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Reducing Re-hospitalizations Using Non-Medical Personnel

Kelly Craig, Camden Coalition of Healthcare ProvidersRachel Wolf, Salud Family Health Centers

October 10, 2013

CARE TRANSITIONS 101

“Care transitions refers to the MOVEMENT patients make

BETWEEN health care practitioners & settings as their

condition and care needs CHANGE during the course of

chronic or acute illness.”1

1 The Care Transitions Program®. (2008) Transitional Care: Definitions. Retrieved: http://www.caretransitions.org/definitions.asp

Inadequate care transitions contributed to [an estimate of] $25-$45 million in wasteful spending in 2011Nearly 1/5 of hospitalized [fee for service Medicare] patients are re-admitted within 30 days of discharge3/4 of those readmissions ($12 billion annual cost) are preventable through proper care transitions

Lack of consistent care post hospitalization

Complete hospital records often not accessible to Primary Care Physicians

Limited information given to patient upon discharge (e.g. self-care, medication management, who to contact with questions)

KEY BARRIERS TO PROPER CARE TRANSITIONS

“Transitional care is a set of actions designed to ENSURE the

COORDINATION and CONTINUITY of health care as

patients transfer between different LOCATIONS or different LEVELS

of care.”2

2 Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):556-557.

Coleman, EA. (2008) The Care Transitions Program®. Retrieved from http://www.caretransitions.org

Health Workforce Solutions LLC, Robert Wood Johnson Foundation. (2008). Care Transitions Intervention. Innovative Care Models. Retrieved from http://www.innovativecaremodels.com/care_models/12/overview

Health Workforce Solutions LLC, Robert Wood Johnson Foundation. (2008). Transitions Care Model. Innovative Care Models. Retrieved from http://www.innovativecaremodels.com/care_models/21/overview

National Committee for Quality Assurance. (2011) Patient Centered Medical Home (PCMH 2011 Standards. Recognition Training. Retrieved from http://www.ncqa.org/Programs/Recognition/RelevanttoAllRecognition/RecognitionTraining/PatientCenteredMedicalHomePCMH2011Standard.aspx

Robert Wood Johnson Foundation. (2012, September 13). Health Policy Brief: Care Transitions. Health Affairs. Retrieved from http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=76

PRESENTATION SOURCES

Camden Coalition of Healthcare Providers

Community-Based Care Management for Vulnerable

PopulationsKelly Craig, MSW, LSW

Camden Coalition of Healthcare Providers

www.camdenhealth.org

John’s Story•44 year old former Pro Wrestler “The Black Scorpion”•Suicide Attempt by hanging•Homeless•Lack of Family Support•Poor Medication Adherence•Drug Use•Seizures & Hypertension•Anxiety & Depression• Insulin Dependent

Patient Centered Care Coordination

Hospital #1

StreetsHospital #2

Transport

BehaviorDay

Program

WileyChristian

Day

PCPNeuro Physical

Therapy

OccupTherapy

PodiatryEndocrine

Ortho-Pedics

Nephro

ShelterApart-ment

Cherry HillPartialDay

Tempus Pharmacy

Collab.Support Program

Accompaniment

SSD

LegalAid

ChildSupport

What is the Camden Coalition of Healthcare Providers?

Mission: “…to improve the health status of all Camden

residents by increasing capacity, quality, coordination, and accessibility of care in the City”

Vision:“To be the first community in the country to

dramatically bend the cost curve while improving quality outcomes”

www.camdenhealth.org

Camden Cost Curve, 2011

www.camdenhealth.org

1% of patients accounted for 26 % of all charges

5% of patients accounted for 58% of all charges

10% of patients accounted for 73% of all charges

Hospital Discharge Framework

The Push

The Carry

The Catch

The Carry: Community Based Care Coordination

Data Triage Outreach Graduation

Tenets of Good Care• Enroll patients based on data; history of

repeat admissions (high cost) and specific inclusion criteria

• Provide immediate and intensive follow-up coordination post discharge (<72 hours)

• Connect patient to PCP as quickly as possible (target = 7 days post d/c)

• Improve the relationship between patient/family and PCP/specialists

• Equal focus of intervention on coaching

www.camdenhealth.org

Key Intervention:Home-Based Medication Reconciliation

www.camdenhealth.org

Registered Nurse Social Worker Behavioral

Specialist Intervention

Specialist Licensed Practical Nurse

Licensed Practical Nurse

Community Health Worker

Health Coach Health Coach

Program Director Associate Clinical Director

Licensed Practical Nurse

Licensed Practical Nurse

Community Health Worker

Health Coach Health Coach

It takes a team

Team Awesome Team

Dynomite

2012-2013 NACHC AmeriCorps Health Navigators

Division of Work (0-30 days)Nursing Health CoachesClinical assessment Make appointmentsMedication reconciliation Transportation enrollment &

trainingEstablish care plan; identify patient goals

Nutritional support AND food security

Accompanied PCP and specialty care follow up appointments

Mobility assistance

Follow-up home visits; care provider reinforcement

Accompaniment

Establish Health Coach plan for second phase

Division of Work (30 days and beyond)

Nursing Health CoachesMedication reconciliation Logistics: make own

appointments, arrange own transportation, access specialty care

Chronic disease maintenance Disease self management: awareness of chronic disease maintenance, can communicate with provider(s) and navigate an agenda

Handle readmissions Social skills: can find resources, life management skills

Schedule hand-off appointment; graduation to PCP

Ongoing social support

The Catch: Primary Care Capacity Building

Care Coordination

•Nurse Care Transitions•Accompanied PCP visit•Weekly care coordination rounds•Accompanied specialty visit•HIE training•Social work assistance

Quality Improvement

•Patient registries•Team meetings•Protocols•Provider/staff Education•EMR Meaningful Use assistance•Data collection/analysis

Patient Engagement

•Chronic Disease self-management education•Group medical visits•Mental health assessment & counseling•Peer support groups•Wellness programs

Expansion to Primary Care• Incorporating Community

HealthCorps Navigators in 4 Primary Care Practices/FQHCs

• Maternal/Child Health programming

The Black Scorpion Speaks…“At first I was reluctant, but the communication and the relationship with the team is wonderful and very supportive. They are always in touch with me and assist me in meeting my goals. For example, guiding me to my new apartment and MICA program. I feel security with the team. I was not just left, put out in the middle of nowhere. They actually did what they said they were going to do and that made all the difference.”

Thank you for your timeQuestions/comments please contact Kelly Craig - kelly@camdenhealth.org

www.camdenhealth.org