High Utilizer Program Lisa Cross, Director of Post-Acute Services Sheryl Mathew, Manager of Post-Acute Services Nicole Bernard, Complex Case Social Worker
Program Goals Program Goals • Identify and begin implementing processes to intervene with patients who are identified as high utilizers of the ESD and provide appropriate resources • Focus on long-term community interventions to decrease unnecessary visits to the ESD High Utilizer Definition • A high utilizer complex case can be identified as a patient who has greater than 10 emergency room encounters in 30 days for non-emergent needs
Program Tools • High Utilizer – Complex Case Committee • Complex Care Flag • Post-Acute Follow-Up Patient • Community Coordination Systemic Issues Psychosocial Barriers Inappropriate Hospital Utilization
Program Tools High Utilizer – Complex Case Committee • Members • Care Management/Post-Acute Services • Community Oriented Primary Care (COPC) • Dallas County Hospital Police Department • ESD Nursing • ESD Physicians Ethics • • Institutional Risk Management • Legal Affairs • Psychiatry • Parkland Financial Services • Homeless Outreach Medical Services (HOMES) • Bimonthly discussion of patient and system barriers resulting in creation of innovative interventions to create positive patient and system outcomes
Program Tools Complex Care Flag • The complex care flag has been created to ensure that the patients using the ESD/UCC at high volumes for non- emergent needs are flagged • Real-time, standardized, interventions across disciplines
Program Tools Post-Acute Care Coordination Post-Acute Follow-Up – Face-to-face visits with patients who have transitioned to the community Warm handoff to partner community agencies – Community Collaboration – Participation in community coalitions – Relationship building and coordination with post-acute providers – Goal is to provide uniform care at each portal of service access Homeless Services Criminal Mental Justice Health Social Parkland Service Agencies
Initial Outcomes P1 High Utilizer Patients: Account Charges P2 P3 $400,000.00 P4 P5 P6 $350,000.00 P7 P8 P9 $300,000.00 P10 P11 Start of intensive intervention P12 $250,000.00 P13 P14 P15 $200,000.00 P16 P17 P18 $150,000.00 P19 P20 P21 $100,000.00 P22 P23 P24 $50,000.00 P25 P26 P27 P28 $0.00 P29 July '16 - Dec '16 Jan '17 - June '17 July '17 - December '17 Jan '18 - April '18
Overall Program Success • Total high utilizer referrals: 276 Successful outcomes: 201 • • Patients with decreased utilization and successfully transitioned to the community for services to address psychosocial needs • Ongoing referrals: 75 High Utilizer Referrals January 2017- December 2018 27% Ongoing High Utilizers Successful Outcomes 73% N=276 patients
Changing How We Look At Data • Data excludes those whose primary presentation is for dialysis or psychiatric concerns • High utilizer definition changed to those with 6 or more ED visits within last 30 days • Analysis of high utilizer demographic data Age Gender N=134 30% Male patients with Female >6 visits in 30 days 43 33 25 70% 15 13 4 N=134 patients with 1 >6 visits in 30 days 20-29 30-39 40-49 50-59 60-69 70-79 80-89
Homelessness Interventions • Lead bi-monthly huddles with care management staff interacting with high utilizers (ESD Homeless Social Workers, HOMES SW’s, Lobby SW, Peer Recovery Navigators) • Collaborate with community partners to determine if patient is utilizing community resources Homeless DFW Homeless Shelters Unknown Human City 7% Impact Square 12% Yes No Metro The Dallas N=134 patients with Stewpot Homeless 81% Alliance >6 visits in 30 days Our Calling
Psychiatric and Substance Abuse Interventions • Collaboration with psychiatric ESD and Mobile Crisis Outreach Team Coordination with community partners to determine patient • utilization of community services • North Texas Behavioral Health Authority (NTBHA) • Metrocare • Substance abuse rehabilitation centers • Referrals placed to Parkland peer recovery navigators Substance Abuse Psychiatric Diagnosis 5% 7% Yes Yes No No Unknown 36% 35% Unknown 58% 59% N=134 patients with >6 visits in 30 N=134 patients days with >6 visits in 30 days
