The document discusses the work of the Camden Coalition of Healthcare Providers in providing clinical care coordination and outreach for complex patients. It outlines the goals of stabilizing patients, coordinating their care, improving their health, and reducing costs. It describes the tenets of providing a team-based approach, enrolling patients based on risk factors, engaging patients early, and developing individualized care plans. The document provides examples of how staff are paired to address different levels of patient medical and social complexity. It also gives a case study of a patient with multiple chronic conditions who was enrolled in their program and benefited from a home-based medication reconciliation intervention.

1. Camden Coalition of
Camden Coalition of
Healthcare Providers
Healthcare Providers
Clinical Care Coordination & Delivery
Community Outreach for Complex Patients:
Basics of Care Management in the
Field
www.camdenhealth.org

2. 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

3. Problem
Transport
Meals Home
PT/OT Home
Nursing
Hospital
Sub-Acute #2
Rehab
Durable Hospital
Goods #1
Charley
Dialysis
PCP
Urology
Nephrology Oncology
Surgery
Eye
Transplant
Pain Cardiology
Mgt GI
Pulm.
www.camdenhealth.org

4. Goals
• Stabilize
• Coordinate
• Improve Health
• Reduce Cost
www.camdenhealth.org

5. 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

6. Variations of Patient Complexity
Higher • 42 y.o. male
• Hx Asthma Exacerbation
• Homeless
• Mental health illness
• No social support
• Crack cocaine addiction
Social Complexity
• 23 y.o. male
• Hx of Type 1 Diabetes • 67 y.o. female
• Lives with grandmother • Hx CHF, HTN, COPD
• Works as day laborer • Depression, anxiety
• Learning disability • 17 meds daily
• Work history
• D/C to LTAC
• Daughter is primary caregiver
High Higher
Medical Complexity
www.camdenhealth.org

7. Staffing pairs to meet complexity
Higher
Social Complexity
SW/HC RN/SW
LPN/HC RN/LPN
High Higher
Medical Complexity
www.camdenhealth.org

8. Staff Composition
Pr. Dir. LPN HC SW
CW
RN LPN HC CHW
www.camdenhealth.org

9. Care Management Workflow
•Admissions
data •Blend of •Completion
•Current day •Assessment medical & of care plan
Data Triage Outreach social Graduation
•Access to •Assignment complexity •Transition to
patient chart PCP
www.camdenhealth.org

10. Enrollment Data
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
www.camdenhealth.org

11. Patient Engagement

12. Patient Level Timeline:
Clinical Phase (0-30 days)
PCP
Home Home Visit Home Home
Visit #1 Visit #2 (w/in Specialty Visits Visit #3 Visit #4
(24-48 hrs) 7 days) (w/in 14 days)
Start Week 1 Week 2 Week 3 Week 4
(d/c date)
RN, SW, L LPN, SW RN LPN, SW LPN, CHW
PN
www.camdenhealth.org

13. Patient Level Timeline:
Social Phase (30-60 days)
Home Home Home Home
Visit #5 Visit #6 Visit #7 Visit #8
Week 4 Week 5 Week 6 Week 7 Week 8
CHW, HC
• Chronic disease self mgt. skills
• Health care navigation skills
• Care plan development
• Coaching
www.camdenhealth.org

14. Case Study “Charley”
• 55-year-old African- Complex chronic conditions
American male • ESRD
• At time of • Renal Carcinoma
enrollment, admitted for GI • Hepatitis B
bleed and SOB (November
2011) • Hypertension
• Medicare/Medicaid • Hyperlipidemia
coverage • Peripheral vascular disease
• Lives alone in high-rise • Asthma
apartment • Glaucoma (blind in one
• 12 medications daily eye)
6 months prior to enrollment • Sleep apnea
• 9 ED visits & 6 inpatient stays • Severe back pain
• Hospitalized on average
every 45 days

15. Key Intervention:
Home-Based Medication Reconciliation
www.camdenhealth.org

17. www.camdenhealth.org

18. Q&A
THANK YOU!