Resource Library

2019 Best Practice Awards Submission for SDoH

GLOSC embarked on building a SDoH program by first hiring a Community Health Liaison whose initial role has been to ensure that the building blocks for SDoH management were in place 2019. The CHL acted as a project lead for building the program as well as personal community resource hub for practice and patient needs. In order to satisfy a resource deficit gleaned from practices without the means to resolve patient needs after they were screened, practice workflows were assessed, false staff perceptions regarding SDoH were addressed, unique processes were developed, and an extensive repository of public and private community resources was built.

2019 Best Practice Awards Submission for SDoH

In May 2019, a pilot of an electronic SDoH screening process began; expanding to additional practices in July. To ensure high-risk patients received appropriate follow-up, the Centralized Disease and Care Management team was implemented to assist with a number of processes including follow-up calls for all patients with positive screens. This new approach ensures patients receive appropriate resources while allowing practice care management teams to work at the top of their license and focus on chronic care management.

2019 Best Practice Awards Submission for Reduction in Utilization

The Advanced Heart Failure Clinic identified a need for additional patient support and a lack of care coordination between the PCP, hospital, and specialty. The decision was made to embed a full time RN Care Manager into the Advanced Heart Failure Clinic. In the first year, the RN CM conducted 1,826 visits with patients. He provided care coordination and supported the Heart Failure Clinic interventions with these patients. Analyzing a cohort of 25 patients, results of this work demonstrate a 43% reduction in ED utilization and a 48% reduction in Inpatient Admissions.

2019 Best Practice Awards Submission for Reduction in Utilization

Centralized support was provided for the transition of care process, initiating the phone call portion of the requirements. To date, there has been over 1,300 transition of care encounters completed on over 1,100 unique patients. This has contributed to the organization's observed decline in emergency department utilization rates. Coordination and collaboration with clinical offices ensures patients have scheduled follow-up visits and centralized supportive care management is provided to PO-specific members free of charge.

2019 Best Practice Awards Submission for Reduction in Utilization

NPO uses the PCMH-N model as the infrastructure for all work, and regarding ED visits, emphasized how specific domains, such as after hour call availability, when implemented, can help reduce ED visits. All practices were educated and reinforced this message. Additional tools were also promoted and provided to aid in the reduction of ED visits including ADT and Medication Reconciliation, patient educational posters and Care Managers. PCMH User Group meetings, site visits, e-mails, Care Manager meetings, and other methods were used so practices can share with and learn from one another. Practices now incorporate tools as soon as they are provided to continue to drive down ED utilization.

2019 Best Practice Awards Submission for Reduction in Utilization

Metro Health committed itself to reduce PCS ED visits for their patient population. Metro Health gave a network-wide, multi-faceted approach to tackle PCS ED visits by carrying open provider panels, creating walk-in appointment slots, conducting extensive marketing of primary care availability, and providing patient education on appropriateness of ED visits. Efforts were also focused to expand their care management program and engage these staff members in ED discharges.

2019 Best Practice Awards Submission for Reduction in Utilization

A Patient Care Navigator contacts high emergency department utilizers using Motivational Interviewing techniques to quickly gain a therapeutic relationship with the patient. Depending on specific diagnosis, the PCN would educate patients on the most appropriate location to receive care, identify and assist with obtaining resources, and support their care plan goals.

2019 Best Practice Awards Submission for Reduction in Utilization

The goal of the program was to include a reduction in utilization by at least five percent as well as an increase in collaboration among care managers across various health organizations. It was a dual effort between LCN and Aetna Better Health to develop a plan for better managing this population. Initially, the focus was on Transition of Care from the inpatient side to either home or long-term care; and in time expanded to manage those frequently utilizing the ED. Collaborative calls allowed for care managers to discuss what barriers may be present, gaps in care, and consulting with outside organizations that may also be interacting with patient. Call time was also used to develop plan for resolution and status/progress reports.

2019 Best Practice Awards Submission for Reduction in Utilization

Case Conferences are a joint effort between inpatient, ambulatory, and community care services that allows for a review of complex patients, communication of challenges and the creation of a consistent care plan. The team consists of a multidisciplinary group with representation from approximately twelve areas. Case Conferences occur monthly with multiple high-utilization patients at each conference. The goal of these Case Conferences is to follow the success of each patient presented and find a reduction in ED utilization and/or readmissions to the hospital, an increase in appointments kept at their ambulatory appointments, as well as favorable changes in other population health metrics.

2019 Best Practice Awards Submission for Reduction in Utilization

Care Management has been an integral part of the practice since 2012, using a team-based approach for maximum effectiveness. The care manager meets with every new patient, explains their role, and provides a business card for future reference. A team approach to managing the care of patients on opioids contributed to a reduction in ED use which has also contributed to a reduction in avoidable inpatient admissions.