outcomes, and expense.
Process for Identifying and
Engaging Patients
List of patients is
generated
Patient consents to
system care
coordination.
Phone Call, Letter, and
note in chart to page
social worker when they
arrive
5 more visits in in
quarter
(BOE Report)
List is reviewed with
Medical Director of
ED and Nurse
Manager of ED
Common Patient Profile
 Patients are generally between the ages of 20 and 40 years of age.
 Diagnosed or undiagnosed anxiety, depression, or substance abuse.
 Chief complaint related to physical symptoms related to depression or
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anxiety (i.e. HA, SOB, palpitations, etc)
Majority are on public assistance (but not ALL)
Majority either have or have had a mental health adult case worker
Often are disconnected primary care physician
Need assistance before qualifying for the Human Service or Mental Health
Services as recommended in their discharge instructions/plan from ED
Many have issues with transportation, housing, food, and medications which
is often not addressed in their ED stay
Often times patients mental health treatment providers are not aware of
their emergency department visits that relate to their mental health
symptoms.
How is Health Care Coordination different from
typical hospital social worker role?
Health Care
Coordinator
Hospital Social
Worker
Community Providerconnecting to resources
Patient is not admitted to
hospital.
60 days of interventions.
Attends follow up health care
appointments with patient.
Discharge Planning
Patient is admitted to
hospital or in ED
Once patient is discharged
Social Worker does not
follow up.
Health Care Coordinator Tasks
Functional
Assessment
Completed
Goal
Development
Screening Tools:
PHQ-9, GAD-7,
Physical Exam,
Pre Questions
Releases are
Signed
Unique
Treatment Plan
Developed
Patient Name: John Doe
Owatonna Clinic MRN: 20-520-879
Owatonna Hospital MRN: 10099999
Date of Birth: 01/01/1900
Date of Plan: 2/9/2011
Goal of Care Plan:
Mr. Doe will reduce overall usage of the Emergency Department and have a
reduction in overall symptoms.
Living Arrangements: Mr. Doe lives in his own apartment. He does not have a lot of
contact with his family. He does engage with his neighbors on fairly regular basis. Mr.
Doe lives on Social Security Disability. He uses the SCAT bus for transportation as
needed. He sometimes has trouble getting to and from appointments when the SCAT bus
is full.
County Involvement: Mr. Doe has an adult mental health case manager, Sara Jane. Mrs.
Jane can be reached at 507-455-9999. Mr. Doe’s financial worker at this time is Deb W.
Deb provides SCAT tickets so Mr. Doe can get to and from his medical appointments.
Mr. Doe’s health insurance provider SCHA has a nurse that provides care coordination
services for Mr. Doe. Her name is Patty Hocking and she can be reached at 507-4558115. Mrs. Hocking assists with arising medical needs and concerns as necessary.
Psychiatric Care: Mr. Does’s psychiatrist is Dr. Peace at the Human Relations Center.
Mr. Doe sees Dr. Peace once every three months unless issues arise. Mr. Doe carries a
diagnosis of Major Depression and Anxiety Disorder NOS. Mr. Doe also has an
ARMHS (Adult Rehabilitative Mental Health Services) worker Patty Sunshine. Mrs.
Sunshine goals with Mr. Doe include learning coping skills for managing his anxiety,
maintaining his apartment, and learning to deal with difficult people. Mr. Doe is not
seeing a therapist at this time but has engaged in this service in the past.
Family Physician: Mr. Doe’s primary care physician is Dr. Doolittle at the Owatonna
Clinic. See attached note about care plan Dr. Doolittle, Dr. Peace and Mr. Doe created.
The Program Data
2013
Managed Care Data
39 Patients
Reviewed Emergency
Department, Overall
Primary Care
Physician Cost
$51,951 reduction in
paid health care
claims
22 Patients
Prior ED Visits = 139
Post ED Visits = 91
Difference = -47
Hospitalizations:
Prior – 17
Post – 13
2012
Patient Satisfaction
1. Patient Survey upon closure of
case.
2. Pre and Post Questions
Survey
Pre and Post Questions
Billable Service
 2011-Successful legislative effort-payment guidelines
imbedded in the HS Omnibus Bill (Sec. 45. Minnesota
Statutes 2010, section 256B.0625)
 Billing expected to be in 15 minute increments at
community health worker hourly salary.
 MS 256B.0625 subd, Covered Services; Medical
Service Coordination.
 Bill 80 hours within a calendar year.
 Can not have two overlapping 60 day occurrences
 Criteria is 4 visits in 3 months.
Contact Information
 Elizabeth Keck, MSW, LGSW
 elizabeth.keck@allina.com
Upcoming RARE Events….
Stay tuned for the next RARE Mental Health Webinar:
New York Office of Mental Health
Dr. Molly Finnertry
June 26, 2014 (Noon-1pm)
Future webinars…
To suggest future topics for this series,
Reducing Avoidable Readmissions
Effectively “RARE” Networking
Webinars, contact:
Kathy Cummings, kcummings@icsi.org
Jill Kemper, jkemper@icsi.org