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Patient navigator program at Wishard
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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
2
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
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
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
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
Learning Objectives
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Wishard Community Health Centers
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
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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
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
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
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
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
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
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
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
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Patient Strengthening Programs Confidential | W-EH |April 9, 2013
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
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
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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)
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
Return on Investment
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Patient Strengthening Programs Confidential | W-EH |April 9, 2013
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
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
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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
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
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Organization Chart
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
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 Community Health Worker1-FTE
Bilingual Care Coordinator, BSW1-FTE
Community Health Worker1-FTE
Bilingual 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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Patient Strengthening Programs Confidential | W-EH |April 9, 2013
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
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
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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
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
Wishard-Eskenazi HealthHealthy Families Program
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Success Stories
Open for Dr. Stelzner
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
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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
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
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]
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
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
Patient Strengthening Programs Confidential | W-EH |April 9, 2013
Patient Strengthening Programs Confidential | W-EH |April 9, 2013