Care Coordination Across the Healthcare Continuum: Journey to Integration
CMS Support • The project described was supported by Funding Opportunity Number CMS-1C1-12-0001 from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. • Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
Patient Care Management Transition: 2014 Old Approach New Approach •Focus is on the high risk patient •Focus is on care coordination for all patients •Episodic acute care is the priority • Continuity and transitions of care •Health care professionals work in across the continuum is the priority isolation •Collaboration among health care team •Care planning is conceptual and siloed members is required •Provider infrastructure is fragmented and •Care planning is aggressive, results information systems are not integrated oriented & prevention is important •Patient and families minimally included in •Provider infrastructure is fully decision making integrated •Emphasis on Patient/Family centered care
Community Health Partnership • Build on existing programs. Over 200 people involved. • Will transform patient care across continuum: clinics, SNFs hospitals, home, and EDs . • Catalyzed by a three-year CMS grant of $19.9M. • East Baltimore Community – 7 zip codes.
Who will J-CHiP “Touch”? • Up to 40,000 adult annual discharges from JHH/JHBMC by year 3. 1000s of ED visits. • About 7000 adult Medicaid and 10-14,000 Medicare patients receiving local community care will be monitored and 3000 targeted . – Mental illness, substance abuse and chronic illness.
Community Health Partnership Hospital/Transitions/ED Component • Readmission and transition efforts began through JHHS Readmissions Task Force efforts in 2009. • HSCRC ARR program New Waiver • “All Payer.” Patient/Family Primary Provider Medication Risk Screens Interdisciplinary ED Education Management Handoff Care Planning Management Transitions of Care
Care Coordination “Bundle” • ED Care Management – ED Care Protocols – Assess Risk and Ease Transition Back to Community • Risk screening—Early and periodic • Patient family education – Self-care management – Condition-Specific Education Modules – “Teach-back” • Interdisciplinary care planning – Multidisciplinary team-based rounds: every day, every patient – Mobility initiative – Projected discharge date on every patient
Care Coordination “Bundle” • Provider handoffs – Provider communication on admission and DC--iPIPE – Discharge summary within 5 days – PCP follow-up within 7-14 days • Medication Management – “Medications in hand” before discharge – Medication reconciliation – Pharmacist Education • Transitions of Care – Phone calls – Home visits (Transition Guide/Pharmacy) • PAL Line: Patient “Anytime” Line – Post-discharge phone calls – After hours triage system
Community Health Partnership Care Coordination Moderate Intense Intervention • Follow Up Phone Call • Follow-up Appt ED In Depth • Post Acute Referrals Outpatient Risk Screen High Intense Intervention • Transition Guide • Post Acute Referrals • Follow-up Appt Decision to Admit Education: AHDP Provider Early Risk Interdis. • Red Flags DC Risk Handoff: • Self-Care Care Screen Assessment • DC Sum Planning • Medications • FU appt • Who to call Hospitalization Adult Admission Access Transition
Community Health Partnership SNF Component Clinical Protocols- • CHF, COPD, Discharge Genesis Heritage FutureCare Canton Harbor FutureCare Northpoint Transition Assessments- • Admission Nursing & Medicine • Planned and Unplanned discharge • Staff Attitudes Brintonwoods Post-acute Care Riverview Surveys Center Skilled Nursing Facility
Community Health Partnership Community Intervention BEGIN Target Population Attend one of the participating clinics within 7 zip codes 1. Member identified to be in 1. Improved Health care the top 20% of people with a 2. Improved Experience with high risk of inpatient admission Healthcare system or ED Visit 3. Reduced Costs of Care GOALS 2. A Clinical Screener will 7. Ongoing relationship verify eligibility and with team members in the complete Demographics and clinic and community Health Status sections of assessment. Assigns to team. 6. Referral to members of the JCHiP Team for self- 3. Community Health Worker management education, outreaches to behavioral support, or identify barriers to getting specialty care. Healthcare services and schedules follow up with Case Manager. 5. Visit with PCP and team at 4. Nurse Case Manager clinic to work on a Care Plan to Visit at clinic to complete identify goals and health care survey of health and services needs. behavioral needs.
