+
Building a
Learning
Collaborative for
High Utilizer
Interventions
Andrea Hallowell Miller
Program Manager,
Cross-Site Learning
John’s Story
• 44 year old former Pro Wrestler
“The Black Scorpion”
• Suicide Attempt
• Homeless
• Lack of Family Support
• Poor Medication Adherence
• Drug Use
• Seizures & Hypertension
• Anxiety & Depression
• Insulin Dependent
2012 Hospital Utilization:
9 inpatient admissions
3 Emergency Department visits
Patient Centered Care Coordination
SSD
Child
Support
Transport
Accompany
Legal
Aid
Hospital
#1
Tempus
Pharmacy
PCP
Neuro
OrthoPedics
Occup
Therapy
Shelter
Collab.
Support
Program
Behavior
Day
Program
Wiley
Christian
Day
Cherry Hill
Partial
Day
Streets
Hospital
#2
Apartment
Nephro
Endocrine
Podiatry
Physical
Therapy
Clinical Interventions
The Push
PUSH
CARRY
The Carry
The
Catch
CATCH
+
The Carry: Community Based
Care Coordination
Data
Triage
Outreach
Graduation
Discharge
• Deceased
• Moved
• Lost contact
• Disengaged
+ Cross-Site Learning Program
 Began
in July 2012 to address the need for
teaching and collaboration around care for high
needs, high cost patients
 Fosters
technical assistance and other resources
for sites across the country
 Moving
toward a “hub” model for collaboration,
with sites serving as regional centers of excellence
for other communities
+
Project Goals
Develop
Common
Language
Find
Collaborators
Build, Test
and Adapt
New Models
Build a
Movement
Influence
Policy
Makers and
Public
Create New
Hubs and
Identify
Faculty
+
CSL Project Sites
Centers for Medicare and
Medicaid Innovations
Robert Wood Johnson Foundation

Boston, MA

Allentown, PA

Cincinnati, OH

Aurora, CO

Cleveland, OH

Kansas City, MO

Grand Rapids, MI

San Diego, CA

Humboldt County, CA

Kennebec County, ME
Independently Funded

Howard County, MD

New Orleans, LA

Pittsburgh, PA
+
National Governors’ Association
State Projects

Alaska

Colorado

Kentucky

New Mexico

Puerto Rico

West Virginia

Wisconsin
+
Known Super-Utilizer Interventions
+
2014 and Beyond
 Manual: Developing
 Interactive
web resources
 Expanded “boot
 Recruiting
 National
a Super-Utilizer Intervention
camp” open house program
new CSL sites
Governors Association Super-Utilizer
Policy Academy
Theory of Change
Clinical
Redesign
Data
Analysis
Community
Engagement
+
Clinical Readiness
Do
you have staff members in your
organization who will take on this
work, or is hiring necessary?
Have
you developed a workflow for
care transitions?
Have
you begun seeing patients?
+
Data Readiness
Have
you used data to define the
problem in your community
(hotspotting)?
Have
you established patient
enrollment criteria?
Have
you determined a strategy for
these patients?
+
Engagement Readiness
Have
you assessed existing
community resources for this
patient population?
Do
you already have connections
with these resources?
Which
organizations do you plan
to target for partnership?
Resources
• andrea@camdenhealth.org
• www.camdenhealth.org
+
• Twitter: @camdenhealth