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Camden Coalition of
Healthcare Providers
Clinical Care Coordination & Delivery
Community Outreach for Complex Patients:
Basics of Care Management in the Field
Camden Coalition of
Healthcare Providers
www.camdenhealth.org
Overview
• Problem & Goals
• Tenets of Good Care
• Patient Variation & Team Composition
• Workflows & Enrollment
• Patient Engagement
• Case Study
• Key Intervention: Medication Reconciliation
• Q & A
www.camdenhealth.org
Problem
www.camdenhealth.org
Charley
Hospital
#1
Sub-Acute Rehab
Hospital
#2
Home
Nursing
Home
PT/OT
Durable Goods
Meals
Transport
Dialysis
Nephrology
Transplant
PCP
UrologyOncology
Surgery
GI
Cardiology
Eye
Pain
MgtPulm.
Goals
• Stabilize
• Coordinate
• Improve Health
• Reduce Cost
www.camdenhealth.org
Tenets of Good Care
• It takes a team
• Enroll based on specific triage data r/t preventable readmissions
• Engage patient at hospital
• Build/maintain rapport with patients/families
• Assess medical/social complexity
• Provide immediate post d/c(<72 hours) inperson intake
assessment
• Accompany to PCP < 7 days post d/c
• Build the relationship between patient/family and PCP/specialists
• Individualized care plan with specific graduation timeline
• Collect information at each step to evaluate/improve program
• Helping patients help themselves to find long-term sustainable
resources
www.camdenhealth.org
Variations of Patient Complexity
www.camdenhealth.org
So
cia
l Co
mp
lexity
• 42 y.o. male
• Hx Asthma Exacerbation
• Homeless
• Mental health illness
• No social support
• Crack cocaine addiction
Medical Complexity
• 67 y.o. female
• Hx CHF, HTN, COPD
• Depression, anxiety
• 17 meds daily
• Work history
• D/C to LTAC
• Daughter is primary caregiver
• 23 y.o. male
• Hx of Type 1 Diabetes
• Lives with grandmother
• Works as day laborer
• Learning disability
High
Higher
Higher
www.camdenhealth.org
So
cia
l Co
mp
lexity
Medical ComplexityHigh
Higher
Higher
Staffing pairs to meet complexity
SW/HC
LPN/HC RN/LPN
RN/SW
SW
CW
Staff Composition
RN LPN
LPN
CHW
HC
HC
Pr. Dir.
www.camdenhealth.org
Care Management Workflow
www.camdenhealth.org
•Admissions data
•Current day
•Access to patient chart
Data•Assessment
•AssignmentTriage
•Blend of medical & social complexity
Outreach
•Completion of care plan
•Transition to PCP
Graduation
Admitted past month, 6 month summary Days 6 mo episodes Admit Facility Inp ED Name dob age sex PCP PracticeName Insurance
06/13/12 Cooper 40 7 3 xxxxxxxxxxxxxx xx/xx/xxxx 55 M JACK GOLDSTEIN CMC Dept of Cooper 44 3 2 xx/xx/xxxx 73 F MARILYN GORDON CAMcare Health Cooper 79 3 xx/xx/xxxx 57 M JOHN KIRBY Cooper Physician HORIZON NJ PPO Cooper 35 2 3 xx/xx/xxxx 21 M NO PHYSICIAN OLOL 1 2 1 xx/xx/xxxx 56 M SELF PAY - Cooper 5 2 1 xx/xx/xxxx 61 M OLOL 4 2 1 xx/xx/xxxx 54 M SELF PAY Cooper 27 2 xx/xx/xxxx 47 M MARILYN GORDON CAMcare Health
06/12/12 Cooper 15 13 1 xx/xx/xxxx 22 F MIGUEL MARTINEZ Cooper Physician Cooper 18 3 2 xx/xx/xxxx 55 M NO PHYSICIAN AMERHLTH/KEYST Cooper 99 3 1 xx/xx/xxxx 64 M DANIEL HYMAN Cooper Physician
06/11/12 Cooper 9 9 5 xx/xx/xxxx 48 M LYNDA BASCELLI Project Hope OLOL 43 9 1 xx/xx/xxxx 71 F INTERNAL BILLING OLOL 17 5 5 xx/xx/xxxx 66 F HORIZON NJ Cooper 27 5 3 xx/xx/xxxx 52 M LYNDA BASCELLI Project Hope OLOL 35 5 1 xx/xx/xxxx 70 F BRAVO HEALTH OLOL 46 4 5 - xx/xx/xxxx 73 F HORIZON NJ OLOL 31 3 2 xx/xx/xxxx 52 F SELF PAY Cooper 2 3 1 xx/xx/xxxx 68 F MINH HUYNH OLOL 1 3 1 xx/xx/xxxx 73 F HORIZON NJ Cooper 34 3 xx/xx/xxxx 62 F ANNA HEADLY Cooper Physician Cooper 131 2 10 xx/xx/xxxx 35 M NO PHYSICIAN OLOL 54 2 6 xx/xx/xxxx 49 F SELF PAY - OLOL 177 2 4 xx/xx/xxxx 91 F HORIZON NJ Cooper 3 2 2 xx/xx/xxxx 51 M NO PHYSICIAN MEDICAID OLOL 139 2 2 xx/xx/xxxx 87 F HORIZON NJ
Thursday, June 14, 2012 Page 1 of 8
Enrollment Data
www.camdenhealth.org
Patient Engagement
www.camdenhealth.org
Patient Level Timeline:Clinical Phase (0-30 days)
Start
(d/c date)
Week 1 Week 2 Week 3 Week 4
HomeVisit #1
(24-48 hrs)
HomeVisit #2
PCP Visit(w/in
7 days)
RN, SW, LPN
LPN, SW RN
Specialty Visits(w/in 14 days)
HomeVisit #3
LPN, SW
HomeVisit #4
LPN, CHW
www.camdenhealth.org
Patient Level Timeline:Social Phase (30-60 days)
Week 4 Week 5 Week 6 Week 7 Week 8
HomeVisit #5
HomeVisit #6
HomeVisit #7
HomeVisit #8
CHW, HC• Chronic disease self mgt. skills• Health care navigation skills• Care plan development• Coaching
Case Study “Charley”
• 55-year-old African-American male
• At time of enrollment, admitted for GI bleed and SOB (November 2011)
• Medicare/Medicaid coverage
• Lives alone in high-rise apartment
• 12 medications daily
6 months prior to enrollment• 9 ED visits & 6 inpatient stays
• Hospitalized on average every 45 days
Complex chronic conditions• ESRD
• Renal Carcinoma• Hepatitis B
• Hypertension
• Hyperlipidemia
• Peripheral vascular disease
• Asthma• Glaucoma (blind in one
eye)
• Sleep apnea
• Severe back pain
Key Intervention:Home-Based Medication Reconciliation
www.camdenhealth.org
www.camdenhealth.org
Q & A
THANK YOU!