T HE SUMMIT T EAM AT O LD T OWN C LINIC P ROVIDING C ARE C OORDINATIONTOA U NIQUE P OPULATION
• Por ortla land, OR (M (Medic icaid id Exp xpansion State) • FQHC and des esign ignated ed He Health th Ca Care for th the e Ho Homeles ess program. • Provid ide in integ egrated pri rimary ry and beh ehavi vioral hea ealth lth care, pharmacy, and co-located ed specia ecialty ty men ental hea ealt lth and substance use e dis isorder ser ervices. • We e ser erve e 5,0 ,000 patie tients per er yea ear, who have e a high igh deg egree ee of of med edical, beh ehavioral l and soc ocia ial nee eeds: • 77% have e a men ental l hea ealt lth dis isorder • 69% have a ch chronic medical l con ondition • 60% have e a substance use e dis isorder • 60% are exp xperien encing hom omel elessness • Rob obust tea eam based ed care with ithin in PCM CMH model • Embedded with ithin la larger soci ocial ser ervices es agen ency (Ce (Central l City City Con Concern)
SUMMIT T EAM M ODEL Care Allows more time to: Coordin- ator • Bu Build ild rel elatio ionship ips • Outreach Pharma- Provider cist 200 • Provide timely support patients • Increase access to team • Smooth transitions of care Complex Social Care Worker Nurse
W HO W E A RE Care Coordinators Team Manager • Jenn and • Jason Mike Health Coordinator Nurse • Andrew • Tonya Data and Quality Pharmacists Specialist • Jan & Theo • Matt Social Research Assistant Worker/Addiction • Anna Counselors Principal Investigator • Heather & • Brian Scotti Consultants (MD, PMHNP, Medical Providers & LCSW) • Meg and • Brianna, Susan, Richard and Tressa
W HAT W E D O Foster relationships Ensure access to primary, specialty, and behavioral health care Facilitate utilization of outpatient care Manage care transitions Provide psychosocial and material supports
R ESEARCH : W HY STUDY S UMMIT ? W HY STUDY OURSELVES ? Le Learning op opportunity to stu tudy how we can an im improve car are for or th this is pop opulation Advance sci science of of man anaging medicall lly an and so sociall lly complex patients holi olistically Fu Funders an and stakehold lder ac accountability Le Learn ab about ou ourselves an and what mak akes OTC a a model l for or in innovation Su Summit is is ou our le learning lab lab for or how we care for complicated patients
Im Improved Clin Clinicia ian Better Be Exp xperience Outcomes Im Improved Lo Lower Pati tient Co Costs Exp xperience
200 5 Minutes in Face-to-Face Visits Per Patient Per Month 200% Increase in PC Engagement Inpatient Days Per Patient Per Month 160 4 120 3 80 2 40 1 30% Decrease in Inpatient Days 0 0 -12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Month Relative to Enrollment (0 = Month of Enrollment) PC Minutes Rate Avg PC Minutes Rate Inpatient Days Rate Avg Inpatient Days Rate
Kim im is is a a 65 65 y/ y/o white woman wit ith th the most kin kind an and th thoughtful dis isposition, unmatchable wit and humor, and she’s also super stylish Go Goals: Move in into a a home wit ith car aregiver su supports, stay ou out of of th the hos ospital, get a a power ch chair, han ang ou out wit ith her r frie friends, an and engage in in MH tr treatment Diagnoses: COPD, CHF, Typ Di ype 2 2 Di Diabetes, a a rectal prolapse, PTSD, Anxiety & Pan anic Attacks In an In and ou out of of hos ospital l over 10 10x th the las last 6 6 mon onths
Kim is “residentially challenged,” in and out of various shelters for years Fin Financial l an and le legal bar arriers have mad ade hou ousin ing extr xtremely ch challengin ing Approved for or AFC/ALF; however, bar arriers have se severely delayed pla lacement “I’m so tired, Heather, and I feel so weak. It’s scary out there. I need help. I can’t care for myself. What am I going to do?”
