Camden Coalition of
Camden Coalition of
Healthcare Providers
Healthcare Providers
Clinical Care Coordination & Delivery
Community Outreach for Complex Patients:
Basics of Care Management in the
Field
September 5, 2012
www.camdenhealth.org
Overview
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Clinical model
Program goals & guiding principles
Evidence-based practice
Team composition
Daily admissions feed
Workflows
Case Presentation: “Charley”
Q&A
Clinical Model
“Highest risk patients”
Risk
Level 1
Data
•Lourdes
•Cooper
•Virtua
Patients Flagged:
• 2+ hospital
admissions < 6
months
Triage
•Medically
complex
•Socially
complex
•6-12 mos.
engagement
Medical
Home
•Assessment
•Assignment
Selection Criteria:
• History of chronic
disease related
admits
• Rule out criteria
• Assigned to
pathway
Risk
Level 2
•Quality
improvement
•Patient
engagement
•Care
coordination
•Medically
complex
•30-90 day
engagement
www.camdenhealth.org
“Intermediate to high risk
patients”
Outreach Program Goals
• Reduce preventable readmissions to the
hospital; reduce costs for complex patients
• No open referrals; patients flagged and
triaged from Health Information Exchange
• No duplicate services; we compliment
services of existing providers
• Facilitate clinical coordination vs.
direct care
www.camdenhealth.org
Guiding Principles
• Enroll patients based on data; history of
repeat admissions (high cost) and specific
inclusion criteria
• Provide immediate and intensive follow-up
coordination post discharge; connect patient
to PCP as quickly as possible (target = 7 days
post d/c)
• Dramatically improve the relationship between
patient/family and PCP & specialists
• Equal focus of intervention on coaching
www.camdenhealth.org
Evidence-Based Practices
• The Transitional Care Model: Mary D. Naylor,
Ph.D., R.N.; University of Pennsylvania School
Of Nursing
• The Care Transitions Program: Eric Coleman,
M.D.; Division of Health Care Policy and
Research at the University of Colorado
Denver, School of Medicine
Outreach Team Composition
High Utilizer Outreach Team
Program Manager & Assistant
RN
Social Worker & Case Worker
LPN (2)
Behavioral Health Specialist
Health Coaches & Community
Health Workers
www.camdenhealth.org
Daily Admissions Feed
Admitted past month, 6 month summary
Admit Facility
Days 6 mo episodes
Inp ED Name
dob age sex PCP
PracticeName
Insurance
CMC Dept of
CAMcare Health
Cooper Physician
HORIZON NJ PPO
06/13/12
Cooper
Cooper
Cooper
Cooper
OLOL
Cooper
OLOL
Cooper
40
44
79
35
1
5
4
27
7
3
3
2
2
2
2
2
3
2
15
18
99
13
3
3
9
43
17
27
35
46
31
2
1
34
131
54
177
3
139
9
9
5
5
5
4
3
3
3
3
2
2
2
2
2
xxxxxxxxxxxxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
55
73
57
21
56
61
54
47
M
F
M
M
M
M
M
M
JACK GOLDSTEIN
MARILYN GORDON
JOHN KIRBY
NO PHYSICIAN
MARILYN GORDON
CAMcare Health
1
2
1
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
22 F
55 M
64 M
MIGUEL MARTINEZ
NO PHYSICIAN
DANIEL HYMAN
Cooper Physician
5
1
5
3
1
5 2
1
1
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
48
71
66
52
70
73
52
68
73
62
35
49
91
51
87
LYNDA BASCELLI
Project Hope
3
1
1
1
SELF PAY SELF PAY
06/12/12
Cooper
Cooper
Cooper
AMERHLTH/KEYST
Cooper Physician
06/11/12
Cooper
OLOL
OLOL
Cooper
OLOL
OLOL
OLOL
Cooper
OLOL
Cooper
Cooper
OLOL
OLOL
Cooper
OLOL
Thursday, June 14, 2012
10
6
4
2
2
Page 1 of 8
M
F
F
M
F
F
F
F
F
F
M
F
F
M
F
INTERNAL BILLING
HORIZON NJ
LYNDA BASCELLI
Project Hope
BRAVO HEALTH
HORIZON NJ
SELF PAY
MINH HUYNH
HORIZON NJ
ANNA HEADLY
NO PHYSICIAN
NO PHYSICIAN
Cooper Physician
SELF PAY HORIZON NJ
MEDICAID
HORIZON NJ
Level 1: Highest Risk
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Significant hospital utilization
2 or more chronic health conditions
Low socioeconomic status
Homeless or unstable housing
Lack of significant social supports
Low-literacy, lack of HS diploma
Behavioral health issues
Generational poverty/urban violence
www.camdenhealth.org
Level 1: Highest Risk Workflow
www.camdenhealth.org
Level 2: Intermediate to high risk
• History of 2 + admissions within past
6 months
• History of chronic disease related admits
• Socially stable
• Rule-out criteria
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–
–
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Oncology
Pregnancy-related
Trauma
Psych-only diagnosis
Level 2: Intermediate to High risk
workflow
www.camdenhealth.org
Outreach & Intervention
• Enrollment & begin outreach at bedside
• Clinical assessment and first home visit
within 24 hours of d/c
– Care plan, resource building, goals, medical
records, etc.
• Schedule PCP appt within 7 days (target)
• Schedule specialty appointments within
14 days (target)
• Individualized engagement period
Case Presentation: “Charley”
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55-year-old African-American
male
At time of enrollment, admitted
for GI bleed and SOB
(November 2011)
Medicare/Medicaid coverage
Lives alone in high-rise
apartment
12 medications daily
6 months prior to enrollment
 9 ED visits & 6 inpatient stays
 Hospitalized on average
every 45 days
• Complex chronic
conditions
– ESRD
– Renal Carcinoma
– Hepatitis B
– Hypertension
– Hyperlipidemia
– Peripheral vascular
disease
– Asthma
– Glaucoma (blind in
one eye)
– Sleep apnea
– Severe back pain
www.camdenhealth.org
Key Intervention:
Home-Based Medication Reconciliation
Patient Centered Care Coordination
Transport
Meals
Durable
Goods
Home
PT/OT
Home
Nursing
Hospita
l #1
Patient
Sub-Acute
Rehab
Hospita
l #2
Dialysis
PCP
Urology
Nephrology
Optho
Transplant
Pain
Mgt
Cardiology
GI
www.camdenhealth.org
Oncology
Surgery
www.camdenhealth.org
Frequently asked questions
• How do you recruit and train quality
staff?
• What is your patient census?
• How do you build relationships with
outside providers?
• What is your referral source?
• What about HIPAA?
• What are your evaluation metrics?
Q&A
Kelly Craig, MSW, LSW
Kelly@camdenhealth.org
856-365-9510 x2004
Jason Turi, MPH, RN
Jason@camdenhealth.org
856-365-9510 x2017