PROVIDING ENHANCED CARE TO PATIENTS WITH COMPLEX NEEDS

JUDI NIGHTINGALE DrPH, RN DIRECTOR, POPULATION HEALTH

The teams previously known as Whole Person Care (WPC) and Health Homes Program (HHP) are now known as CalAIM Enhanced Care Management (ECM) are now comprised of a group of care managers which are in all community health clinics as well as the main campus. The team is comprised of:

• An RN care manager

• A Behavioral Health Specialist (BHS) care manager

• A Care Coordinator (CC)

• Two Community Health Workers (CHW)

The goal of this group is to provide care management to high risk, complex needs patients, with the intention of helping them improve their health and reduce the impact of chronic disease. Each member of the ECM team is trained in motivational interviewing and employs this training when they set goals. Since the goals are set with the patient, the patient is more likely to be engaged in reaching them.

The team receives a list of high need patients from Inland Empire Health Plan (IEHP). IEHP uses two social determinants of health (SDOH) risk screens, (the John Hopkins ACG screen and the Healthy People Index (HPI) screen). Patients are rated as high, medium and low risk for utilization of resources, including unnecessary emergency department usage, and inpatient utilization. Depending on the level of risk, the ECM team contacts enrolled patients between one and two times per month and often, more frequently.

To start care, ECM team members complete an initial screening to determine eligibility for enrollment. They also complete a Whole Person Health Score (WPHS) screen and a CHA. ECM team members have relationships with, and access to, many community and County services and make referrals to resources through Connect IE and other methods. The team also ensures that these referrals are provided or, they problem solve with patients/clients to assist with barriers.

An ECM team can enroll up to a total of 250 patients into care. There are targets set for enrollment per team member, as well as, per team. The entire RUHS ECM team also has targets for achievement in the following areas,

• Creating/implementing/updating a care plan on a monthly basis (or more frequently depending on risk stratification).

• BP documentation

• BP achievement

• PHQ9 documentation

• PHQ9 improvement

• A1C documentation

• A1C improvement

• Completion of a CHA

The ECM team enrolls clients who are screened and referred by the RNs in the Probation Department also as transition out of incarceration is one of the enrollment criteria. There have been almost 17,000 probationers screened. In data analysis on outcomes, there was a 65% reduction in reincarceration. There are many success stories from this group. Here is one example of someone who was helped by this team:

SITUATION:

-Client had multiple medical problems, including congestive heart failure, hypertension, atrial fibrillation, recent hospitalization for pneumonia requiring a thoracentesis. He was told that his heart was working at 10% from meth-induced cardiomyopathy. He was wearing an external life vest defibrillator and reported feeling recent shocks. He said the doctor gave him 6 weeks to live.

-Other diagnoses included were depression and anxiety. Client and longtime/supportive girlfriend were homeless, which made charging his defibrillator difficult.

-Client was not interested in going to a shelter due to crowds and the possibility of being separated from girlfriend.

SUCCESS:

-WPC Outreach Team met with client and obtained information that the client was a Veteran. Client was placed in brand new Veteran housing within a month of screening.

-His health improved drastically. His heart function increased to 40% and he no longer needs the external defibrillator. He also married his girlfriend.

The Enhanced Care Management team can assist the highest risk members of the community with their training and knowledge of available resources. The populations who may qualify for ECM enrollment are as follows:

Homeless Community

Has one of the following:

• Lacks a fixed, regular, and adequate nighttime residence

• Has a primary residence that is a public or private place not designed for, or ordinarily used for habitation

• Lives in a shelter

• Is exiting an institution to homelessness

• Will imminently lose housing in the next 30 days

• Is an unaccompanied youth or member of a family with children and youth who are defined as homeless under other Federal statues

• Is fleeing domestic violence

And has one of the following:

• Complex physical health need*

• Complex behavioral health need*

• Complex developmental health need*

*with inability to successfully self-manage, for whom coordination of services would likely result in improved health outcomes and decreased utilization high-cost services

HIGH UTILIZERS – 21+

Has one of the following:

• 5 or more emergency room visits in the last 6 months

• 3 or more unplanned hospital* and/or short-term skilled nursing facility stays in the last 6 months

*unplanned hospital stays exclude voluntary sur-

Geries And Deliveries

SUBSTANCE USE DISORDER (SUD) – 21+

Has all of the following:

• A DSM diagnosis of substance-related and addictive disorder (excl. tobacco use)

• One or more complex SDOH risk factors* And one of the following:

• At high risk for institutionalization, overdose, and or suicide

• Use of hospital, ER, or urgent/crisis care for sole source of care

• Two or more ED visits or two or more hospitalizations due to SMI or SUD in the last 12 months

*e.g., lack of access to basic needs, inability to work or engage in the community, former foster youth, recent law enforcement contact related to mental health or substance use.

SERIOUS MENTAL ILLNESS (SMI) – 21+

Has all of the following:

• A DSM diagnosis of mental disorder (or one is suspected)

• Experiences personal distress, disability or dys function in social/work/personal life, or at risk of loss of function related to social/work/personal life

• One or more complex SDOH risk factors* And one of the following:

• At high risk for institutionalization, overdose, and/or suicide

• Use of hospital, ER, or urgent/crisis care for sole source of care

• Two or more ED visits or two or more hospital izations due to SMI or SUD in the last 12 months

*e.g., lack of access to basic needs, inability to work or engage in the community, former foster youth, recent law enforcement contact related to mental health or substance use.

INDIVIDUALS TRANSITIONING FROM INCARCERATION– 18+

• Is an individual transitioning from incarceration in the last 12 months And has at least one of the following:

• Chronic mental illness

• Substance Use Disorder (SUD)

• Chronic disease (e.g., hepatitis C, diabetes)

• Intellectual or developmental disability

• Traumatic brain injury

• HIV or pregnancy