In-Reach Hospital Program
Coordinating Multiple Service Providers
Rare Presentation
Partnership between:
 South Central Human Relations Center
 Steele County Human Services
 South Country Health Alliance
 Allina Health Owatonna Hospital
October 2nd 2012
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
(Crystal Report)
List is reviewed with
Medical Director of
ED and Nurse
Manager of ED
How is Systems Care Coordination different from
typical hospital social worker role?
 Social worker walks with the patient rather than makes
referrals from the hospital environment.
 Functional Assessment and Community support plan is
developed with the patient to stabilize their mental and
physical health.
 Sixty days of case management with a goal of the
patients transitioning to community based support
services.
 Collaborative to get all of the service providers working
together with the patient.
Inputs
Activities
Licenses Social Worker
Computer
Phone
Funding Contracts with:
 SCHRC
 Owatonna Hospital
 SCHA
 Steele County
Human Services
ED Use: 5(+) times in 3 months
(MD Medical Director, RN
Manager, & Systems Care
Coordinator Review)
 Engage patients in
partnership to reduce ED
visits & use community
resources for appropriate
care.
 Releases of Information
obtained
 Functional Assessment
 Community Support Plan
 Care Plan with patient,
Primary Care, & Systems
Care Coordinator is used
when patient presents to ED
 Community referrals
Outputs
196 Patients Served
102 Care Plans Developed
$1,886,365 decrease in
Emergency Department visits
and hospitalizations 1 year post
intervention
64% decrease in ED visits two
years post intervention
81% decrease in ED visits three
years post interventions.
Immediate Outcomes
Intermediate Outcomes
Patients will reduce ED visits
Patients will get connected
to services and resources in
the community
•
•
•
Providers coordinate
efforts to help
vulnerable populations
seek & obtain primary
care
Patients increase
preventive services to
improve health, reduce
complications & costs
Patients manage chronic
conditions to reduce
severity, negative health
outcomes, & expense
Long Term Outcomes
Shared responsibility
between primary care,
mental health, community
services and the
Hospital
Reduction in health care
costs.
Common Patient Profile
 Patients are 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





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 with case worker and primary care physician
Need assistance before qualifying for the Human or Mental Health Services
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
The Program Data
Managed Care Data
 January 2012 to July 2012
 39 clients
 Reviewed Emergency Department, Overall Primary Care
Physician Cost
 $51,951 reduction in paid health care claims
Billable Service
 2011-Successful legislative effort-payment guidelines
imbedded in the HS Omnibus Bill (Sec. 45. Minnesota
Statutes 2010, section 256B.0625)
 Currently in final process of approval from CMS with
MNDHS
 Billing expected to be in 15 minute increments at
community health worker hourly salary.
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.
Patient Name: John Doe
Owatonna Clinic MRN: 20-520-879
Owatonna Hospital MRN: 10099999
Date of Birth: 01/01/2011
Date of Plan: 2/9/2011
Care Plan:
Care plan for Fibromyalgia:
Treatment Recommendations for Fibromyalgia:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
When should patient use ED for treatment of Fibromyalgia:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Should narcotic medications be used to treat Fibromyalgia: _______________________
Care Plan for Back Pain:
Treatment Recommendations for Back Pain:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
When should patient use ED for treatment of Back Pain?:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What medications should be used to treat Back Pain if patient presents to ED?:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Care Plan for Migraine/Headaches:
Treatment Recommendations for Migraines/Headaches:
Contact Information
 Elizabeth Keck, MSW, LGSW
 elizabeth.keck@allina.com