Ravenswood/Stanford Community Partnership Pilot to Improve Health Outcomes for Complex High Cost High Utilizers Loretta Sun,
1 LCSW ,
Jaimie Lyons,
1 Dept.
1 LCSW ,
Christy Silva,
2 MBA , Erika
Simpson,
2 MPH , Justin
Wu,
2 MD , Jaime
Chavarria,
2 MD ,
Jonathan G. Shaw, MD
2,3 MS
of Case Management and Social Work, Stanford Health Care, Stanford, CA 2 Ravenswood Family Health Center, East Palo Alto, CA 3 Stanford University School of Medicine, Stanford, CA
Background/Need
Project Description
Identified Barriers
•A small minority of patients account for a disproportionate number visits to the SHC emergency department (ED) •ED overuse contributes to overcrowding and longer wait times for all patients •High utilizers include patients assigned to community based clinics (“medical homes”) •Often, care could be more efficiently/effectively managed elsewhere; appropriate level of care, resulting in a lower net costs to all parties
• 1 SHC social worker (MSW) hired in a bridging role with community partner, Ravenswood Family Health Center, to support 21 mutual patients (Caseload 1:21) • Population: 21 RFHC-assigned patients who were highest SHC ED users
•24% Homeless •19% Lack familial support &/or live alone •19% Ongoing substance use (pre-contemplative) •14% Narcotic-dependent •14% Poorly controlled diabetes •14% Somatization Disorder •14% Have only 1 caregiver/source of support
– All were in SHC’s top 200 overall highest users of the ED – Age range: 1 ½ - 67 years old
• Pilot program’s goals include: – – – –
Enrolling mutual patients to coordinate care between RFHC and SHC Facilitate engagement with RFHC as their medical home Support improvement in patients’ health outcomes Reduce over-utilization of the ED and avoid unnecessary readmissions
Lessons & Conclusions • Mobility of MSW between partner sites facilitated real-time feedback from stakeholders to implement changes
Data & Outcomes • Nearly all (95%) of patients showed reduced ED usage 1 year later
–
‾ Total reduction of SHC ED use by 55%
• 71% are still engaged with primary care at RFHC
Future recommendations: Provide dual credentialing (open access) for MSW; to further improve communication
Comparison of SHC ED Usage Among the Intervention Cohort, pre- vs post- Pilot Program 180
• MSW role requires resource knowledge and psychosocial skills to navigate complex healthcare systems and health needs
June-Nov 2016 (163)
Total # of ED Encounters
Stanford Health Care (SHC) High Risk Program •Improves the health and well-being of patients with multiple medical and/or mental health co-morbidities •Ensures timely access to and coordination of medical and psychosocial services •Goals are to reduce overutilization of the ED and avoid costly and unnecessary re-admissions through: 1. COORDINATING CARE
160 140
Key skills include: – Trauma-informed care – Motivational Interviewing – Understanding addiction and pre-contemplative stage of change
120 100 80
June-Nov 2017 (74)
60 40
Between primary care medical home and SHC (ED, inpatient, outpatient specialty care)
• Patients specifically benefit from
20 0
2. ESTABLISHING A MEDICAL HOME Helping patients manage their diseases as outpatients in preventing exacerbations and addressing commonly related acute problems
Ravenswood Family Heath Center (RFHC) Mission: “To improve the health of the community by providing culturally sensitive, integrated primary and preventative health care to all, regardless of ability to pay or immigration status, and collaborating with community partners to address the social determinants of health.”
Per Patient # of ED Encounters
–
June-Nov 2017
As of 11/1/17 n=21
June-Nov 2016
30 25 20
– Ongoing, frequent collaboration and communication among multiple providers and support systems – MSW co-attending visits supports health literacy – Coordination of transportation needs – Care plan support to realize post-visit needs (i.e., medication management, PT/OT)
Implications/Next Steps
15 10 5 0 1
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Top 21 Highest Utilizers of SHC ED, from RFHC Clinic
14
15
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18
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21
• Replicate pilot with other surrounding counties’ Federally Qualified Health Centers • Determine sustainability of program & caseload • Compare to similar SHC users who did not receive partnered case management, e.g.: – ↑↓ Outpatient use ↑↓ ED/Hospital use
Acknowledgments: This pilot study was supported by funding from Stanford Health Care Community Partnership Program.