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