UW Medicine Harborview Medical Center

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Britton Waters
3 years ago
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What is the biggest barrier to long term stability?
What is one of the main goals of intensive outreach?
What type of alerts does the PES liaison provide?

1 UW Medicine Harborview Medical Center Emergency Department Psychiatric Emergency Services PES Liaison and High Utilizer Case Management Program

2 High Utilizer Case-Management Team RSN and MIDD funded programs to provide prevention, intervention and linkage for PES consumers and assertive outreach and engagement for high utilizers of the ED. The PES liaison is an RSN program and provides linkage, coordination as well as systems alerts, network care conferences and care plans for PES consumers. The MIDD funded high utilizer case-managers provide assertive outreach and engagement for a designated high utilizer caseload. Individuals receive intensive services, including intensive outreach and advocacy to provide linkage for housing, chemical dependency, d mental health, and medical follow-up. Current Team consists of 3 clinical staff that share the PES liaison ison duties and HUP case-management caseload with program support: Mental Health Practitioner Lead Ann Allen Mental Health Practitioners Josh Torregrosso and Carolyn Borys Data entry and program assistant staff support Reached full capacity in August of 2009

The MIDD funded high utilizer case-managers provide assertive outreach and engagement for a designated high utilizer caseload.

3 Case Profile High Utilizer Criteria - 4 ED visits in a six month period Homeless or in danger of losing housing Lack of effective engagement or alienation from traditional resources Increasing inability to cope with street life due medical concerns ns Most clients have concurrent mental health, chemical dependency and medical concerns Most common linkage needs: funding, primary care, chemical dependency treatment, mental health treatment and housing Housing need is huge and biggest barrier to long term stability

clients have concurrent mental health, chemical dependency and medical concerns Most common linkage needs: funding, primary care,

4 CM Principles and Interventions Program is based on successful UCSF ED Casemanagement Program Assertive efforts to engage patient in ED and in the community Respectful and compassionate care Relationship building in the field Shelters, parks, freeway ramps, agency waiting rooms, fast food restaurants, buses Concrete resource provision food vouchers, bus tickets, etc. Harm Reduction Approach to CD issues Motivational Strategies Networking with agencies to provide continuity of care Close team communication and supports Client self determination and care planning Network care conferences.

restaurants, buses Concrete resource provision food vouchers, bus tickets, etc.

5 Case Study Person A ~50 y. o. man Homeless Chemical dependency primary alcohol Increasing medical problems with multiple ER visits for cellulitis and withdrawal seizures Legal Issues Interventions Assertive outreach and engagement Supported Housing Bus tickets Aggressive networking of supports Key Network Linkages Reach Seattle Indian Health Board DSHS - NA outreach worker CD ITS Supported Housing KC Detox Now sober, stable housing, reconnected to family and native community

withdrawal seizures Legal Issues Interventions Assertive outreach and engagement Supported Housing Bus tickets

6 Case Study #2 Person B ~40 year old man Multiple medical problems including diabetes and chronic back pain with non compliance with medications and physical therapies Alcohol dependent Depressed In danger of losing his housing Enrolled in mental health but not engaged; case-manager engaged in medical advocacy. Intervention Care plan developed to include time management, motivational interviewing and communication skills as well as focus on behavioral positive reinforcement. Now patient is increasingly engaged with his mental health providers, returned to physical therapy, actively managing his diabetes. Working on his CD issues (not yet clean). He was able to retain his housing

Intervention Care plan developed to include time management, motivational interviewing and communication skills as well as focus on behavioral positive reinforcement.

7 Measuring Impacts Provided serves to over 93 patients by the end of the 3 rd Quarter of this year. (Over 100 to date) Active caseload of 30 patients in the program at any given time. Expected length of service is 3 moonths HMC Decision Support identifies and provides data of ED high utilizers Number of ED visits and cost associated are collected Jail visits are available through public information Ambulance/SPD/Medic resources can be reviewed via medical record.

Expected length of service is 3 moonths HMC Decision Support identifies and provides data of ED high utilizers

8 ED Visit Data per Patient ED Visits (Pre and Post CM) Number of ED visits Before CM After CM Individuals

20 15 10 Before CM After CM 5 0 1 2 3 4 5

9 Profile of Medical Cost of First 18 patients. Medical System Costs $500,000 $450,000 $400,000 $350,000 Costs $300,000 $250,000 $200,000 $150,000 Pre CM Start Post CM Start $100,000 $50,000 $ Individuals

Costs $300,000 $250,000 $200,000 $150,000 Pre CM Start Post

10 Pre and Post Jail Visits Number of Jail Visits Year Prior to CM 3 S1 Post CM

11 911 Usage by Initial Patient Cohort AMR/911 Calls Pre CM Visits Post CM visits

12 Program Contact Ann M. Allen, LICSW (206)

2012 Complex Case Management Program Evaluation

2012 Complex Case Management Program Evaluation Our mission is to improve the health and quality of life of our members 2012 Complex Case Management Program Evaluation Table of Contents Introduction Page

UW Medicine Harborview Medical Center

What is the biggest barrier to long term stability?

What is one of the main goals of intensive outreach?

What type of alerts does the PES liaison provide?