Blackstone Community

Health Team Patient Centered Medical Community

CTC Progress ReportFebruary 13, 2015

Background• Goal: To demonstrate directional improvement in health

and total cost outcomes for the identified high risk/high cost/high impact patients.

• Patients targeted: Health Plans sent CSI practices lists of patients

flagged as high risk/high cost

CSI practices screened lists to identify patients who are high impact

Screened lists were sent back to Health plans to establish Baseline target population

Background• Aim of Interventions:

o Identify and address social needs that affect health and barriers to care

o Provide “high touch” support for Care Management plans established by practice Nurse Care Managers

o Provide patients with social support to manage their health

o Bring relevant information back to primary care teams

Structure• Blackstone Community Health Team is based out

of Blackstone Valley Community Health Center• Offices are located at 36 Park Place, Pawtucket,

Rhode Island• Staffing Model

o 3 FTE Community Resource Specialist*o .5 FTE Coordinatoro .5 FTE Managero .75 FTE Behavioral Health Nurse Care Manager# *(Staffing down to 2 FTE from 11/3/2014-1/9/2014) #(Start date: 12/29/2014)

Structure• Current Participating Practices:

o Blackstone Valley Community Health Center (BVCHC)o Memorial Hospital of Rhode Island Family Care Center (FCC)o Hillside Family Medicine

• Potential Expansion Practices:o Family Medicine at Women’s Careo Memorial Hospital of Rhode Island Internal Medicine Centero Nardone Medical Associateso University Internal Medicineo University Medicine- East Avenue

Structure• Community Health Team Activities:

o Weekly Meetings with CSI Practice Nurse Care Managers to review patients for outreach and active cases and develop methods to integrate CHT with the practice

o Patient engagement via telephone, “warm-handoff” in at the practice, or visit to a patient’s home

o Conduct assessment of social needs and barriers to care, during patient home visits when possible

o Develop and implement patient care plans:• Provide assistance to patients to obtain social resources and

connect with community agencies• Support and extend nurse care manager care plans• Help patients navigate health care system• Provide social support to patients in managing their health

Structureo Participate in training provided by BVCHC and RIPIN

o Program development and implementation: Move from concept to operation• Workflows, policies, procedures

• Documentation, data-capturing, reporting capability

• Integration between CHT and primary care teams

Baseline Target Population

• Total Number of Patients: 413• Insurance:

o BCBS: 120o NHP: 190o United: 102o Tufts: 1

• Practice: o BVCHC: 160o FCC: 189o Hillside: 64

• Demographics:o Mean Age: 49.77 years of ageo Age Range: 15-99 years of ageo Gender: M 144 F 269

Outreach Activity 8/25/2014-12/31/2014

Practice Active Declined In Outreach Ineligible

Unable to

ContactPre-

OutreachNot Appropriate for

CHT per Practice TotalBVCHC 19 7 10 5 5 105 9 160FCC 18 4 4 2 1 160 0 189Hillside 6 1 0 1 2 48 6 64Total 43 12 14 8 8 313 15 413

0

10

20

30

40

50

60

BVCHC FCC Hillside

Num

ber o

f Pa

tien

ts

Practice

Outreach Activity by Practice

Not Appropriate forCHT per Practice

Unable to Contact

Ineligible

In Outreach

Declined

Active

55

29

16

Outreach Activity 8/25/2014-12/31/2014

Payer Active Declined In Outreach Ineligible

Unable to

ContactPre-

OutreachNot Appropriate for

CHT per Practice TotalBCBS 9 4 1 2 0 102 2 120NHP 26 7 7 5 7 126 11 189Tufts 0 0 0 0 0 1 0 1United 8 1 6 1 1 84 2 103Grand Total 43 12 14 8 8 313 15 413

0

10

20

30

40

50

60

70

BCBS NHP Tufts United

Num

ber o

f Pa

tine

ts

Payer

Outreach Activity by Payer

Not Appropriate for CHT perPractice

Unable to Contact

Ineligible

In Outreach

Declined

Active

18

63

19

Outreach Activity 8/15/2014-12/31/2014

Outreach Activity 8/15/2014-12/31/2014

BCBS NHP Tufts United0

20

40

60

80

100

120

140

102

126

1

84

Pre-Outreach Patients by Payer

Pre-Outreach

Payer

Num

ber o

f Pati

ents

Successes:• Actively engaging patients- “warm-

handoffs”, establish relationships

• Regular communication with practices

• Enhancement of Nurse Care Management Activities

• Identifying and resolving social needs and barriers to care

• “High touch” patient support

• Gleaning information from home visits to inform clinical team.

Challenges:• Are we targeting the right patients? –

o Review of high risk list is time intensiveo It is difficult to gauge ‘impactability” with

unfamiliar patients.

• Synthesizing CHT and Clinical assessment and plans (starting to make progress)

• Targeted CHT interventions – Drivers of cost are unclear, relying upon broad approach to impact cost

• Limited ability to communicate electronically with practices

• Insufficient community resources

• Adding patients onto busy NCM panels/work loads

Next Steps• Develop and Implement CHT Behavioral Health

Interventions

• Complete development of EHR documentation and reporting

• Establish Pawtucket/Central Falls Community Health Council

• Explore potential Pharmacy and Dietary interventions

• Enhance Community Resource Specialist skill sets to support behavioral change (e.g. Health Coaching)