In-Reach Hospital In-Reach Hospital Program Program

Coordinating Multiple Service Providers Rare Presentation

Partnership between: South Central Human Relations Center Steele County Human Services South Country Health Alliance Allina Health Owatonna Hospital October 2nd

2012

Objectives of the Program

Process for Identifying and Engaging Patients

How is Systems Care Coordination different from typical hospital

social worker role?Social worker walks with the patient rather than Social worker walks with the patient rather than

makes referrals from the hospital environment.makes referrals from the hospital environment. Functional Assessment and Community support Functional Assessment and Community support

plan is developed with the patient to stabilize plan is developed with the patient to stabilize their mental and physical health.their mental and physical health.

Sixty days of case management with a goal of Sixty days of case management with a goal of the patients transitioning to community based the patients transitioning to community based support services.support services.

Collaborative to get all of the service providers Collaborative to get all of the service providers working together with the patient.working together with the patient.

Inputs

Licenses Social Worker Computer Phone Funding Contracts with:

SCHRC Owatonna Hospital SCHA Steele County

Human Services

Activities

ED Use: 5(+) times in 3 months (MD Medical Director, RN Manager, & Systems Care Coordinator Review)

Engage patients in partnership to reduce ED visits & use community resources for appropriate care.

Releases of Information obtained

Functional Assessment Community Support Plan Care Plan with patient,

Primary Care, & Systems Care Coordinator is used when patient presents to ED

Community referrals

Outputs

196 Patients Served

102 Care Plans Developed $1,886,365 decrease in Emergency Department visits and hospitalizations 1 year post intervention 64% decrease in ED visits two years post intervention 81% decrease in ED visits three years post interventions.

Immediate Outcomes

Patients will reduce ED visits Patients will get connected to services and resources in the community

Intermediate Outcomes

• Providers coordinate efforts to help vulnerable populations seek & obtain primary care

• Patients increase preventive services to improve health, reduce complications & costs

• Patients manage chronic conditions to reduce severity, negative health outcomes, & expense

Long Term Outcomes

Shared responsibility between primary care, mental health, community services and the Hospital Reduction in health care costs.

Common Patient Profile Patients are between the ages of 20 and 40 years of age. Diagnosed or undiagnosed anxiety, depression, or substance

abuse Chief complaint related to physical symptoms related to

depression or anxiety (i.e. HA, SOB, palpitations, etc) Majority are on public assistance (but not ALL) Majority either have or have had a mental health adult case

worker Often are disconnected with case worker and primary care

physician Need assistance before qualifying for the Human or Mental

Health Services recommended in their discharge instructions/plan from ED

Many have issues with transportation, housing, food, and medications which is often not addressed in their ED stay

The Program Data

Managed Care Data

January 2012 to July 2012 39 clientsReviewed Emergency Department, Overall

Primary Care Physician Cost $51,951 reduction in paid health care claims

Billable Service2011-Successful legislative effort-payment

guidelines imbedded in the HS Omnibus Bill (Sec. 45. Minnesota Statutes 2010, section 256B.0625)

Currently in final process of approval from CMS with MNDHS

Billing expected to be in 15 minute increments at community health worker hourly salary.

Patient Name: John Doe Owatonna Clinic MRN: 20-520-879 Owatonna Hospital MRN: 10099999 Date of Birth: 01/01/1900 Date of Plan: 2/9/2011 Goal of Care Plan: Mr. Doe will reduce overall usage of the Emergency Department and have a reduction in overall symptoms. Living Arrangements: Mr. Doe lives in his own apartment. He does not have a lot of contact with his family. He does engage with his neighbors on fairly regular basis. Mr. Doe lives on Social Security Disability. He uses the SCAT bus for transportation as needed. He sometimes has trouble getting to and from appointments when the SCAT bus is full. County Involvement: Mr. Doe has an adult mental health case manager, Sara Jane. Mrs. Jane can be reached at 507-455-9999. Mr. Doe’s financial worker at this time is Deb W. Deb provides SCAT tickets so Mr. Doe can get to and from his medical appointments. Mr. Doe’s health insurance provider SCHA has a nurse that provides care coordination services for Mr. Doe. Her name is Patty Hocking and she can be reached at 507-455-8115. Mrs. Hocking assists with arising medical needs and concerns as necessary. Psychiatric Care: Mr. Does’s psychiatrist is Dr. Peace at the Human Relations Center. Mr. Doe sees Dr. Peace once every three months unless issues arise. Mr. Doe carries a diagnosis of Major Depression and Anxiety Disorder NOS. Mr. Doe also has an ARMHS (Adult Rehabilitative Mental Health Services) worker Patty Sunshine. Mrs. Sunshine goals with Mr. Doe include learning coping skills for managing his anxiety, maintaining his apartment, and learning to deal with difficult people. Mr. Doe is not seeing a therapist at this time but has engaged in this service in the past. Family Physician: Mr. Doe’s primary care physician is Dr. Doolittle at the Owatonna Clinic. See attached note about care plan Dr. Doolittle, Dr. Peace and Mr. Doe created.

Patient Name: John Doe Owatonna Clinic MRN: 20-520-879 Owatonna Hospital MRN: 10099999 Date of Birth: 01/01/2011 Date of Plan: 2/9/2011 Care Plan: Care plan for Fibromyalgia: Treatment Recommendations for Fibromyalgia: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ When should patient use ED for treatment of Fibromyalgia: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Should narcotic medications be used to treat Fibromyalgia: _______________________ Care Plan for Back Pain: Treatment Recommendations for Back Pain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ When should patient use ED for treatment of Back Pain?: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ What medications should be used to treat Back Pain if patient presents to ED?: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Care Plan for Migraine/Headaches: Treatment Recommendations for Migraines/Headaches:

Contact InformationElizabeth Keck, MSW, LGSWelizabeth.keck@allina.com