Essentia HealthEly Clinic

Age and Disabilities OdysseyHealth Care Homes – Minnesota Style

June 17, 2013

Essentia Health - Ely Clinic

Health Care Home

Service Area

Service Area• Co-located with Ely Bloomenson Community

Hospital (EBCH)– a non-affiliated critical access hospital

• Service Area = 6 communities, 7 townships– 12,214 residents + 15,000 seasonal residents

• Closest tertiary care facility is 50 miles away – Essentia Health – Virginia Hospital, Virginia, MN

Ely Clinic – What We DoEssentia Health – Ely Clinic (Ely Clinic)

– Sole provider of primary care and specialty outpatient services

– 7 physicians-including 1 internist– 2 Nurse Practitioners

• Outreach Services– Orthopedics, behavioral health, derm, cardiology, OB-

GYN, general surgery

• 25,000 pt visits a year• Provide 24 / 7 ER services• OB-30-60 deliveries a year

The Nature of EH – Ely Clinic• Professionals

– Live here because we want to live here

• Community of limited resources– 17.4% Poverty

• St. Louis-15.1%• Hennepin-12.1%• Ramsey-15.8%

– Highest poverty among those 6-34 years of age

– Age• 22% > 65 years of age

• Have been a clinic of “firsts”– Certified Health Care Home:

2012– Anticoagulation– Electronic Health Record-2004– Integrated Behavioral Health

with Primary Care– Telemedicine (behavioral

health, wound care, derm)– DIAMOND– Current Primary Care

Redesign Pilot Site– MDH Community Care Team

Site

Our Health Care Home

• Strong Chronic Disease Management Program– Top in Diabetes Care for NE MN

• “Grow” Nursing-woefully under utilized in Clinic setting• Clinic Support Clerk-performs non nursing clinical

functions• Integrate ALL employees in coordination of services-

schedulers, registration– All staff are on look out for patients in need

• Reserved schedule slots for hospital discharges• Community Care Team & Community Health Worker• Strong Infrastructure Means Strong Programs

– Hardest work is developing the infrastructure

TransitionsA. EBCH and Essentia Affiliated Hospital admissions, discharges, and ED admissions

reports to clinic DailyHigh acuity patients identified for care coordination and follow up

B. Clinical pharmacy consultation for all hospital discharges with extensive med lists.

C. Nursing Home DischargeNP provides transitional planning for patient in conjunction with the nursing home social work staff.

D. Acuity / Severity Report Reviewed WeeklyIdentify any patients that may have been "missed" because they are seen outside the local hospital.

E. Capture of Hospitalizations / ED admits from Non Essentia Facilities---In development

F. Current Care Coordination Patients (includes MSHO & eldercare) Care coordinators participate in discharge planning for all enrolled patients.

G. Appointment HoldsEach provider has a hold on their schedule each day for discharged patients.

Improving Outcomes ThroughCare Coordination

Provide Information and Resources

Provide Connection and Warm Handoff

Identify and Address Barriers

Team Care Coordination

Patient

Community Care Team

Mission: The Community Care Team provides

collaborative care and

support to help you

achieve your wellness goals.

Vision• Adequate resources are available to citizens when

needed to help them with their physical health, mental health and psychosocial challenges.

• Professionals in health, education, and public service are trained in recognizing when someone is confronted with such challenges and are prepared to provide an appropriate response in giving assistance.

• Patients and their supporters have the tools and resources to help them be a partner in meeting their wellness, treatment and recovery goals.

Ely Area Community Care Team

• Essentia Health-Ely & Babbitt Clinics

• Community Hospital• Nursing Home• 2 Mental Health Agencies• 2 School Districts• County Public Health &

Human Services • 2 Community/Family

Members

• Free Clinic• Parish Nurse• Community College• Mental Health Clubhouse• Head Start• Hospice & Palliative Care• Local youth & Family Non-profit• Local Respite/Caregiver

Support Nonprofit• Food Shelf

Breaking Down Silos

Monthly CCT Meetings Include Opportunities to:• Network• Learn About Other Services• Case Management• Develop Tools and Systems for Collaboration• Address Specific Concerns• Work Together on a Project

Improving Outcomes

CCT Model In Action • Warm Handoffs• Holistic View of Individuals • Strong Community/ Provider Network• Emphasizes Strengths of Each Service• Fills in the Gaps• Supports the Individual and Family

Community Health Worker

• Coordinate non-medical issues that affect health and wellness of our patients

• Care Manager for patients whose primary needs are not medical

• Provides support to RN care coordinator for psychosocial needs of CDM patients.

• Provides information and warm referrals for patients who need connections to additional resources, but do not need care coordination

• Provides resource for ALL staff

CHW Certification

• MN certification • Several schools in person and South Central

College online program• Opens DHS billable stream for diagnosis based

education• Education we are excited to explore offering:

– New ADD medication – Budgeting (making sure you allow funds for good

food, medications, laundry…)– Organization (state benefit paperwork…)

Ely Clinic’s Internal Model

Essentia Health

Ely Clinic

and Babbitt Clinic

Health Care Homes

Community Care Team

Care Coordination Team

•RN Care Coordination

•Community Health Worker

{Behavioral Health Specialist}