Superutilizer Success Preventing rehospitalizations of a patient with

Superutilizer Success: Preventing rehospitalizations of a patient with uncontrolled diabetes Katharine Royer, MSc, BSc and Carolyn Junior, BSc The Where: Camden, NJ The Why: Systems-Based Learning • Population: ~77, 000 • 42% live below poverty line • 20% of patients account for 90% of healthcare costs Failures Provider relationships Education The Who: Julia • • Medical Day Programs MANNA referral process Family motivation Non-profit & corporate relationships 57 yo who lives in North Camden with two sons Worked as instructional aide for 18 yrs Medical History/Diagnoses Uncontrolled type 2 diabetes Bilateral amputee Coronary artery disease Gastroparesis Anxiety/depression Reason for recent ER visits/admissions Nausea/vomiting Abdominal pain Uncontrolled diabetes Lack of social support Anxiety/depression 6% 5% 5 IP 78% 3 • IP ER Sept. 28 Dec. 13 Dec. 16 2012 Care Coordination (23. 37 hrs) • 1 Dec. 27 1% 3% 4% • IP 2 3% 83% Patient Encounters (58. 75 hrs) The What: Our Intervention IP 4 10% 7% • 6 Months before intervention • 3 IP Stays~$17, 600 cost in receipts • 2 Months after intervention • 1 IP Stay~$8000 in receipts; 2 ED Visits~$906 in receipts Intervention Home Visit Specialist Visit Phone Community Hospital Clinical Coordination Social Coordination Caregiver/Family Coordination Medical Appointment Scheduling Medical Transport Planning The How: Utilization/Cost Data Length of Stay (Days) Successes ER Feb. 26 Mar. 3 2013 • • Enrollment in day program • Socialization & medical support Referred to MANNA meal delivery service • Access to balanced diet Switched PCP • Supportive relationship/patient empowerment Increased HHA hours • Diabetes management Home Depot Wheelchair ramp donation • Safety for getting in/out of house Acknowledgements CMMI “Team Awesome”: Jason Turi (RN), Angel Mitchell (LPN), Raquel Medina (LPN), Sharine Eliza (Community Health Worker), Bill Nice (Intervention Specialist), Kelly Craig (Director of Care Management Initiatives) Bill & Elizabeth at Home Depot, Delran, NJ Rebuilding Together MANNA Generations Plus