Post on 21-Sep-2020
Building a Community Care Network for High-Needs Patients
Rachelle H. Schultz
President/CEO Winona Health March 1, 2016
Conflict of Interest Rachelle Schultz, MHA
Has no real or apparent conflicts of interest to report.
Agenda
• Learning Objectives
• Organization Profile
• Community Care Network
• Population Health Profile
• Health Coaching Program
• Results/Outcomes
• Client Stories
Learning Objectives
• Discuss different ways to help patients who repeatedly show up in your ED because of poor management of chronic conditions;
• Identify how these non-traditional interventions can lead to decreases in readmissions, preventable visits and total cost of care;
• Recognize how smart registries can help your organization manage these hard-to-reach patients.
A Summary of How Benefits Were Realized for the Value of Health IT During this presentation each of the
domains for Value of Health IT will be
incorporated. However, particular
emphasis is on patient engagement and
population health and electronic secure
data.
http://www.himss.org/ValueSuite
Winona Health
• Winona Health Services is an integrated community owned, nonprofit organization.
– Hospital licensed for 99 beds
– Emergency Services/Urgent Care
– Primary Care Clinic Locations (3)
– Specialty Care Services
– Senior Services
• Long Term Care Facility
• Hospice & Palliative Care
• Memory Care Facilities
• Assisted Living
Winona
Winona Community Profile 8% of Adults have diabetes
10% report poor mental health days
35% of kids are eligible for school lunch program
15% childhood obesity
27% adult obesity
16.4% living below poverty line
Health Rankings-Robert Wood Johnson County Health Rankings
Of 87 Counties in Minnesota, Winona ranks:
Health Outcomes #6
Health Factors #37
Health Behaviors #43
Clinical Care #56
Social & Economic #25
Physical Environment #61
Transforming Healthcare
Key Strategies:
Community Care Network (CCN)
IHP/SIM grant (Medicaid)
Minnesota Rural ACO (Medicare)
Smart Registries
Health Information Exchange (HIE)
Objectives:
Improving community & population health
Patient engagement
Total Cost of Care
Social Determinants of Health
Recognizing the Need
• Increasing needs of individuals with chronic health conditions
• Healthcare systems charged with finding ways to decrease overall cost of care
• Patients discharged from hospitals & EDs trying to manage their chronic healthcare conditions at home
• Patients with little support or understanding of their medical conditions
• No reimbursement for readmissions within 30 days
• Preventable admissions, emergency room visits, etc.
Things Fall Apart
• Inability to manage care needs due to social constraints
• Social Isolation
• Exacerbations of multiple chronic illnesses
• Inability of patient/families to recognize and react to signs of acute illness
• Low health literacy
• Limited support systems and resources
• Medication management errors
• Handoffs
• Non medical issues show up in healthcare system
Community Building Solution: Community Care Network
(Key) Criteria to Identify High Risk Patients
• Low health literacy
• Utilization of ED for primary care (CCN client ED visits range from 3 to 34 in one year)
• Frequent hospital admissions / readmissions (CCN client hospitalizations range from 3 to 12 in one year)
• Frequent clinic or ED visits for social needs
• No primary care provider relationship
• Multiple chronic conditions
• Limited support systems and resources
Who Qualifies for the CCN?
• Voluntary Program
• No age limit
• Anyone with a chronic disease
• Target high risk patients 80/20 Rule
-Frequent hospitalizations
-Frequent ED visits
-Frequent clinic visits for non-medical reasons
• It’s not home health care
-No homebound or skilled criteria
• No reimbursement for this program
Community Care Network
• Average age is 58 (range is 18-96 years)
• 25% have diabetes
• 19% have COPD or another lung disease
• 55% have mental health and/or chemical
dependency issues
124 CCN Clients
*67 on Medicaid
*82 on Medicare
Target: ~400 clients
Population Health Profile IHP population (Medicaid) ~4,000 individuals in the IHP Population:
• 44% are 18 or younger
• 92% have moderate to very high morbidity
• 23% have multiple chronic conditions
• 20% of ED visits are made by 2% of the population
• 14% of Outpatient visits are made by 1% of population
• 17% have seen more than 5 unique providers
• Individual patient cost ranges from $0 to $451,000
• 52% of most recent E&M visits were to NP's and PA's
• Top Diagnoses: Depression, Asthma, Hypertension, Diabetes, Low back pain
ACO population (Medicare)
• Currently being defined.
Managing Population Health
Smart Registries
• Diabetes
• Hypertension
• Well Child
• Well Adult
• Senior Wellness
• +5 more in 2016
Connect a Community
Health Information Exchange
(HIE)
Community Partners
-Nursing Homes
-County Public Health
-Mental Health Providers
-Disability Providers
Health Coaching Program
• Partnership with Winona State University
• Students get credit for class and practicum(s)
34 (42 total have been trained) health coaches deployed into community (waiting list)
See clients for ~1 hour/week to work on goals
Volunteers to the CCN
• Non-nursing students
• Class content focus
building relationships, therapeutic comm., strategies to cope with chronic conditions
• Expanding Health Coaching opportunities to broader community (e.g. retired staff, neighbors, friends, family)
Who are Health Coaches?
• A care team member who helps connect patients with providers and community resources.
• Health Coaches act as a liaison between the patient, clinical care team, family, and community.
• Health coaches:
– Have a positive impact on adherence
– Help make links to community resources
– Contribute to better outcomes
– Role facilitates lower cost for healthcare
– Improve health
– Accountability partner
Benefits of Health Coaches
• Health Coaches can develop relationships with the patients that healthcare personnel cannot.
– 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
Results/Outcomes
• Clients & overall system have realized significant benefits:
Decrease in total cost of care by ~40% for clients in the
CCN for one full year: $545,000!
Year 1-2 Reductions:
*ED Visits 88-91%
*Readmissions 85-94%
(client base 40)
Year 3 Reductions:
*ED Visits 45%
*Readmissions 49%
*Client Visits 34%
(client base 120+)
Patient A prior to program
34 ED visits in one year
27 Clinic visits in one year
2 Hospitalizations
Since admission to CCN
2 ED visits
3 Clinic visits
0 Hospitalization
Success due to:
Health coach involvement
Cognitive skills and activities
Increased social engagement
Client Stories
Patient B prior to program:
Regular ED/UC visitor
No Medical Conditions: believes
she has them
Misses appts, runs out of meds
Since admission to CCN
Fires/Rehires CCN
Calls CCN before going to ED
Initiating getting help for herself –
gaining personal insight into herself
Success due to:
Discipline and patience
CCN meets her where she is at
Build trust; accept being “fired”
A Summary of How Benefits Were Realized for the Value of Health IT As presented the Value of Health IT
manifests in all of the domains shown.
Our CCN program is a holistic approach
that demonstrates the powerful impact of
a holistic approach that incorporates each
of these value propositions. There is far
more value to be achieved.
http://www.himss.org/ValueSuite
Your Thoughts?
Contact Information:
Rachelle H. Schultz, CEO
Winona Health
855 Mankato Avenue
Winona, MN 55987
(507) 454-3650
rschultz@winonahealth.org