W HO IS A S UMMIT PATIENT ? Difficulty managing medical conditions when they do see the PCP due to behavioral/substance use issues Lengthy problem/medication list Lots of no shows/not engaged in primary care Frequent hospital re-admissions They can feel traumatized or alienated from the healthcare system High degree of chaos Systemic and historical barriers to accessing care
Smooth the edges Aim to decrease of our complex Walk with patients Trickle-Down patient suffering systems to and guide them on Compassion: as they face empower patients their journey Inject compassion medical illness and and offer them through complex into our complex chaotic social choice and medical systems care system environments support in their care
Aftercare Advocacy Review Action Outreach Care Planning Transitions Goal Hub Setting DME Disease Monitoring Referrals Pill Counts Engagement Scribing
Care Coordinators (CCs) can provide meaningful warmth and support CCs provide crucial communication between patients, specialists, and PCPs to avoid gaps in care and ensure patients needs are being met Navigating our systems can be complex and daunting - CCs can sometimes take responsibility for tasks that overwhelm patients CCs can provide further support and advocacy by sometimes accompanying patients to appointments. CCs are able to help improve outcomes for patients and providers by offering individualized support and follow-through
W HO IS A SUMMIT PATIENT & HOW CAN SUMMIT HELP ? • Someone with advanced • Summit can do occasional home medical illness who has a hard visits, hospital visits and time engaging in primary care accompany patients to specialists appointments • Someone who may benefit from • Most Summit appointments are longer appointments and increased care coordination and 60 minutes. Care Coordinators navigation assist in navigating the healthcare system • A patient who may not go to • Summit can assist with care the ED often, but when they do they are often admitted for a transitions and med medical issue management
• Homelessness & • Chronic Kidney Disease • Trauma Unstable Housing • Congestive Heart • Anxiety Failure • Food Scarcity • Depression • COPD • Poverty • Substance Use • Chronic/Severe • Barriers to accessing • Severe & Persistent Infections and Wounds Mental Illnesses a myriad of • Diabetes resources for care and basic needs • End Stage Liver Disease
W HAT DOES S UMMIT DO ? Comprehensive patient intakes Care transitions Close follow-up, Outreach & home visits Offers longer appointments, after-hours line Healthcare navigation & support Behavioral health and addiction medicine specialists Accompany patients to specialist appointments 17
Hospital/ Nursing Specialist ED Homes/ Home Appoint- Health ments Patient Substance +Team Use Tx Housing Mental Criminal Health Justice System
Background • 27 y/o African American male, lived in an AFH and not happy with his care • Used a power chair for mobility • Required very specific ostomy supplies due to the nature of his abdominal surgeries • Wanted fistula reversal surgery Pertinent Medical History • Short-gut Syndrome secondary to abdominal GSW • Multiple abdominal surgeries and fistulas • Bilateral AKAs • Illeostomy • History of SBOs
Flux within Housing – not Frequent hospitalizations Nutrition deficiencies due happy with care at his due to n/v, electrolyte to short-gut syndrome AFH, push-back from the imbalances, dehydration home about patient Difficulty obtaining needed Patient desire to ostomy supplies – Pain Re-establish with insurance no longer gastroenterology and Management covered the brand he was revisit surgical options using
Patient moved to a new AFH, good rapport with the caregiver Appointments made with GI surgery team (team was familiar with patient), dietician Plan for port placement with home health support for administering IVFs with vitamin supplementation Pain management plan with primary care provider Connected patient with wound/ostomy nurse to figure out a new plan for ostomy supplies Assistance with scheduling required tests prior to any surgical intervention
Patient developed a good relationship with the new AFH caregiver Patient became very engaged with the Summit Team Patient was glad to begin the necessary studies and procedures in order to have surgical intervention Patient was not entirely adherent with home health schedule for IV fluids and nutrition Patient continued to often use the ED when in distress During one of the pre-surgical studies, Patient had an aspiration event and subsequently died.
Gaps in in care • TBI resources • Trauma informed settings for respite/long term care • Hospice for socially vulnerable patients • Substance use disorder treatment services for medically complex individuals Maintaining pati tient tru trust acr cross systems Retaining tea eam fle flexibili lity to o acc ccommodate pati tient nee eeds whil ile gr growing Ho How do o you ou mea easure success? “Winning” the financial case
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