Community Health Partnership Community Patient Characteristics High Risk Group = 1000 PPMCO patients Patient characteristics: Medical and Behavioral Conditions 36% have 6 or more chronic conditions. Lung disease Heart disease: 98% – Asthma: 42% – Conditions – Emphysema: 29% » Coronary Artery Disease (condition leading to heart Kidney disease: 28% attack): 58% Substance use » Heart Failure: 32% – Smoking: 71% – Modifiable risk factors – Substance abuse: 45% » Hypertension: 84% – Alcohol Abuse: 29% » Smoking: 71% Diabetes: 49% » High Levels of Cholesterol : 52%
JHM Care Management Continuum: Structure, Roles, Processes Community-based Transitional / In home Care: Population Structure/Roles Acute Illness Care Health Management Scope / Population • Time limited, • Time limited intense • No time limit (Who: includes the • Episodic care episodic care • Continuous case breadth of the management management management for high population and the time • ED/Admission through • Home setting risk frame or episode for discharge and post- • post-acute period (30- • On-going surveillance intervention) acute handoffs 60 days) Goals (for episode and • Return to clinical • Self-care mgmt. and • Primary, secondary context) baseline patient activation and tertiary prevention • Utilization (LOS) • Complications • Risk reduction • Pt/Fam Satisfaction prevention and mgmt. • Self-care mgmt. • Safe transitions & • Transition to knowledge and support handoffs community • QOL maintenance Site (Where) • Hospital, ED, Pre-op • Home • Medical Home clinics • Hotel/shelter, etc. • Specialty care • Acute rehab/SNF • Home and Community
JHM Care Management Continuum: Structure, Roles, Processes Community-based Structure/Roles Acute Illness Transitional / In home Care: Population Care Health Management Intensity (What) • Clinical Case Mgmt. • Coordination of all • Monitoring health • Psycho-social, post-acute services status changes behavioral, economic • Transitions coaching • High risk Care Mgmt. resources • Skilled home/Hospice • Chronic disease mgmt. • Protocols/Pathways care • Health coaching, • Telephonic contact • Acute/Sub Acute rehab lifestyle mgmt. Roles (Who) • Nurse Case Managers • Transitions Coaches • Community CMs (CMs) • Home Care CMs/Field • Health Behaviors • PAL CMs nurses Specs • Social Workers • PT CMs • Health Educators • Multi-Disciplinary Team • Community Social • Community Health Workers Workers (CHWs). • Community CMs
JHM Care Management Continuum: Structure, Roles, Processes Community-based Processes Acute Illness Transitional / In home Care: Population Care Health Management Complex Case Mgmt. • All hospitalized and ED • Pts. identified during • Population risk screens • Pt. identification/ pts. Screened (tools acute/or newly and/or referrals • Screening and population identified post acute • In-depth assessment of • In-depth assessment characteristics • Screening by post- patient needs • Individualized • Identification based on acute team • Individualized, interdisciplinary screening • Collaboration with interdisciplinary care care/transitions • Individual assessments Medical Home/PCPs plan planning with patients/family • Receipt of patients • Self care mgmt. • Communication and • Care Planning and from SNF/Acute Rehab support collaboration Goals/Collaboration • Community health • Care coordination interventions (social determinants of health) • Use of population Evidenced –based • Structured Care • Continuation of Care care Methodologies (orders, plans/guidelines evidenced based • Disease, health protocols, pathways, • SNF, HF and COPD guidelines behavior protocols etc.). protocols • Analysis of population • Risk Stratification • Screening tools • Outcomes mgmt. data for targeted related to transitions interventions • Decision support tools • Triage protocols • Outcomes mgmt. • Decision support tools
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