In-Reach Hospital Program
Coordinating Multiple Service Providers
South Central Human Relations Center
Steele County Human Services
South Country Health Alliance
Allina Health Owatonna Hospital October 2nd 2012
Access to the full spectrum of needed provider services through access assistance
and advocacy for correct health care program enrollment resulting in optimal care.
Efficient patient encounters assisted by unique treatment plans easily accessed in
Excellian and system care coordinator in attendance at clinic visits
Objectives of the Program
To encourage health care providers to coordinate their efforts to assure
the most vulnerable patient populations seek and obtain primary care.
To increase preventive services including screening and counseling, to
those who would otherwise not receive such screening to improve health,
reduce complications, and cost.
To provide a mechanism for improving both quality and efficiency of care
for vulnerable individuals with an emphasis on those most likely to remain
uninsured or underinsured.
To manage chronic conditions to reduce their severity, negative health
outcomes, and expense.
Process for Identifying and
List of patients is
Patient consents to 5 more visits in in
system care quarter
coordination. (Crystal Report)
Phone Call, Letter, and List is reviewed with
note in chart to page Medical Director of
social worker when they ED and Nurse
arrive Manager of ED
How is Systems Care Coordination different from
typical hospital social worker role?
Social worker walks with the patient rather than makes
referrals from the hospital environment.
Functional Assessment and Community support plan is
developed with the patient to stabilize their mental and
Sixty days of case management with a goal of the
patients transitioning to community based support
Collaborative to get all of the service providers working
together with the patient.
Inputs Activities Outputs
Licenses Social Worker ED Use: 5(+) times in 3 months 196 Patients Served
Computer (MD Medical Director, RN
Phone Manager, & Systems Care 102 Care Plans Developed
Funding Contracts with: Coordinator Review)
SCHRC Engage patients in $1,886,365 decrease in
Owatonna Hospital partnership to reduce ED Emergency Department visits
SCHA visits & use community and hospitalizations 1 year post
Steele County resources for appropriate intervention
Human Services care.
Releases of Information 64% decrease in ED visits two
obtained years post intervention
81% decrease in ED visits three
Community Support Plan
years post interventions.
Care Plan with patient,
Primary Care, & Systems
Care Coordinator is used
when patient presents to ED
Long Term Outcomes
Patients will reduce ED visits
• Providers coordinate
Patients will get connected Shared responsibility
efforts to help
to services and resources in between primary care,
the community mental health, community
seek & obtain primary
care services and the
• Patients increase Hospital
preventive services to Reduction in health care
improve health, reduce costs.
complications & costs
• Patients manage chronic
conditions to reduce
severity, negative health
outcomes, & expense
Common Patient Profile
Patients are between the ages of 20 and 40 years of age.
Diagnosed or undiagnosed anxiety, depression, or substance abuse
Chief complaint related to physical symptoms related to depression or
anxiety (i.e. HA, SOB, palpitations, etc)
Majority are on public assistance (but not ALL)
Majority either have or have had a mental health adult case worker
Often are disconnected with case worker and primary care physician
Need assistance before qualifying for the Human or Mental Health Services
recommended in their discharge instructions/plan from ED
Many have issues with transportation, housing, food, and medications which
is often not addressed in their ED stay
The Program Data
Managed Care Data
January 2012 to July 2012
Reviewed Emergency Department, Overall Primary Care
$51,951 reduction in paid health care claims
2011-Successful legislative effort-payment guidelines
imbedded in the HS Omnibus Bill (Sec. 45. Minnesota
Statutes 2010, section 256B.0625)
Currently in final process of approval from CMS with
Billing expected to be in 15 minute increments at
community health worker hourly salary.
Patient Name: John Doe
Owatonna Clinic MRN: 20-520-879
Owatonna Hospital MRN: 10099999
Date of Birth: 01/01/2011
Date of Plan: 2/9/2011
Patient Name: John Doe Care plan for Fibromyalgia:
Owatonna Clinic MRN: 20-520-879
Owatonna Hospital MRN: 10099999 Treatment Recommendations for Fibromyalgia:
Date of Birth: 01/01/1900
Date of Plan: 2/9/2011
Goal of Care Plan: ________________________________________________________________________
Mr. Doe will reduce overall usage of the Emergency Department and have a
reduction in overall symptoms. When should patient use ED for treatment of Fibromyalgia:
Living Arrangements: Mr. Doe lives in his own apartment. He does not have a lot of ________________________________________________________________________
contact with his family. He does engage with his neighbors on fairly regular basis. Mr. ________________________________________________________________________
Doe lives on Social Security Disability. He uses the SCAT bus for transportation as ________________________________________________________________________
needed. He sometimes has trouble getting to and from appointments when the SCAT bus
is full. Should narcotic medications be used to treat Fibromyalgia: _______________________
County Involvement: Mr. Doe has an adult mental health case manager, Sara Jane. Mrs.
Care Plan for Back Pain:
Jane can be reached at 507-455-9999. Mr. Doe’s financial worker at this time is Deb W.
Deb provides SCAT tickets so Mr. Doe can get to and from his medical appointments.
Mr. Doe’s health insurance provider SCHA has a nurse that provides care coordination Treatment Recommendations for Back Pain:
services for Mr. Doe. Her name is Patty Hocking and she can be reached at 507-455- ________________________________________________________________________
8115. Mrs. Hocking assists with arising medical needs and concerns as necessary. ________________________________________________________________________
Psychiatric Care: Mr. Does’s psychiatrist is Dr. Peace at the Human Relations Center. ________________________________________________________________________
Mr. Doe sees Dr. Peace once every three months unless issues arise. Mr. Doe carries a
diagnosis of Major Depression and Anxiety Disorder NOS. Mr. Doe also has an When should patient use ED for treatment of Back Pain?:
ARMHS (Adult Rehabilitative Mental Health Services) worker Patty Sunshine. Mrs. ________________________________________________________________________
Sunshine goals with Mr. Doe include learning coping skills for managing his anxiety, ________________________________________________________________________
maintaining his apartment, and learning to deal with difficult people. Mr. Doe is not ________________________________________________________________________
seeing a therapist at this time but has engaged in this service in the past.
What medications should be used to treat Back Pain if patient presents to ED?:
Family Physician: Mr. Doe’s primary care physician is Dr. Doolittle at the Owatonna
Clinic. See attached note about care plan Dr. Doolittle, Dr. Peace and Mr. Doe created.
Care Plan for Migraine/Headaches:
Treatment Recommendations for Migraines/Headaches:
Elizabeth Keck, MSW, LGSW