Changing the System for

Vulnerable People

Shelly Virva LCSW

Associate Clinical Director Behavioral Health Integration

National Center for Complex Health and Social Needs

Camden Coalition of Healthcare Providers

MissionSpark a field and movement that unites communities of caregivers in Camden and across the nation to improve the wellbeing of individuals with complex health and social needs.

VisionA transformed healthcare system that ensures every individual receives whole-person care rooted in authentic healing relationships.

Objectives:1. Defining “Super Utilizer” (complex care).

2. Lessons learned from the field.

3. Ingredients for success.

Defining Super-utilzer(Complex Care Patient)

What’s the problem we are trying to solve?

Important Pre Work Questions

• What is the goal of our intervention? • This should be achievable.

• Who is our target population?• Sub-population vs entire group?

• How do we define this? • Do we have the data to support this?

Data, Data and More Data

How•How do you know this is your target population? (what does the data say?)

•How will you measure success? (what data will you use to show this?)

•How can we share data among all engaged agencies?

Using the data to help build (or tweak) your intervention.

• What does the data say?• What data points are you using?• Common high utilization data points:

• Inpatient • Emergency Department• Pharmacy• Imaging

• Cost, length of stay, number of units?

If Only I knew This Before I Started

• C-Suite Support

• Senior Leadership Champion

• Data and Finance Help

Partnering for Complex People

The Effect of the Silos• Duplication• Fragmentation• Increased Cost• Missed Opportunity• Tough to solve complex problems alone• Poor Patient Experience

Breaking Down the Silos

• Who is on the Cross Continuum Team?

• Reach In• Reach Out• Stop Reinventing the

Wheel

Tools and Structure

What do you need to build collaboration across systems?

Tools

• Business Associates AgreementContract between a HIPAA covered entity and a HIPAA business associate (BA) that is used to protect personal health information (PHI) in accordance with HIPAA guidelines.

• http://www.camdenhealth.org/cross-site-learning/resources/engagement/hospitalprovider-agreements-for-super-utilizer-interventions/

• One Contact PersonReferralsQuestions

• Huddles• Coordinate care• Treatment planning• Identification of new opportunities for

collaboration• Integrated Consent

Inter-organizational Collaboration –Case Conferencing & Sharing Resources

Community CollaborativeSolving complex problems with shared resources

sdasT

Towork together

with shared dataand public input

DeliverBetter care atLower costs

Encourages a group of stakeholders in a community

A Community collaborative isan innovative community based model of delivery that…

Questions?

Resources:https://www.camdenhealth.org/https://www.nationalcomplex.care/https://www.complex.carehttp://www.ohsu.edu/xd/education/schools/school-of-medicine/departments/clinical-departments/psychiatry/grand-rounds/upload/21-OHSU-Health-Resilience-Program.pdfhttps://www.hqp.org/McLeroy, K. R., Norton, B. L., Kegler, M. C., Burdine, J. N., & Sumaya, C. V. (2003). Community-Based Interventions. American Journal of Public Health, 93(4), 529–533.

Lauran Hardin MSN RN-BC, CNL Senior Director Cross Continuum Transformation, National Center for Complex Health and Social Needs

•Hardin, L., Kilian, A., & Spykerman, K. (2017). Competing health systems and complex patients: An interprofessional collaboration to improve outcomes and reduce healthcare costs. Journal of Interprofessional Education and Practice, 7, 5-10. http://jieponline.com/article/S2405-4526(16)30103-3/pdf