+Building a Learning Collaborative for High Utilizer Interventions

Andrea Hallowell Miller

Program Manager, Cross-Site Learning

John’s Story•44 year old former Pro Wrestler “The Black Scorpion”•Suicide Attempt•Homeless•Lack of Family Support•Poor Medication Adherence•Drug Use•Seizures & Hypertension•Anxiety & Depression• Insulin Dependent2012 Hospital Utilization:9 inpatient admissions3 Emergency Department visits

Patient Centered Care Coordination

Hospital #1

Streets

Hospital #2

Transport

BehaviorDay

Program

WileyChristian

Day

PCP

Neuro PhysicalTherapy

OccupTherapy

PodiatryEndocrine

Ortho-Pedics

Nephro

Shelter

Cherry HillPartialDay

Tempus Pharmacy

Collab.Support Program

Accom-pany

SSD

LegalAid

ChildSupport

Clinical Interventions

The Push

The Carry

The Catch

+The Carry: Community Based Care Coordination

Discharge•Deceased•Moved •Lost contact•Disengaged

Data Triage

Outreach

Graduation

+Cross-Site Learning Program

Began in July 2012 to address the need for teaching and collaboration around care for high needs, high cost patients

Fosters technical assistance and other resources for sites across the country

Moving toward a “hub” model for collaboration, with sites serving as regional centers of excellence for other communities

+Project Goals

+CSL Project Sites

Robert Wood Johnson Foundation

Boston, MA

Cincinnati, OH

Cleveland, OH

Grand Rapids, MI

Humboldt County, CA

Kennebec County, ME

Centers for Medicare and Medicaid Innovations

Allentown, PA

Aurora, CO

Kansas City, MO

San Diego, CA

Independently Funded

Howard County, MD

New Orleans, LA

Pittsburgh, PA

+National Governors’ Association State Projects

Alaska

Colorado

Kentucky

New Mexico

Puerto Rico

West Virginia

Wisconsin

+Known Super-Utilizer Interventions

+2014 and Beyond

Manual: Developing a Super-Utilizer Intervention

Interactive web resources

Expanded “boot camp” open house program

Recruiting new CSL sites

National Governors Association Super-Utilizer Policy Academy

Theory of Change

+Clinical Readiness

Do you have staff members in your organization who will take on this work, or is hiring necessary?

Have you developed a workflow for care transitions?

Have you begun seeing patients?

+Data Readiness

Have you used data to define the problem in your community (hotspotting)?

Have you established patient enrollment criteria?

Have you determined a strategy for these patients?

+Engagement Readiness

Have you assessed existing community resources for this patient population?

Do you already have connections with these resources?

Which organizations do you plan to target for partnership?

+

Resources

•andrea@camdenhealth.org

•www.camdenhealth.org

•Twitter: @camdenhealth