Bringing Care to PatientsComplex Care as an Extension of the Care Team

Overview

What do we need to do to support

patient care in a HHP

Innovative ways to deliver services

Advantages of bringing care to the

patient

Best practices: home & shelter visits

Co-locating clinical services

What do we need to do to

support patient care

Develop strategies and processes to aid

in transitions of care

Work on internal process for enhanced

communication among the care team

Work on external communication with

community partners

Develop templates within EHR to support

documentation and use of data quality

indicators

Innovative ways to deliver

care

Know your patient population you are serving

Use educational materials and strategies appropriate for that population

Know the community resources they may utilize

Think “outside the box” on how you may meet the patients needs:

Bring care to the patient

Advantages of Bringing Care

to Patients

Reduces Barriers to Health Care

Helps patients better manage their chronic diseases

Problem-solve medication management

Better view of social determinants

Better understanding of psychosocial issues

Creates a trusting relationship

Enables more effective phone follow-up

Reducing Readmissions & Costs

16.6

14.4

16.2

14.915.2 15.2

15.6

19.8

15.5

17.2

15.9

14.4

13.4

14.7

15.815.2 15

17.6

14.3

9.9

2012-20132013-2014

2014-2015

2015-2016

0

5

10

15

20

25

Nov.2012

Dec.2012

Jan.2013

Feb.2013

Mar.2013

Apr.2013

May.2013

Sept.2013

Dec.2013

Feb.2014

Mar.2014

Apr.2014

May.2014

Sept.2014

Jan.2015

May.2015

June.2015

Sept.2015

Oct.2015

Apr.2016

Readmission Rate Readmission Rate Target

Reducing Avoidable ED Visits & Costs

54.67 55.49

62.3563.89 63.25 63.49 63.3

32.2

41.02

50.26 50.12 50.01 49.85

29.98

39.02

44.8343.68

25.2624.04

30.5

52.1 50.88 50.47

43.79

0

10

20

30

40

50

60

70

Nov.2012

Dec.2012

Jan.2013

Feb.2013

Mar.2013

Apr.2013

May.2013

Sept.2013

Dec.2013

Feb.2014

Mar.2014

Apr.2014

May.2014

Sept.2014

Jan.2015

May.2015

June.2015

Sept.2015

Oct.2015

Apr.2016

Avoidable ED visits/1000 Avoidable ED visits/1000 Target

Best Practices: Home Visits

Team Approach

Uses licensed & unlicensed staff

Nurse: care plan & medical case

management

Care coordinator: works on social

determinants

Two staff at every intake

Train on home visit safety

Staff use cell phone to check in

Best Practices: Home Visits

Involve family & caregivers in care plan for

best outcomes

Involve Social Worker on psychosocially

complex patients to improve engagement

Involve community partners for best access

to resources and support

APS

IHSS

Skilled home care

Best Practices: Shelter &

Community Visits

Work with Shelter staff

Meet with shelter case manager to identify housing resource goals

Verify with staff who is helping with what to avoid

service duplication

Community visits: meet in public places only

Library

Coffee shops

Co-Locating Clinical Services/

Building Relationships

Reduces Barriers to Care

Creates a “Community” of care

Brings care to where groups of patients reside

One stop for multiple services

Reduces transportation stresses for patients

Allows for more “curb side” conversations with

care teams

Building Partnerships

Create partnership agreements & clear

expectations

Regular meetings with standing agendas

Create shared goals

Review of data (Data Driven Improvement)

Problem-solve as a team

Bridges to Health

Co located in Sonoma County Behavioral Health

Severally mentally Ill are more comfortable in familiar environment; more likely to attend visits

Integration of services: safer care, medication management more comprehensive

Offer medical case management & chronic disease education in a culturally sensitive way

Creation of new roles

Care Coordinator /MA

Peer Advocate

Brookwood Health Center

Project Nightingale

Focus on individuals Experiencing Homelessness

Easier for individuals to obtain primary care post hospitalization-the more likely they will attend visits

Dedicated staff to focus coordination of care services is essential

High acuity for complex care –multiple weekly visits

Reduction in hospital utilization -readmit rates

Healthcare for the Homeless Care Transitions

2015-2016

Measure QTR 1 QTR 2 QTR 3 QTR 4TOTAL TO

DATE

# patients enrolled since July 1, 2015 24 26 34 47 129

# patients connected to PCP 18 28 21 42 109 (84%)

# patients attended PCP visit within 30 days of

enrollment20 21 10 33 84 (65% )

# patients connected to shelter 13 15 24 27 79 (61%)

# patients readmitted to the hospital within 30 days 0 4 0 26 (5%)

Known utilization

# patients with an ER visit within 30 days post

discharge9 7 7 11

34 (29%)

Known utilization

# patients helped with transportation 7 16 17 40 80

# patients connected to food source 5 4 10 13 32

# patients screened for substance abuse services 24 26 34 47 129 (100%)

# patients connected to substance abuse services 6 3 1 2

12

(56 more offered but

declined)

# patients connected to SSI/SDI benefits 13 15 21 17 66

# patients with documented personal health goals 24 25 34 45 127 (99%)

Care Coordinator co-located at

Santa Rosa Memorial Hospital

Links patients without PCP to Medical Home

Meets with patient during ER visit determines MediCal/Medicare assignment schedules appropriately

Uninsured.. makes appointment & links to application assistance

Creates follow-up appointments with Medical Home

Follow-up phone call within a week of post ER visits

Educates patients on “ambulatory sensitive” conditions

ED Coordination: Data Collection

SRCHC Future Projects

The Palms Inn Health Center

Co-location of services in a hotel converted to housing for homeless & veterans

Integrated medical & behavioral Health

Care Coordination /Complex Care on site

Open for all the neighborhood to receive services

Start small; build as we grow

Other Possibilities

Teleconference with PCP in the clinic

Mobile van to underserved

neighborhoods or housing projects

Others?

Questions?