CARE MANAGEMENT AT RUSH: A FOCUS ON PRIMARY CARE Robyn Golden, LCSW - - PowerPoint PPT Presentation

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CARE MANAGEMENT AT RUSH: A FOCUS ON PRIMARY CARE Robyn Golden, LCSW - - PowerPoint PPT Presentation

Jan 23, 2024 239 likes •407 views

CARE MANAGEMENT AT RUSH: A FOCUS ON PRIMARY CARE Robyn Golden, LCSW Associate Vice President, Popula3on Health and Aging Rush University Medical Center Social work involvement, whether through leadership roles or core services within an

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CARE MANAGEMENT AT RUSH: A FOCUS ON PRIMARY CARE

Robyn Golden, LCSW Associate Vice President, Popula3on Health and Aging Rush University Medical Center

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“Social work involvement, whether through leadership roles or core services within an interprofessional team, has posi3ve effects on heath outcomes and is less expensive then usual care that may not include social work.”

  • American Journal of Public Health, 2017
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Healthcare’s Blind Slide- It takes a team!

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An Opportunity to Contribute

  • Role for social workers in enhancing the pa<ent’s primary care

encounter and addressing the “Blind Side”

  • Address gaps in care resul3ng from

insufficient 3me, staff, resources

  • Provide compensatory support to

meet pa3ents’ medical and psychosocial concerns

  • Assess pa3ents’ psychosocial

considera3ons and their impact on medical status

  • Educate providers how to support

pa3ent self-management

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Our Work at Rush

Rush Popula+on Health and Aging services advance Rush’s vision of transforming health care by providing tailored support and longitudinal care management to address the unique barriers to health and wellness for individuals, families, and communi+es.

We accomplish this by:

  • Addressing the social determinants of health
  • Focusing on the needs of the whole person in

the context of caregivers and the community

  • Reducing fragmenta<on across disciplines

and care seLngs

  • Improving interprofessional collabora<on

and suppor3ng front line care teams

  • Developing best and promising prac<ces for

care management

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Population Health and Aging at Rush

Services

  • Transi3onal care
  • Primary care-based care management
  • Behavioral health care management
  • Care management for neurology and cancer care
  • Care management for value-based contracts (Medicaid, Medicare)
  • Psychotherapy
  • Evidence-based workshops
  • Resource Centers and programming
  • Helpline and centralized intake

Staffing / Workflow

  • SW staffed and supported by centralized departments
  • SW integrated into Rush primary care, outpa3ent specialty care, and discharge planning teams
  • SW par3cipates in interprofessional rounding (hospital and clinics)
  • Interven3ons ini3ated via clinician referral, posi3ve screener (PHQ-9), registry, or self-referral

via helpline

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Step 1

MD/team referral, ini<ates Pa<ent / Caregiver Engagement

Step 2

Assessment & Care Plan Development

Step 3

Case Management (Telephonic

  • r in-person)

Step 4

Goal ASainment

Step 5

Ongoing Care Supports, as needed

AIMS: An outpatient intervention

  • Ambulatory Integra<on of the Medical and Social Model (AIMS)
  • Team of Master’s level clinical social workers integrated into primary and
  • utpa3ent specialty care teams

(Rowe, et al., 2016)

www.theaimsmodel.org

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Intervention Documentation: EPIC EMR

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AIMS in Action: Mr. W

  • Pa<ent: Mr. W: 78-year-old, AA man living alone in large metropolitan area
  • Presen<ng issues: inadequate finances, depression, mul3ple chronic

condi3ons (diabetes, hypertension, hyperlipidemia, GERD, chronic renal insufficiency), transplant history

  • Contacts: 2 in person, 6 telephonic
  • Clinical skills/ac<vi<es: mul3dimensional assessment, care coordina3on,

mo3va3onal interviewing, resource linkage, psychoeduca3on, counseling strategies (CBT, MI, rela3onal/interpersonal), interprofessional collabora3on

  • Outcome: connec3on to benefits programs, reduced financial stress,

engagement in psychotherapy, self-reported improved confidence in ability to manage chronic condi3ons

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Social Work Contributions

  • Care Management tasks
  • Mul3-dimensional assessment
  • Care plan development
  • Iden3fy and coordinate services
  • Pa3ent engagement
  • Resources to support ongoing

care

  • Specialized skills
  • Strength-bases approach
  • Mo3va3onal Interviewing
  • Behavioral Strategies (CBT)
  • Psychoeduca3on
  • Average <me spent

addressing non-medical needs: 155.15 minutes (SD=85.82)

  • Pa3ent contact, family member

contact, agency contacts, consulta3on with other members of health care team, 3me researching services and supports

  • Does NOT include 3me

documen3ng in EHR

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  • To date: Posi<ve pa<ent and provider feedback in surveys,

promising results in retrospec<ve study of u<liza<on for AIMS par<cipants vs. similar Rush popula<on, 50+ years old

  • Current research efforts
  • Quasi-experimental study of impact on u3liza3on, health, and sa3sfac3on
  • Iden3fying returns on investment in AIMS interven3ons
  • Quan3fying social work impact on provider sa3sfac3on / burnout rates
  • Impact on depression scores

Measuring Our Impact

U<liza<on Metric AIMS Mean

(n=640)

Rush Comparison

(n=5,987)

Hospital Admission 0.51* 1.0 30-day Readmissions 0.15* 0.35 ED Visits 0.10* 0.95

*StaAsAcally significant using one-sample t-test (Rowe, et al., 2016)

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Provider Satisfaction and Burnout Survey

  • 35-item ques3onnaire about how addressing pa3ents' social

needs affects provider sa3sfac3on and prac3ce

Impacts on Prac<ce (n=59) Agree Pa3ents’ unmet non-medical needs prevent from providing quality care. 45 (76.3%) Addressing unmet non-medical needs takes 3me from addressing pa3ents’ health care needs. 46 (79.4%) When unable to address my pa3ents’ social needs, they are at risk of nega3ve outcomes. 50 (84.8%

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Publications

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Growth Opportunities

  • Con<nuing to refine model,

iden<fy best prac<ces & impact

  • Community-based
  • rganiza<ons (CBOs)

implemen<ng AIMS in partnership with local prac<ces / health systems

  • Aging network and other CBOs
  • We’re always looking for more

partners!

  • Sustainability avenues
  • Medicare FFS billing
  • pportuni3es (PCP bills)
  • Chronic Care Management

(99490, 99487, 99489)

  • General Behavioral Health

IntegraAon (99484)

  • Quality metrics – MACRA, Merit-

based Inven3ve Payment System

  • U3liza3on reduc3on – ACOs
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Building Our Future

  • Our Center for Excellence in Aging transforms

health care at Rush to enable individuals, families and communi3es to live healthy as long as possible

  • Our Center for Health and Social Care

Integra<on serves as a na3onal convening and technical assistance hub to advance prac3ces (like AIMS) that break down barriers to health

  • Helped plan a consensus study from the

Na<onal Academies on “Integra3ng Social Needs Care Into the Delivery of Health Care to Improve the Na3on's Health”

  • Fully funded! Launching summer 2018
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Thank you!

Want to learn more or explore replica<ng AIMS? Robyn Golden, LCSW Associate Vice President of Popula3on Health and Aging Robyn_L_Golden@rush.edu