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Cmmi oct final
- 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 GoodCare • 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 PatientComplexity 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 tomeet 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 pastmonth, 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
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- 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 MedicationReconciliation www.camdenhealth.org
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