Ca Care Transition Summit Ju June 18, 2019
An award winning 403(b) non profit complex case management organization specializing in delivering evidenced based medical and behavioral health care in the metropolitan Detroit area. Who ar are e we Our mission is to identify gaps in care and social determinants which have a significant effect on the cost and success of medical treatments.
• Medication Reconciliation • Health Education/ Health Coaching • Clinical Assessment • Navigation of Community Resources Our ur Mod odel • Person Centered Planning • Life Skill Development • Facilitation of Health Care Partnerships
• Our Strategy Integrating patient centered care coordination models across medical, behavioral, and social systems to address social determinants of health. Com omplex x Case ase • Our Foundation Man anagement We currently utilize the successful Camden Coalition Model which highlights the focus on social determinants of health and the research of Dr. Jeffrey Brenner.
• Our Approach We have developed a focused approached to reconnecting patients back to there primary care providers and away for local emergency departments. Com omplex x Case ase Man anagement • Goal focused Coordinate all services with the patients, providers and the health care administrators with a focused goal of reducing the overall cost of care and improving patient outcomes
Partner 4 health has four programs that we provide to Health Plans, PHO’s and Hospitals to address social determinants of health and inpatient post discharge needs. Out utreach • Community Outreach App pproach • Emergency Diversion • Hospital to Home (Transitional Care Program) • Maternal Support
High risk patients Identified • Case management assigned Com ommunit ity • Initial psychosocial assessment • Primary care appointment scheduled Out utreach • Ongoing community outreach Prog ogram • Monthly care coordination review
Licensed Social Workers imbedded in ED Em Emer ergency • Psychosocial assessment completed at bedside • Community appointment scheduled Div iversion • Post discharge follow up Prog ogram • Referral to outreach services, pharmacy or health education
Hospital Transitional Care Nurse visit (Inpatient) • Psychosocial assessment completed at bedside Hos ospit ital l to o • Health education prior to discharge Hom ome • Medication reconciliation by Pharmacist • Discharge planning needs coordinated Prog ogram • Referrals to ongoing community outreach services
Board Certified Midwife Community Outreach Mater ernal l • Psychosocial assessment completed su support t • Prenatal and Postpartum visits Prog ogram • Referrals to ongoing community outreach services
Staffing tea eam • Advance Practice Provider • Nurse Care Manager • Community Outreach Worker • Pharmacist • Mental Health Social Worker • Physician advisor P4H is dedicated to implementing an integrated healthcare delivery model for patients with multiple or complex medical conditions, that are most often combined with behavioral health problems and socioeconomic challenges.
Average Cos Cost model Savings Base Year Costs Insureds in Program Year Over Year Net Average Year over Year Cost Reductions* Cost Reductions/Insured >$100K 8 $ 822,219 74% > $50K < $100K 18 $ 277,002 30% >$25K < $50K 27 $ 189,305 33%
Community Roots • All staff from the local metropolitan Detroit communities. Patient Experiences • Our staff have over a 100 years of combined experience in transitional care management, Hospital discharge planning, and community outreach services. Affiliated Partners Com ompetit itiv ive • Partners 4 Health is currently affiliated with Common Ground, Oakland Family Services, Neighborhood Service advantages adv Organization and Southwest Solutions. Financial Outcomes • Currently we are saving our health plan providers an average cost of $1 million a year. • 15% Reduction in hospital readmission rates in 2018
Questions DaJuan Smith, MSW, LMSW President/CEO Partners 4 Health 313-686-0202 dsmith2@nso-mi.org
Addressing Social Determinants of Health at ProMedica Linda Chambers Associate Vice President Rehab Services and SDOH Clinical Integration
“ THOUGH HEALTH CARE IS ESSENTIAL TO HEALTH IT IS A RELATIVELY WEAK HEALTH DETERMINANT ” McGinnis/Foege “Actual Cases of Death in the US” JAMA November 1993
