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Building a Learning Collaborative for High Utilizer Interventions. Andrea Hallowell Miller Program Manager, Cross-Site Learning. John’s Story. 44 year old former Pro Wrestler “The Black Scorpion” Suicide Attempt Homeless Lack of Family Support Poor Medication Adherence Drug Use - PowerPoint PPT Presentation
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+Building a Learning Collaborative for High Utilizer Interventions
Andrea Hallowell Miller
Program Manager, Cross-Site Learning
John’s Story•44 year old former Pro Wrestler “The Black Scorpion”•Suicide Attempt•Homeless•Lack of Family Support•Poor Medication Adherence•Drug Use•Seizures & Hypertension•Anxiety & Depression• Insulin Dependent2012 Hospital Utilization:9 inpatient admissions3 Emergency Department visits
Patient Centered Care Coordination
Hospital #1
Streets
Hospital #2
Transport
BehaviorDay
Program
WileyChristian
Day
PCP
Neuro PhysicalTherapy
OccupTherapy
PodiatryEndocrine
Ortho-Pedics
Nephro
Shelter
Cherry HillPartialDay
Tempus Pharmacy
Collab.Support Program
Accom-pany
SSD
LegalAid
ChildSupport
Clinical Interventions
The Push
The Carry
The Catch
+The Carry: Community Based Care Coordination
Discharge•Deceased•Moved •Lost contact•Disengaged
Data Triage
Outreach
Graduation
+Cross-Site Learning Program
Began in July 2012 to address the need for teaching and collaboration around care for high needs, high cost patients
Fosters technical assistance and other resources for sites across the country
Moving toward a “hub” model for collaboration, with sites serving as regional centers of excellence for other communities
+Project Goals
+CSL Project Sites
Robert Wood Johnson Foundation
Boston, MA
Cincinnati, OH
Cleveland, OH
Grand Rapids, MI
Humboldt County, CA
Kennebec County, ME
Centers for Medicare and Medicaid Innovations
Allentown, PA
Aurora, CO
Kansas City, MO
San Diego, CA
Independently Funded
Howard County, MD
New Orleans, LA
Pittsburgh, PA
+National Governors’ Association State Projects
Alaska
Colorado
Kentucky
New Mexico
Puerto Rico
West Virginia
Wisconsin
+Known Super-Utilizer Interventions
+2014 and Beyond
Manual: Developing a Super-Utilizer Intervention
Interactive web resources
Expanded “boot camp” open house program
Recruiting new CSL sites
National Governors Association Super-Utilizer Policy Academy
Theory of Change
+Clinical Readiness
Do you have staff members in your organization who will take on this work, or is hiring necessary?
Have you developed a workflow for care transitions?
Have you begun seeing patients?
+Data Readiness
Have you used data to define the problem in your community (hotspotting)?
Have you established patient enrollment criteria?
Have you determined a strategy for these patients?
+Engagement Readiness
Have you assessed existing community resources for this patient population?
Do you already have connections with these resources?
Which organizations do you plan to target for partnership?
