Breaking Down Barriers to Care Pamela Crider, MSN, CNP Christine Karpen, MSW, LSW. MetroHealth Medical Center
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1 Breaking Down Barriers to Care Pamela Crider, MSN, CNP Christine Karpen, MSW, LSW MetroHealth Medical Center
2 Goals: Improved Outcomes Better patient experience Improved Communication Ease of access Lower Cost of care
3 Focus on the Super Utilizer
4 Super Utilizer patients have: Complex medical and social needs Are among the sickest 5 percent of the population and account for 60 percent of the nation s healthcare costs
5 Super Utilizer patients have: Have one or more chronic conditions that are poorly controlled Lack Ties to Primary Care Wind up in the ED, driving up costs without better outcomes
6 The Face of a Super Utilizer: History of trauma Depression Substance abuse Personality Disorder Family and Social issues Limited resources (housing, transportation) Barry J. Jacobs, Psy.D. Crozer-Keystone Family Medicine Residency Program
7 Background Population Health: New approach being implemented throughout the country Medicare and Hospital incentives: Focus on preventative care and patient re-hospitalization ACO: MetroHealth Care Partners E-ACO: MetroHealthy Red Carpet (2015): Grace Model training Geriatric Resources for Assessment and Care of Elders
8 Team Approach: Geriatrician Nurse Practitioner Pharmacist Mental Health Nurse Practitioner Social Worker Care Coordinator Care Navigator
9 Criteria for Inclusion: ACO Member 2 ED visits within the last 12 months 1 inpatient visit within the last 12 months Cuyahoga County Residence Top 10% risk stratification ranking
10 Criteria for Exclusion: Dialysis Active Cancer Treatment Pregnancy Safety Concerns due to condition of the patient s home Active substance abuse Dependent on patient compliance Non-compliance with Red Carpet Program
11 New Patient Home Visit: Team visit Nurse Practitioner and Social Work Home assesment IDT Meeting: Bringing assessment and information to team meeting for discussion and recommendations PCP and Specialist notification with recommendations from team Recommendations implemented by team and Providers
12 Nurse Practitioner Role: Medical History Medication Reconciliation Physical examination Safety Evaluation Chronic Disease Education Urgent visits for medical intervention
13
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15 Social Worker Role: Psychosocial history and assessment Depression Screen (PHQ-9), Mini-Cog, SLUMS, caregiver assessment Diagnosis understanding and health goal discussion Interventions APS, program resource referral, mental health referral End of Life discussion and Advanced Directives Inpatient Connection
16 Barriers: Family support Patient knowledge and understanding Transportation Lack of resources
17 Program Features: Urgent Access Line Red Carpet Care 8am-10pm daily access, Monday-Sunday Direct connection to providers, Red Carpet Team Cab vouchers Red Carpet Care Navigator to assist with appointments EMMI Education
18 ED / Inpatient Stay: Team member hospital visits Clinical Review meeting: Octane levels: Weekly calls and visits Cruise Control Regular Octane High Octane Prevention Plan and new recommendations
19 Red Carpet Comprehensive Clinic: Same day and Urgent appointment access Nurse Practitioner and Social Work team Extensive chronic disease education Varied appointment length Disease treatment (IV, wound care, breathing treatments, etc.)
20 Tools for Success: Weight scale BP cuff Emergency medications Medication organization
21 Results: Decrease in ER visits Enhanced patient experience Fluid transition between Inpatient and Outpatient Lower costs
22
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