Strengthen Programs Patient Navigation - Dr Sarah Stelzner (2)

COMMUNITY BASED & HOME VISITATION STRENGTHEN PROGRAMS

PATIENT NAVIGATION | PRENATAL CARE COORDINATION | HEALTHY FAMILIES

BY: SARAH M. STELZNER,MD PATRICK L. WOOTEN, MS., HCM - PROGRAM DIRECTOR

Introduction of Speaker

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Sarah M. Stelzner, M.D., is the Assistant Clinical Professor of Pediatrics for Indiana University School of Medicine. She brings her cultural heritage into her work. As a woman of Mexican Nicaraguan heritage who spent part of her childhood in Latin America, her ability to speak Spanish, and understand cultural differences, greatly enhances the trust and communication between her and her patients. Dr. Stelzner has used these skills while training in primary care at the University of California, San Francisco, serving patients in the Mission district at San Francisco General Hospital, and volunteering in the Haight-Ashbury Free Medical Clinic. In 1998 Stelzner joined the Indiana University School of Medicine faculty as a clinical assistant professor of pediatrics. She directs the child advocacy rotation for second-year residents, organizes a yearly multidisciplinary health education project in Calnali, Mexico, and serves a rapidly growing Hispanic community at Wishard Hospital and Eskenazi Health Center, Indianapolis.

Dr. Sarah M. Stelzner, MD

Assistant Clinical Professor of Pediatrics

Patient Strengthening Programs Confidential | W-EH |April 9, 2013

Program Director

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Patrick L. Wooten, MS., HCM

Director, Patient Navigation and Community Health Program


Patrick Lamar Wooten, M.S., is director of Patient Navigation and Community Health Programs at Wishard Health Services. In this position, he provides leadership in a broad range of patient care activities, including assisting in the improvement of patient relations between staff and patient/families by identifying and eliminating barriers to patient care and access. He also provides directorial oversight of the Wishard-Eskenazi Medical Center Community Health Center Social Workers, Healthy Families, Patient Navigation, and Prenatal Care Coordination Program. Patrick is a board member for the Central Indiana Affiliate of Susan G. Komen. He is also an active affiliate of IU Simon Cancer Center-IUSCC Health Disparities Advisory Committee and serves as a critical link between IUSCC and Wishard. by identifying effective strategies that focus on efforts of reducing cancer risks, early detection, accrual to clinical trials, and enhancing the survivorship and quality of life for cancer patients.

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Wishard-Eskenazi Health CentersPrimary Care Network

Patient Navigation & Community Health Programs

History of NavigationWishard-Eskenazi Health Patient NavigationPrenatal Care Coordination Home Visitation Healthy Families Home Visitation

Success Stories & Top Three Lessons Learned


Learning Objectives

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Wishard Community Health Centers


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WishardHospital

MidtownMental Health

EskenaziHealthCenter(FQHC)

Non-FQHCSites

EmployeeHealthClinics

Blackburn

Cottage Corner

GrassyCreek

NorthArlington

PecarForestManor

WestsidePrimaryCareClinic

Eagledale

Linwood

38th

Street

Primary Care Network

BartonAnnex

38th

Street


History of Patient Navigation

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Harlem New York Established by Dr. Harold Freeman in 1990 to

combat cancer disparities with funding from the American Cancer Society

Wishard Health Services Based upon Dr. Freeman’s model Adapted for use in primary care Includes home-visitation complements


Wishard-Eskenazi Health Center Patient Navigation

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The goal of the Wishard-Eskenazi Health Center Patient Navigation Program is to increase overall patient health outcomes and quality of life by helping patients: Navigate: through the healthcare system

and community resources Identify: barriers to care Connect: to programs and services to

address those barriers


Emphasis of Community Health Center Navigators

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Primary Care New patients entering primary care Emergency Department patients requiring Primary

Care follow-up Hospitalized patients requiring Primary Care follow-

up


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Patient Demographic(2012 - All Locations - All Statuses Report)

Ethnicity Count

American Indian or Alaskan Native 14

Asian 160

Black or African American 5050

Hispanic or Latino 2072

Native Hawaiian or Other Pacific Islander 47

Two or more races 213

Unknown 200

White 3027

Totals 10783

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Process OverviewPATIENT NAVIGATION – WISHARD AMBULATORY CARE

PN receives notification of new patient

scheduled at CHC and ED follow-up patients

PN mails out introductory letter to patient (7 days out)

PN calls to confirm appointment (3-5

days out from appt)Pt confirms appt.

• PN informs patient of what to expect at first visit• PN informs patient of items to bring to provide to registrar

• PN coaches patient on importance of keeping appointments• PN instructs patient on use of TeleVox system

• PN provides patient with PN’s contact information/cell number• PN offers patient site tour on day of appointment or another day prior

Yes No

PN offers to reschedule

appt. or cancel if unable to attend

TeleVox reminder call (24/48 hrs from appt)

PN meets patient for tour (day of or prior to appt)

PN remains available for patient/family for future scheduling or access needs (contact via PN cell number,

or if patient presents on “no show” list in the future)

Yes

No


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Process OverviewUrgent Clinics

PATIENT NAVIGATION – WISHARD AMBULATORY CARE

Walk-in patient seeking urgent MED/

PED services at Wishard CHC

Patient is triaged, roomed, and provided medical service from

NP/physician

Navigator enters room & conducts urgent care survey/primary care needs assessment

Patient has established PCP?

