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South County Community Health Team

Patient Centered Medical CommunityCTC Progress Report

January 9, 2015

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South County Community Health Team (CHT)

managed & administered by SC Hospital Healthcare System

Primary Care Practices Community Health Team

Coastal NarragansettCoastal WakefieldDr. CunniffDr. DelSestoDr. DemirsSC Internal MedicineSC Hospital Family MedicineSC Walk-In and Primary CareThundermist WakefieldWood River Health Services

1 FTE Manager - 9/14½ FTE Analyst & 1 FTE CRS-

10/141 FTE CRS - 11/141 FTE BH Care Manager - 12/14

Office Set UpMedical Office Bldg - SCHHS

Co-located within SCMG primary care practice

Office furnishings Equipment for office &

community visits

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South County CHTOrientation, Training & Activities

Hospital Orientation – guiding values, patient confidentiality, safety, environment of care , policies & more

PCP Office Meetings – case reviews, warm handoffs, after hours protocols

Community Resource Agencies – Basic Needs Network

Community Health Services – VNS & other home care; pharmacy services; hospital case management, behavioral health & nutrition resources

Trainings – RIPIN Navigation; Skills building including confidentiality, cultural & linguistic sensitivities, home visit safety, MI and other patient engagement techniques; NextGen documentation

Program Implementation – development of materials , workflows, data capture and integrating use of NextGen

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South County CHTTarget Population

Health Plan high risk/cost reports - Spring/Summer of 2014 Practices reviewed reports for patients with “high impactability” Referrals made to CHT Patient data compiled and baselines submitted to the Health Plans - October 2014

Total = 209 patients

Outreach• NCMs began introducing program to patients - August 2014• CHT began outreach and engagement - October 2014

• 1st Wave - 38 patients from 5 practices 2nd Wave - 14 patients from 2 additional practices 3rd Wave – 40 patients from 3 additional practices

BH Care Manager primarily focused on patients identified by CRS and NCMs

BCBSRI = 116

United Medicaid =46

NHPRI = 41

Medicare = 4

Uninsured = 1 Tufts = 0

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South County CHT Activity through 12/31/14

92 patients actively engaged or in outreach/pre-outreach Age range 18 – 100; average 58 years Male = 42; Female = 50

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South County CHTCRS Activity through 12/31/14

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South County CHT CRS Activity through 12/31/14

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South County CHTActive Patients as of 12/31/14

Engagement*35 of 36 were warm

handoffs8 in office, 18 in home, 6

by phone, 4 in community3 report 5 ED visits in past

6 months, 14 report at least 1

7 report inpatient stays, 1 reports 10 admits

14 report 8 or more Rx14 either agreed to or

report already enrolled in Currentcare

Health, Barriers & Limitations*16 report 3 or more

medical18 report depression or

other MH18 report multiple barriers

to health – transportation, housing, healthy food

21 report 1 or more ADL limitations

* data base in development

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South County CHT Patient Story

Young woman, early 20’s, victim of domestic violence, recent miscarriage and numerous Psych admissions. No longer eligible for shelters due to history of suicide attempts. Involved with CMHC health home. Currently living with her father, his girlfriend, their 5 children. Now working 2 jobs, attempting to save enough $ to afford an apt.

Release signed for BH CM to coordinate with health home. CRS assisting with housing and other community resources.

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South County CHT Patient Story

Man in his early 50’s, living with his wife. Hx of working full time, staying active. Now unemployed for a few years, several medical issues - obesity, diabetes, chronic pain. Wife works part-time, considerable financial debt. Since loosing his job, he reports rarely leaving his home, daily alcohol use. History of BH issues, but no op tx, 2 inpt admits many years ago. He identifies desire to stop alcohol.

CRS assisting with financial resources & budget. BH Care Manager consulting with PCP/NCM, and health plan social worker regarding resources for sobriety. BH care manager providing brief supportive therapy. Goal referral to appropriate detox program when ready.

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South County CHTPatient Story

Married woman, late 50’s significant Psych hx with suicide attempts and hospitalizations. Currently in therapy and on medications however many active symptoms as well as substance use. Patient has called on 2 occasions asking advice on psych admission to adjust medication.

Has signed release for BH Care Manager to provide care coordination. In agreement to discuss symptoms and SA use with PCP and current therapist.

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South County CHT

Successes Challenges

RIPIN CRS trained and prepared workforce to assist with navigation and resources

Collaboration with NCMs/PCPs - warm hand offs and ongoing case discussions

BH CM valuable asset to the team - providing support to patients having difficulty with healthy living & self-management as well care coordination

Difficulty determining cost drivers, reasons for high risk/cost or areas of impactability

Difficulty not having direct access to the health plan high cost reports Uses valuable case

review time with NCMs Incomplete

demographic data files

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South County CHTNext Steps

Development of NextGen to capture all activityAssessments - Interactions - Care Plans - ReleasesData extraction and reporting

Matching target population with Meditech information to generate utilization data and timely hospital activity reports

Expansion of target population by submitting new patient referrals to the health plan baselines (2nd cohort?)

BH CompactsImproved transportation options