Collaborating for Care Management Innovation

March 3, 2013
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With the onset of sequestration, Texas stands to lose funding for Head Start services, children’s vaccines and meals for seniors.  Add to this potential losses in law enforcement and education funding, one can see that programs, once aiding children, seniors and the homeless by keeping them out of the emergency room, might cease to address this critical need.  Compound these losses with the pressure being exerted by value based purchasing and the dilemma becomes magn

With the onset of sequestration, Texas stands to lose funding for Head Start services, children’s vaccines and meals for seniors.  Add to this potential losses in law enforcement and education funding, one can see that programs, once aiding children, seniors and the homeless by keeping them out of the emergency room, might cease to address this critical need.  Compound these losses with the pressure being exerted by value based purchasing and the dilemma becomes magnified tenfold.  As if accountable care organizations, medical homes, hospitals and healthcare systems did not have enough on their plate, one wonders where they will find the resources to supplement these activities?

One enterprising non-profit has tackled this challenge head-on.   Billed as a nine-year old strategic initiative with a mission to improve the quality, capacity, and accessibility of the healthcare system for vulnerable populations in the City of Camden, the Camden Coalition has analyzed local healthcare system claims data for the purpose of building a repository and sharing data with regards to this typically transient population.  In addition, they operate several health project initiatives that demonstrate a collaborative approach to improving care delivery and patient outcomes in their area.  And by building relationships with executive leadership of the hospitals, social service/public health agencies, state government agencies, leaders at the statewide Medicaid health plans, and policymakers, they have taken a discretely modern approach to healthcare delivery.

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Current innovative initiatives garnering attention include the Coalition’s Care Management and Care Transitions programs, aimed at reducing hospital utilization by directing outreach to the ‘high flier’ population whom frequently lack appropriate access to primary and mental health care.  Designed to target high cost, complex patients for improved care transitions and care coordination, the Coalition is steadfastly working to move these patients into a medical home model.  Upon presenting at the emergency room, patients are divided into one of two groups:  a) those with no primary care access and significant mental/social issues and b) patients with more stable primary care and mental health status.

In the Care Management program, patients meeting specific criteria receive assistance from a social worker, a health outreach worker/medical assistant and a nurse practitioner with primary/specialty care coordination, applying for government assistance, finding temporary shelter and enrolling in medical day programs.  Through stabilization of their social environment and health conditions, the team’s ultimate goal of finding a primary care medical home for the patient can begin.

Patients participating in the Care Transitions program are enrolled in and receive assistance from embedded care management nurses and health coaches from one of two Camden Federally Qualified Health Centers (FQHC) – CAMcare and Project HOPE.  On the path to becoming patient-centered medical homes, these FQHCs are fostering better care transitions and coordination with their hospital and health system partners.

These bold programs have been facilitated by city-wide use of health information exchange and electronic health record use for this targeted population, thereby allowing providers to share information and analyze data for additional care coordination.  Data analysis also remains integral for the monthly Care Management Committee meeting, held at rotating hospitals, in order to review and refine current processes for these programs. And by bringing together emergency room physicians, hospitalists, specialists, social workers, and nurse discharge planners across the city, more efficient and effective discharge planning and care coordination can help decrease utilization and improve safety, experience and ultimately, quality of care.

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