Payor Source Interventions • Connecting those with Medicaid to their insurance case manager • Refer patient to Parkland Financial Services to screen for eligible benefits (SSDI, Medicaid/Medicaid) N=134 patients Payor Types with >6 visits in 30 days 1% 2% Medicare/Managed 7% Medicare Aged 65+ Medicaid/Managed Medicaid 65+ 14% Uninsured/Charity Care 65+ Medicare/Managed 51% Medicare 1-64 years old Medicaid/Managed Medicaid 1-64 years old 25% Uninsured/Charity Care 1-64 years old N=134 patients with >6 visits in 30 days
Medical Home Interventions • For those identified as connected with Medical Home medical home in COPCs, refer to Value Based Care • For those identified with medical home in Community specialty outpatient clinic, connect with Oriented Primary Care: PCP clinic SW 28% Specialty • For those who utilize HOMES clinic, refer to Outpatient Clinics 49% Social Workers on mobile unit • Peer Navigators attempt to engage patients Homeless Outreach Medical in the community at shelter of origin 9% Services • For those identified with no medical home None 14% • Acute Response Clinic • Referrals to COPC N=134 patients • Partnership with City Square/Baylor with >6 visits in 30 days Community PCP Clinic
Success Story – Ms. R ESD Encounters January 2018-January 2019 Medical/Psychiatric History • 54 year old female 35 • Squamous cell carcinoma (in remission) 30 Number of Encounters 29 29 • Fibromyalgia • Hypertension 25 • Bipolar disorder 20 18 15 15 Psychosocial Barriers 14 14 14 14 10 • Homeless 10 8 • Lack of social support 6 5 • Uninsured with no income 2 1 0 • Non-compliant with social work referrals • Frequent lobby utilizer Intervention Patient Outcome • Care coordination across departments (main ESD; psychiatric ESD; care management/post-acute services) • Patient established connections with multiple social service agencies in community and is obtaining assistance with • Referred and connected to Parkland COPC and established permanent housing options care with COPC social worker via Value-Based Care program • Patient continues to utilize COPC clinic for medical needs and has continued engagement with COPC social worker via • Secondary gain reduced via split flow process in ESD Value Based Care referral • Faith Health Initiative referral placed • Secured a permanent placement for the patient at the Salvation Army homeless shelter • Referred and connected with City Square case manager • Referred to PFS for assistance with SSDI filing
Success Story – Mr. W ESD Encounters January 2017-January 2019 Medical/Psychiatric History • 47 year old male 40 • Arthritis 36 35 • Schizophrenia Number of Encounters 30 27 27 25 Psychosocial Barriers 23 20 21 20 20 • Greater than 2 year utilizer of ESD services • Chronically homeless after relocating from 15 13 Massachusetts 11 11 10 9 9 • Inability to identify/locate next of kin 5 4 5 5 5 • Capacity concerns 3 3 2 2 3 1 1 0 0 • Loss of funding and income Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Intervention • Care coordination across departments (main ESD; Patient Outcome psychiatric ESD; care management/post-acute team) during each encounter • Patient placed in a long-term care facility as SSI-pending • Next of kin located and patient connected with family in • Multiple attempts to engage patient with Salvation Army Massachusetts • Referred to PFS for social security disability application • Post-acute social worker continues to attempt family assistance reunification while SSDI determination is pending • Parkland neurocognitive clinic referral secured and testing subsequently was conducted, resulting in a determination that patient does not have capacity
Barriers • Transient nature of patient population • Access to community resources • Affordable housing • Lack of emergency shelter beds • Mental health resources
Moving Forward • Further explore: • Social determinants of health • Socially driven vs medically driven ESD encounters • Inpatient admissions, readmissions, and medical complexity of those identified as high utilizers • Redefining successful outcomes • Continued collaboration with DFW community partners
Laissez le bon ton roulet!
Losing Your Mojo
Losing Your Mojo
Losing Your Mojo
Losing Your Mojo
Losing Your Mojo
Losing Your Mojo
Creating A Village, Finding Our Mojo Lisa Cross, Director Post-Acute Services February 26, 2019
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