The King County Experience W4A Conference - May 29, 2014

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1 The King County Experience W4A Conference - May 29, 2014

2 Services Offered King County currently contracts with CHPW for Chronic Care Management (CCM) and Care Transitions (CT) services CT services are a 30 day intervention that includes a facility visit, home visit and three follow up calls CCM services are authorized in 30 day intervals and may include home visits, clinic visits, phone calls and care coordination activities

3 Typical Client Profile Homeless Active Substance Abuse Mental Health Issues Complex Medical Issues Non-Adherent to recommendations No primary care provider Low education and health literacy History of high utilization History of trauma

4 Engagement Challenges Client is discharged prior to the referral Homelessness difficult to find Client has no phone Limited cell minutes Distrust of the system Active substance abuse Mental Health issues Disjointed systems

5 Tips and Tricks for Finding This Population Start with the referral does the discharge planner know this client? Can they call next time s/he comes in? If enrolled in substance abuse or mental health services call the CM. Those on Methadone can usually be tracked at the clinic Call the PCP s office ask staff to have the client call at next visit or staff can meet client at the next scheduled visit.

6 Tips and Tricks Continued Check the jail register Check with local shelter staff Check ACES for alternate phone numbers or addresses. Sometimes the narrative reveals other providers or relatives that can be contacted Call the mobile medical or dental van Be persistent and use various communication methods telephone, letter, in person Be flexible and nimble!

7 Keys to Engagement The right personnel Ask for Permission Building Rapport Be Authentic Meet the client where they are (physically, emotionally, motivationally) ideally see in the hospital prior to discharge Curiosity Hat Motivational Interviewing Techniques Non- Judging Believe in what you re doing enthusiasm is very attractive Motivational interviewing Assessing Importance and Confidence Validate Concerns Resist the Right Reflex

8 Working With MCO s Challenges Staffing changes Model changes Unstable referral volume planning for staffing Funding/ reimbursement rates CCM denials Continuity of care Opportunities Affect real change in the lives of our clients Increase quality of life Decrease costs Increase collaboration with community partners

9 Case Example 1 Client Details 39 y.o. male from Pacific Islands CHF, CVA, uncontrolled diabetes, HTN, CKD, gout, hx of alcohol abuse, hx of Meth use Frequent ED visits with frequent hospital admits Family just drops off at ED and leaves PCP frustrated that he never comes to appointments and wonders what meds he is taking LTSS CM unaware of frequent ED visits Intervention RNCM coached client and family in home using MI RNCM attended clinic visit with client and family, bringing meds and notes from last hospital stay Coordinated with ER staff, PCP, LTSS CM, and culturally competent family interaction Results Family helps schedule routine PCP visits; client watches diet, medication compliance, and works on goals such as MH support ED visits have stopped; diabetes controlled; CHF managed with less edema and pneumonia

10 Case Example 2 Client Details 46 y.o. Native American Female IV drug use, alcohol abuse, TB, frequent abscesses Poor alliance with PCP; used the roving medical van infrequently and TB clinic Frequent ED use and hospitalization. Exits against medical advice because of addiction to heroin Intervention RNCM used MI to develop a trusting relationship and understand why client would exit the hospital AMA. RNCM coordinated care with health plan, ED, inpatient-provider, TB clinic, housing CM, CD CM, transportation and Methadone Treatment program. Results Client successfully entered Methadone treatment (because of diligent coordination) Abscesses have stopped and thus access to emergent care Every team member was doing their best, but just not coordinating outside their bubble

11 Contact Information Samantha Santor, MSW, CDP, MHP Chronic Care Management Supervisor Seattle/King County Aging and Disability Services

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