• Schedule return appointment via PHS and/or by contacting the CHC• Schedule specialty visits/referrals designated by NP (if applicable)• Provide patient with an appointment itinerary

Yes No

• Link patient to PCP based on resident geographic• Schedule new MED/PEDS appointment via PHS and/or by contacting CHC• Schedule specialty visits/referrals designated by NP (if applicable)

PN mails out introductory letter to patient (7 days out)

PN calls to confirm appointment (3/5 days out from appt)

Patient confirms appt.

• PN informs patient of what to expect at first visit• PN informs patient of items to bring to provide to registrar• PN coaches patient on importance of keeping appointments• PN instructs patient on use of TeleVox system• PN provides patient with PN’s contact information/cell number• PN offers patient site tour on day of appointment or another day prior

Yes No

PN offers to reschedule appt.

or cancel if unable to attend

TeleVox reminder call (24/48 hrs

from appt)

PN meets patient for tour (day of appt)

PN remains available for patient/family for future scheduling or access needs (contact via PN cell number, or if patient presents on “no show” list in the future)


Return on Investment

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ROI =(Gain from Patient Navigation – Cost of Patient

Navigation )

Patient Navigation

Wishard-Eskenazi Health Patient Navigation ROI Link: http://connect.iu.edu/p64u2s4h89k/?

launcher=false&fcsContent=true&pbMode=normal

ROI for Patient Navigation the benefit (return) of the program is divided by

its cost the result is expressed as a percentage or a

ratio

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Patient Navigation Community Health Programs Consortium

Healthy Families

Patient Navigation

Prenatal Care

Coordination


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Home-based services/education to help pregnant Wishard-Eskenazi Health Center patients get the right resources

Individualized support and coordination of services to maximize healthy pregnancy outcomes and decrease infant mortality and morbidity

Prenatal care and childbirth classes provide information on: Breastfeeding Danger signs of pregnancy Healthy eating How your baby grows Labor and delivery

Prenatal Care Coordination Home Visitation Service


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Organization Chart


Director, Patient Navigation/Community Health Programs

RN, Team Leader - West Office.90-FTE

MSW, Team Leader- West Office1-FTE

RN, Team Leader- East Office1-FTE

MSW, Team Leader - East Office1-FTE

Care Coordinator, BSW1-FTE

Community Health Worker 1-FTE

Bilingual Care Coordinator, BSW1-FTE

Bilingual Community Health Worker1-FTE


Bilingual Care Coordinator, BSW1-FTE

Community Health Worker1-FTE


Community Health Worker1-FTE

Office Coordinator – East Office1-FTE

Bilingual Referral Specialist – East Office1-FTE

Prenatal Care Program Staff

Office Coordinator: 1-FTEsCare Coordinators; 3-FTEsReferral Specialist: 1-FTE RN Team Leads: 1.90-FTEsMSW Team Leads: 2-FTEsCommunity Health Works:6-FTEs

Total Program FTE’s: 14.9

9 out of 14 staff are Bilingual

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Coordination Client Summary(2012 – Clients Enrolled)

Race Count %

Black 327 40%

Hispanic 369 45%

Other 51 6%

White 71 9%

Grand Total 818

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History Intensive home visitation demonstration

project initiated in Hawaii in 1985 Healthy Families America developed in 1992

by Prevent Child Abuse America Located in over 430 communities in 35 states Indiana has 49 sites providing services in all

92 counties 1 site designated for Wishard-Eskenazi Health

patients

Healthy Families


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Voluntary home visitation program providing child development information, access to health care and community resources and parent education

Designed to strengthen families and promote healthy childhood growth and development

Help reduce child abuse and neglect, childhood health problems and juvenile delinquency

Intervention starts at the 3rd trimester of pregnancy (for mom) and last until 3 years of age for the child


Wishard-Eskenazi HealthHealthy Families Program

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Success Stories

Open for Dr. Stelzner


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Three Top Lessons Learned

1. Eskenazi Health Center is a unique FQHC model called a “public entity co-applicant model.”

2. The goal of the Wishard-Eskenazi Health Center Patient Navigation Program is to increase overall patient health outcomes and quality of life by helping patients: Navigate: through the healthcare system and community

resources Identify: barriers to care Connect: to programs and services to address those barriers

3. Wishard Patient Navigation Program is Based upon Dr. Freeman’s model Adapted for use in primary care Includes home-visitation complements


Contact Information

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Dr. Sarah M. Stelzner, MDAssistant Clinical Professor of Pediatric Indiana University School of Medicine

Office (317) 278-3411 | Fax (317) [email protected]

Patrick L. Wooten, MS., HCM Director, Patient Navigation & Community Health Programs

CHC Social Workers | Healthy Families | Patient Navigation | Prenatal Care Coordination

Wishard-Eskenazi Health Center - Ambulatory Care1001 W 10th Street, BA 403 | Indianapolis, IN 46201

Office (317) 630-6143 | Blackberry (317) 945-9392 | Fax (317) 287-3045 [email protected]


mailto:[email protected]

mailto:[email protected]

References

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DC Cancer Consortium. (2012). Retrieved November 7, 2012 from http://dcpnavigatorrp.wikispaces.com/Patient+Navigation+History

Healthy Families America (2013). Retrieved February 14, 2013 from http://www.healthyfamiliesamerica.org/home/index.shtml

Health and Hospital Corporation of Marion County DataMart. (2002). Retrieved October 7, 2012 from http://www.hhcorp.org/

Wishard Health Services. (2011). In About Us. Retrieved November 7, 2012 from: http://wishard.edu/about-us.html

Wishard Health Services. (2013). In Patient Navigation. Retrieved February 10, 2013 from: http://wishard.edu/PatientNavigation.html


Strengthen Programs Patient Navigation - Dr Sarah Stelzner (2)

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