Care Management Webinar

Camden Coalition of

Healthcare Providers

Community Outreach for Complex Patients:

Basics of Care Management and

Care Transitions in the Field

Kelly Craig, Director of Care Management Initiatives

Jason Turi, Clinical Manager of Care Transitions

July 20, 2012

Camden Coalition of

Healthcare Providers

www.camdenhealth.org

Overview

• Clinical model

• Program goals & guiding principles

• Evidence-based practice

• Team composition

• Daily admissions feed

• Care management: High risk

• Care transitions: Intermediate risk

• Q & A

Clinical Model


•Lourdes

•Cooper

•Virtua

Data•Assessment

•AssignmentTriage

•Medically complex

•Socially complex

•6-12 mos. engagement

High Risk

•Quality improvement

•Patient engagement

•Care coordination

Medical Home

•Medically complex

•30-90 day engagement

Interm.

RiskPatients Flagged:

• 2+ hospital

admissions < 6

months

Selection Criteria:

• History of chronic

disease related

admits

• Rule out criteria

• Assigned to pathway

“Care Transitions”

“Care Management”

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


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 and PCP

• Equal focus of intervention on coaching


Outreach Team Composition

High Risk Outreach Team Intermediate Risk Outreach Team

RN RN

MA LPN

Health Coaches Health Coaches

Social Worker


Admitted past month, 6 month summary Days 6 mo episodes Admit Facility Inp ED Name dob age sex PCP PracticeName Insurance

06/13/12 Cooper 40 7 3 xxxxxxxxxxxxxx xx/xx/xxxx 55 M JACK GOLDSTEIN CMC Dept of Cooper 44 3 2 xx/xx/xxxx 73 F MARILYN GORDON CAMcare Health Cooper 79 3 xx/xx/xxxx 57 M JOHN KIRBY Cooper Physician HORIZON NJ PPO Cooper 35 2 3 xx/xx/xxxx 21 M NO PHYSICIAN OLOL 1 2 1 xx/xx/xxxx 56 M SELF PAY - Cooper 5 2 1 xx/xx/xxxx 61 M OLOL 4 2 1 xx/xx/xxxx 54 M SELF PAY Cooper 27 2 xx/xx/xxxx 47 M MARILYN GORDON CAMcare Health

06/12/12 Cooper 15 13 1 xx/xx/xxxx 22 F MIGUEL MARTINEZ Cooper Physician Cooper 18 3 2 xx/xx/xxxx 55 M NO PHYSICIAN AMERHLTH/KEYST Cooper 99 3 1 xx/xx/xxxx 64 M DANIEL HYMAN Cooper Physician

06/11/12 Cooper 9 9 5 xx/xx/xxxx 48 M LYNDA BASCELLI Project Hope OLOL 43 9 1 xx/xx/xxxx 71 F INTERNAL BILLING OLOL 17 5 5 xx/xx/xxxx 66 F HORIZON NJ Cooper 27 5 3 xx/xx/xxxx 52 M LYNDA BASCELLI Project Hope OLOL 35 5 1 xx/xx/xxxx 70 F BRAVO HEALTH OLOL 46 4 5 - xx/xx/xxxx 73 F HORIZON NJ OLOL 31 3 2 xx/xx/xxxx 52 F SELF PAY Cooper 2 3 1 xx/xx/xxxx 68 F MINH HUYNH OLOL 1 3 1 xx/xx/xxxx 73 F HORIZON NJ Cooper 34 3 xx/xx/xxxx 62 F ANNA HEADLY Cooper Physician Cooper 131 2 10 xx/xx/xxxx 35 M NO PHYSICIAN OLOL 54 2 6 xx/xx/xxxx 49 F SELF PAY - OLOL 177 2 4 xx/xx/xxxx 91 F HORIZON NJ Cooper 3 2 2 xx/xx/xxxx 51 M NO PHYSICIAN MEDICAID OLOL 139 2 2 xx/xx/xxxx 87 F HORIZON NJ

Thursday, June 14, 2012 Page 1 of 8

Daily Admissions Feed

Care Management: High Risk

• Hospital utilization in the city– Appropriate vs. inappropriate

• 2 or more chronic health conditions

• Low socioeconomic status

• Homeless or unstable housing

• Lack of social supports

• Low-literacy, lack of HS diploma

• Behavioral health issues

• Generational poverty/urban violence


Care Management Workflow


Case Presentation #1

• 62-year-old male

• At time of enrollment, admitted for DKA (July

2011)

• History of homelessness

• Medicare/VA benefits

• Complex chronic conditions– Diabetes

– Chronic kidney disease

– CHF

– COPD

– Substance use


Outreach and Intervention

• 2011 hospital utilization

– 3 ED visits

– 10 inpatient stays

• Contributors to hospital readmissions

• Main interventions

– Coordinated care with homeless services

provider

– Arrange long-term care placement


1 year pre-enrollment Charges = $112,664; Receipts: $22,365

Post-enrollment (10 months)Charges = $64,974; Receipts= $12,380

0

0.5

1

1.5

2

2.5

3

Len

gth

of s

tay

ED IP


Care Transitions: Intermediate Risk

• History of 2 + admissions within past

6 months

• History of chronic disease related admits

• Socially stable

• Rule-out criteria

– Oncology

– Pregnancy-related

– Trauma

– Psych-only diagnosis

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

Care Transitions Workflow


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)

• Planned 30 - 90 day engagement

Patient Case Presentation #1

• 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


Key Intervention:

Home-Based Medication Reconciliation

Patient Centered Care Coordination


Patient

Hospita

l #1

Sub-Acute Rehab

Hospita

l #2

Home

Nursing

Home

PT/OT

Durable Goods

Meals

Transport

Dialysis

Nephrology

Transplant

PCP

UrologyOncology

Surgery

GI

Cardiology

Optho

Pain

Mgt

Q & A

Kelly Craig, MSW, LSW

Director, Care Management Initiatives

[email protected]

856-365-9510 x2004

Jason Turi, MPH, RN

Manager, Care Transitions

[email protected]

856-365-9510 x2017

Care Management Webinar

Health & Medicine

Transcript of Care Management Webinar