+ Building a Learning Collaborative for High Utilizer Interventions Andrea Hallowell Miller Program Manager, Cross-Site Learning
John’s Story • 44 year old former Pro Wrestler “The Black Scorpion” • Suicide Attempt • Homeless • Lack of Family Support • Poor Medication Adherence • Drug Use • Seizures & Hypertension • Anxiety & Depression • Insulin Dependent 2012 Hospital Utilization: 9 inpatient admissions 3 Emergency Department visits
Patient Centered Care Coordination SSD Child Support Transport Accompany Legal Aid Hospital #1 Tempus Pharmacy PCP Neuro Ortho. Pedics Occup Therapy Shelter Collab. Support Program Behavior Day Program Wiley Christian Day Cherry Hill Partial Day Streets Hospital #2 Apartment Nephro Endocrine Podiatry Physical Therapy
Clinical Interventions The Push PUSH CARRY The Carry The Catch CATCH
+ The Carry: Community Based Care Coordination Data Triage Outreach Graduation Discharge • Deceased • Moved • Lost contact • Disengaged
+ Cross-Site Learning Program n Began in July 2012 to address the need for teaching and collaboration around care for high needs, high cost patients n Fosters technical assistance and other resources for sites across the country n Moving toward a “hub” model for collaboration, with sites serving as regional centers of excellence for other communities
+ Project Goals Develop Common Language Find Collaborators Build, Test and Adapt New Models Build a Movement Influence Policy Makers and Public Create New Hubs and Identify Faculty
+ CSL Project Sites Robert Wood Johnson Foundation Centers for Medicare and Medicaid Innovations n Boston, MA n Allentown, PA n Cincinnati, OH n Aurora, CO n Cleveland, OH n Kansas City, MO n Grand Rapids, MI n San Diego, CA n Humboldt County, CA n Kennebec County, ME Independently Funded n Howard County, MD n New Orleans, LA n Pittsburgh, PA
+ National Governors’ Association State Projects n Alaska n Colorado n Kentucky n New Mexico n Puerto Rico n West Virginia n Wisconsin
+ Known Super-Utilizer Interventions
+ 2014 and Beyond n Manual: Developing a Super-Utilizer Intervention n Interactive web resources n Expanded “boot camp” open house program n Recruiting new CSL sites n National Governors Association Super-Utilizer Policy Academy
Theory of Change Clinical Redesign Data Analysis Community Engagement
+ Clinical Readiness n. Do you have staff members in your organization who will take on this work, or is hiring necessary? n. Have you developed a workflow for care transitions? n. Have you begun seeing patients?
+ Data Readiness n. Have you used data to define the problem in your community (hotspotting)? n. Have you established patient enrollment criteria? n. Have you determined a strategy for these patients?
+ Engagement Readiness n. Have you assessed existing community resources for this patient population? n. Do you already have connections with these resources? n. Which organizations do you plan to target for partnership?
Resources • andrea@camdenhealth. org • www. camdenhealth. org + • Twitter: @camdenhealth
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