Katharine Royer, MSc, BSc and Carolyn Junior, BSc
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Katharine Royer, MSc, BSc and Carolyn Junior, BSc The Where: Camden, NJ •Population: ~77,000 •42% live below poverty line •20% of patients account for 90% of healthcare costs The Who: Julia •57 yo who lives in North Camden with two sons •Worked as instructional aide for 18 yrs Medical History/Diagnoses Reason for recent ER visits/admissions Uncontrolled type 2 diabetes Bilateral amputee Coronary artery disease Gastroparesis Anxiety/depression Nausea/vomiting Abdominal pain Uncontrolled diabetes Lack of social support Anxiety/depression The What: Our Intervention •Enrollment in day program • Socialization & medical support •Referred to MANNA meal delivery service • Access to balanced diet •Switched PCP • Supportive relationship/patient empowerment •Increased HHA hours • Diabetes management •Home Depot Wheelchair ramp donation • Safety for getting in/out of house The Why: Systems-Based Learning Failures Successes Provider relationships Education Medical Day Programs MANNA referral process Family motivation Non-profit & corporate relationships Acknowledgements CMMI “Team Awesome”: Jason Turi (RN), Angel Mitchell (LPN), Raquel Medina (LPN), Sharine Eliza (Community Health Worker), Bill Nice (Intervention Specialist), Kelly Craig (Director of Care Management Initiatives) Bill & Elizabeth at Home Depot, Delran, NJ Rebuilding Together MANNA Generations Plus Care Coordination (23.37 hrs) Clinical Coordination Social Coordination Caregiver/Family Coordination Medical Appointment Scheduling Medical Transport Planning 78% 4% 7% 6% 5% Patient Encounters (58.75 hrs) 83% Home Visit Specialist Visit Phone Hospital Community 3% 3% 1% 10% Superutilizer Success: Preventing rehospitalizations of a patient with uncontrolled diabetes The How: Utilization/Cost Data •6 Months before intervention •3 IP Stays~$17,600 cost in receipts •2 Months after intervention •1 IP Stay~$8000 in receipts; 2 ED Visits~$906 in receipts Length of Stay (Days) 1 2 3 4 5 IP IP IP IP ER ER Sept. 28 Dec. 13 Dec. 16 Dec. 27 Feb. 26 Mar. 3 2012 2013 Intervent ion
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Superutilizer Success: Preventing rehospitalizations of a patient with uncontrolled diabetes. Katharine Royer, MSc, BSc and Carolyn Junior, BSc. The Where: Camden, NJ Population: ~77,000 42% live below poverty line 20% of patients account for 90% of healthcare costs. - PowerPoint PPT Presentation
Transcript of Katharine Royer, MSc, BSc and Carolyn Junior, BSc
Katharine Royer, MSc, BSc and Carolyn Junior, BSc
The Where: Camden, NJ•Population: ~77,000•42% live below poverty line•20% of patients account for 90% of healthcare costs
The Who: Julia•57 yo who lives in North Camden with two sons•Worked as instructional aide for 18 yrs
Medical History/Diagnoses
Reason for recent ER visits/admissions
Uncontrolled type 2 diabetesBilateral amputeeCoronary artery diseaseGastroparesisAnxiety/depression
Nausea/vomiting Abdominal painUncontrolled diabetesLack of social supportAnxiety/depression
The What: Our Intervention•Enrollment in day program
• Socialization & medical support•Referred to MANNA meal delivery service
• Access to balanced diet•Switched PCP
• Supportive relationship/patient empowerment•Increased HHA hours
• Diabetes management•Home Depot Wheelchair ramp donation
• Safety for getting in/out of house
The Why: Systems-Based Learning
Failures Successes
Provider relationshipsEducation
Medical Day ProgramsMANNA referral processFamily motivationNon-profit & corporate relationships
AcknowledgementsCMMI “Team Awesome”: Jason Turi (RN), Angel Mitchell (LPN), Raquel Medina (LPN), Sharine Eliza (Community Health Worker), Bill Nice (Intervention Specialist), Kelly Craig (Director of Care Management Initiatives)
Bill & Elizabeth at Home Depot, Delran, NJRebuilding TogetherMANNAGenerations Plus
Care Coordination (23.37 hrs)
Clinical CoordinationSocial CoordinationCaregiver/Family CoordinationMedical Appointment SchedulingMedical Transport Planning
78%
4%
7%6% 5%
Patient Encounters (58.75 hrs)
83%
Home VisitSpecialist VisitPhone
HospitalCommunity
3%
3%
1%
10%
Superutilizer Success: Preventing rehospitalizations of a patient with
uncontrolled diabetes
The How: Utilization/Cost Data•6 Months before intervention
• 3 IP Stays~$17,600 cost in receipts•2 Months after intervention
• 1 IP Stay~$8000 in receipts; 2 ED Visits~$906 in receipts
Len
gth
of
Sta
y (D
ays)
1
2
3
4
5IP
IP
IP
IP
ER ER
Sept. 28 Dec. 13 Dec. 16 Dec. 27 Feb. 26 Mar. 32012 2013
Intervention
