In-Reach Hospital Program

Coordinating Multiple Service Providers Rare Presentation

Partnership between: South Central Human Relations Center Steele County Human Services South Country Health Alliance Owatonna Hospital-Allina Health Systems November

5th 2014

Objectives of the ProgramTo encourage health care providers to coordinate their efforts to assure the most vulnerable patient populations seek and obtain primary care.

To increase preventive services including screening and counseling, to those who would otherwise not receive such screening to improve health, reduce complications, and cost.

To provide a mechanism for improving both quality and efficiency of care for vulnerable individuals with an emphasis on those most likely to remain uninsured or underinsured.

To manage chronic conditions to reduce their severity, negative health outcomes, and expense.

Program Value

PatientAccess to the full spectrum of needed provider services through access assistance and advocacy for correct health care program enrollment resulting in optimal care.

ProvidersEfficient patient encounters assisted by unique treatment plans easily

accessed in Excellian and system care coordinator in attendance at clinic visits.

Cost Savings

Process for Identifying and Engaging Patients

List of patients is generated

5 more visits in in quarter

(BOE Report)

Phone Call, Letter, and note in chart to page social worker when they arrive

List is reviewed with Medical

Director of ED and Nurse

Manager of ED

Patient consents to system care

coordination.

How is Health Care Coordination different from typical hospital

social worker role?

Health Care Coordinator Community Provider- connecting to resourcesPatient is not admitted to hospital.60 days of interventions.Attends follow up health care appointments with patient.

Hospital Social WorkerDischarge Planning Patient is admitted to hospital or in EDOnce patient is discharged Social Worker does not follow up.

Health Care Coordinator Tasks

Functional Assessment Completed

Goal Developmen

t

Releases are Signed

Screening Tools: PHQ-9,

GAD-7, Physical Exam, Pre Questions

Unique Treatment

Plan Developed

Key Interventions Health care coaching; accessing health care

at the correct locationHealth care coordinator; social worker housed

at the hospital with other key medical staff versus human services or community mental health center

Care plan development for emergency department staff for future emergency department visits

Attending appointments with patients; ensuring they are talking with physician about symptoms, treatments, and concerns; modeling how to interact with their care providers

Key Interventions Health care coordinator walks with the patient

through a variety of service delivery systems. Attention is given to simple barriers to health

care that are generally not addressed in discharge plans.

Educating patients on the language they may want to sue with their physicians

Owatonna Hospital

The Program Data

Managed Care Data 39 PatientsReviewed Emergency Department, Overall Primary Care Physician Cost $51,951 reduction in paid health care claims

22 PatientsPrior ED Visits = 139Post ED Visits = 91Difference = -47Hospitalizations:Prior – 17Post – 13

20

13

20

12

Patient Satisfaction

1. Patient Survey upon closure of case.

2. Pre and Post Questions Survey

Contact InformationElizabeth Keck, MSW, LGSWelizabeth.keck@allina.com