U.S. Healthcare from A GLOBAL PERSPECTIVE More people die of preventable The United States spends more money The United States has a significantly diseases and complications in the U.S. per person on healthcare than any lower life expectancy than other countries than in any other developed nation.* other nation with comparable incomes. that spend less on healthcare. 1 Japan 2 Switzerland 3 Singapore 4 Spain 5 Australia . . . . 31 U.S. *Per 1000,000 Source: Reverehealth, https://reverehealth.com/vbc/vbc-providers/
U.S. Healthcare from a GLOBAL PERSPECTIVE Exhibit ES-1. Overall Ranking
Domains of SDOH RIS RISK
ARE RE WE E ASKI KING TH THE E RIG RIGHT QUESTIONS? We do … But we don’t … Ask about and encourage exercise Ask about safety in neighborhoods Ask about and encourage people to Ask about diet and ability to secure lose weight healthy food Check vital signs Screen for mental health Check a child’s growth Look for signs of toxic stress Provide physical examinations Ask about insurance information Ask if they can’t read Provide education to patients Criticize patients who fail to show up Ask if they have transportation for appointments
• Food Insecurity Screens: 970,572 • SDOH Screens: 118,030 • Screening employees through EAP 55% HAD POSITIVE NEEDS IDENTIFIED • 39% of those screened had needs in four domains or more • 87% of those screened had a high motivation score Social Determinants TOP NEEDS: • Financial Strain of HEALTH SCREENING • Behavioral Health • Food
Impact of HUNGER ON HEALTH • Hungry people are 2.9 times more likely to be in poor health and have a higher likelihood of chronic conditions. • They are also 2.45 times more likely to be obese as a result of poor nutrition. • Newborns are 1.81 times more likely to be underweight, often leading to lifelong development and chronic conditions. • Experiences with hunger had a negative impact on the health of children 10 – 15 years later. • Children who are hungry are 4 times more likely to need professional counseling. • Hungry teens are 5 times more likely to commit suicide.
HUNGER in the U.S./Toledo • 13% of U.S. households are food insecure • 19.5% of U.S. households with children More than are food insecure 1 IN 5 FAMILIES • 30.3% of U.S. households – single moms with children with children • 31% of seniors cut or skip meals due to lack EXPERIENCE of resources FOOD • 24% undocumented workers HARDSHIP • 91% people returning from prison in Toledo • Almost 75% of SNAP recipients are seniors, disabled or working parents • SNAP benefits are often exhausted before the end of the month HUNGER IS A MAJOR HEALTH CRISIS!
Food is MEDICINE AMBULATORY: PCP writes a referral for patients that are identified as food insecure. Patients OF 4,000 MEDICAL PATIENTS receive 2- 3 days’ worth of healthy food for their COMPLETING SCREEN AND household FOOD PHARMACY REFERRAL: ACUTE CARE: Referral upon discharge. Patients • Reduced ED usage (3%) receive box of food upon leaving hospital • Reduced readmission FOOD RECLAMATION: Food normally thrown away is reclaimed and provided to community hot rates (53%) feeding site • Increased primary care URBAN FARM: Three-acre farm growing 20 fresh fruits and vegetables visit rates (4%) HCR PILOT: Food at discharge for SNF patients • Reduced pmpm (15%) in Detroit and Flint markets
Connecting Clinical Outcomes AND SDOH DATA Moms who deliver Low- birth weight babies are … • More than twice as likely to have domestic violence (24%) compared to all referred patients (12%) • Almost twice as likely to report transportation needs (41%) compared to all referred patients (27%) • More likely to cite house instability (40%) compared to all referred patients (27%) • More likely to report using substances (24%) compared to all referred patients (14%)
Correlating Demographics to Needs
PLA LACE MATTERS to Health
THE EBEID NEIGHBORHOOD PROMISE • Catalytic, $50-million, 10-year commitment to neighborhood revitalization • National neighborhood revitalization model focused on health • CDFI Investment: Additional $45M loan pool for housing development, schools, business support • Social infrastructure and capital development
PLA LACE-BASED, HE HEALTH FOCU CUSED Financial Opportunity Center
THANK YOU !
Michigan State Innovation Model (SIM) TRIPLE AIM Better Care
Backbone Organizations in Community Health Innovation Regions (CHIRs) serve as Chief Health Strategist to build community capacity to drive improvements in population health
NM CHIR NM SIM funds are dedicated to five pilot sites in Michigan. The Northern Michigan Community Health Innovation Region (NMCHIR) is our rural pilot.
Recommend
More recommend
