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?
Top Related