Winona Health: Community Care
Network Program
Robin Hoeg, RN, MS,
Service Line Leader of Inpatient Services
Paula Philipps, RN, BSN
Cassie Boddy, LSW
April 30, 2014
Participants:1-866-639-0744, no code needed
Webinar Objectives:
• Describe the overall goals of the Community Care Network
program
• Identify ways the program helps overcome care gaps in the
community
• Discuss the role of the health coach within the multidisciplinary
team
• Discuss the significance of early results on overall sustainability of
the program
Community Care Network
Robin Hoeg, RN, MS, Service Line Leader of Inpatient Services
Paula Philipps RN, BSN
Cassie Boddy, LSW
Outline of Presentation
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Background of Community Care Network
Recognizing and linking needs in the community
Developing the community program
Review of outcomes and results
Community Care Network
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Idea, concept and innovation
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Meadville Medical Center & Allegheny College
Meadville, PA
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Intention
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Reduce hospital and emergency department readmissions
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Increase primary care clinic visits
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Maintain patients in their home environment
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Offer health coach philosophy
What is our BIG picture?
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Improving community health
Patient engagement
Cost avoidance
Recognizing the Need
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Increasing population with staggering health care
needs
Hospitals are being charged with finding ways to
treat patients more efficiently and thereby decreasing
length of stays and decreasing overall cost of care
Patients are leaving hospitals earlier and bearing the
burden of managing their health care needs at home
No reimbursement for readmissions within 30 days.
What’s Missing?
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Care Gaps
 Meeting criteria
 Working in silos
 What do patient’s want?
 Poor communication
 Lack of coordination
Care Transitions
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Medication errors
Non compliance due to social constraints
Exacerbations of chronic illness
Inability of patient/families to recognize and
react to signs of acute illness
Handoffs
Who are our high risk patients?
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Readmissions
Low health literacy
High users of emergency department
Frequent hospital admissions
Frequent clinic visits for social needs
Multiple chronic diseases
Impact of Health Literacy
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Limited health literacy skills are associated with an
increase in preventable emergency room visits and
hospital admissions
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33-69% of medication related hospitalizations were due
to poor adherence
Though shared decision-making is associated with
improved outcomes, only 9% of patients actually
participate in decisions.
50% of patients leave visits not understanding what their
provider has told them.
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Program Development
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Utilized model from Meadville
Started by admitting a patient who was frequently
hospitalized
Adapted model to meet Winona’s needs
No rules = greater creativity
Told our story
Recognized benefits of trained health coaches
Program Development/
Health Coach Curriculum
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Partnered with Winona State University
Students get credits for class and practicum(s)
Purposefully recruit non-nursing students
Class content focus
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building relationships
therapeutic communication
strategies to cope with chronic conditions
Students are required to do at least one semester
practicum with a CCN client
What are health coaches?
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A new team member who helps connect patients
with providers and community resources.
Health Coaches act as a liaison between the patient,
family, community and primary care provider.
Health coaches:
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Have a positive impact on adherence
Help make links to community resources
Contribute to better outcomes
Control costs
Improve Health
Accountability partner
Benefits of health coaches
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Health Coaches can develop relationships with the
patients that healthcare personnel can not.
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See patients in their own environment where the patient is
most comfortable and in control
Become confidants and “Cheerleaders”
Celebrate success no matter how small
Provide self-management support
Bridge the gap between clinicians and client
Help client navigate the health care system
Offer emotional support
Serve as a continuity figure
CCN Team Members
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RN
Social Worker
Health coaches
Interdisciplinary panel
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Dietician
Mid-level Provider
Administration
PT/OT
Chaplain
Counselor
Purpose of Program
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Reduce an individual’s healthcare costs
Reduce hospital admissions
Reduce Emergency Department visits
Provide support to individuals by bridging gaps in
care at the appropriate setting
Improve healthcare outcomes
Improve an individual’s overall health
Improve an individual’s quality of life
Reduce overall health care costs in our community
Who Qualifies?
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No age limit
Anyone with a chronic disease
Target the high risk patients
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Frequent hospitalizations
Frequent ED visits
Frequent clinic visits for non-medical reasons
It’s not home health care
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No homebound or skilled criteria
Results/Outcome
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10/1/13 - 12/31/13
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ED Visits: 91% reduction
Rehospitalization: 94% reduction
1/1/14 - 3/31/14
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ED Visits: 88% reduction
Rehospitalization: 85% reduction
Client Story
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Prior to program
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Since admission to CCN (10/4/14)
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34 Emergency Department visits in one year
27 Clinic visits in one year
2 Hospitalizations
2 Emergency Department visits
3 Clinic visits
0 Hospitalization
The Success:
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Health coach involvement
Cognitive skills and activities
Increased social engagement
Reflections
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Age of clients
Visit is driven by client, not staff
Vulnerability of the clients after a hospitalization or
clinic visit
The impact of listening and how we can improve
Seeing how the system fails our clients (multiple
providers)
Impact of health coaches
Barriers to admission
Questions?
Upcoming RARE Events….
Stay tuned for the next ….
Webinar:
May 20, 2014
A Perfect Partnership: Ensuring a Safe Patient Transition With a Post
discharge Firefighter Visit
Park Nicollet and St. Louis Park Fire Department
Action Learning Day:
June 17, 2014
Action Learning Day and Reception Celebration
Crown Plaza Hotel, Plymouth, MN
Registration now open!
Future webinars…
To suggest future topics for this series,
Reducing Avoidable Readmissions
Effectively “RARE” Networking
Webinars, contact:
Kathy Cummings, kcummings@icsi.org