Developing a coordinated care organization in northwest Oregon’s Yamhill County presented an opportunity to build an organization that reflected the community’s vision for high-quality, more efficient, integrated care for Medicaid beneficiaries.
When assessing the needs of the community, it became clear to Yamhill Community Care Organization’s (YCCO’s) Clinical Advisory Panel (CAP) that a small percentage of Medicaid beneficiaries with multiple chronic conditions were utilizing emergency department services inappropriately and driving a majority of the costs.
To be successful in meeting cost and quality goals, the CAP recommended the development of the Community HUB program and hiring a team to focus care on this high-utilizer population. Emily Williamson is a key member of this team. As the community health nurse, she works closely with other HUB staff to help identify high-utilizer patients and develop interventions to break the cycle of inappropriate emergency department visits.
IDENTIFYING HIGH-UTILIZER PATIENTS
At her office based at Northwest Senior & Disability Services, Emily begins her day by checking the fax machine. Although some referrals to the HUB come to her by email and phone, the majority arrive by fax. Referrals come in from emergency department providers, primary care providers, and other community providers. The growing number of provider referrals is indicative of the significant, behind the scenes relationship-building work that Emily has done since the HUB was established.
In the first few months of the program, Emily and her team identified potential patients using data from CareOregon, a Medicaid plan operating in YCCO’s region. Subsequent input from emergency department providers and others helped HUB services expand to be more proactive about preventing patients from becoming high-utilizers. Although referrals from providers are now the main source of identifying patients, Emily still sifts through the CareOregon spreadsheets she receives monthly from CareOregon.
Today, Emily receives four new referrals. Emily receives all referrals, and it is her responsibility to triage the referrals to assess whether or not the patient needs a physical health assessment, a behavioral health consultation, or other services. Emily phones a staff coordinator from Project Able to refer two of the patients that need behavioral health support. Project Able is a community resource that provides peer support services to YCCO patients with behavioral health needs and other comorbidities. The partnership between the HUB and Project Able has been invaluable in helping the HUB team expand resources available to patients with behavioral health needs.
Emily then checks her email and notes a reply from one of the primary care providers who is interested in setting up a meeting with her to learn about the HUB program. Emily often brings one of the HUB’s community health workers with her on these informational visits. “It is helpful to make these introductions between the HUB team and the providers early,” Emily says. Community health workers often accompany patients to primary care appointments to help support the patient and ensure coordination of services.
WORKING AS A TEAM
Sara, one of the community health workers, comes to Emily to discuss a new patient. The patient has been treated for chronic back pain in the emergency department numerous times over the past few months. The patient does not have a regular source of primary care and is generally distrustful of the medical system. Recently YCCO engaged a naturopathic practice in its network to provide its patients with an alternative source for primary care. The two agree that Sara should discuss this option with the patient.
Emily calls to check in with one of her patients who has a history of chronic obstructive pulmonary disease and pneumonia. The patient has had more than 15 hospitalizations and emergency department visits over the past year. The patient does not qualify for home visiting and is too independent to move into an assisted living facility; therefore, Emily has been working with the patient to develop her self-management skills. The patient wanted to focus on quitting smoking and becoming more active. Emily asks the patient about her smoking cessation goals. She also asks how many times the patient has been able to go up or down the stairs each day. The patient describes how she is managing her cravings and says that she is now using the stairs five times a day, up from three times a day last week.
Emily then heads to the monthly meeting of the Yamhill High-Utilizer Subcommittee. Approximately 15 people have gathered around the table today, including CCO staff, an Oregon Health Authority Innovator Agent,9 a community health worker, emergency department providers, and community stakeholders. The purpose of this subcommittee is to review and analyze high-utilizer data and coordinate overall efforts for high-utilizer patients. Today there are no complex patient cases that need to be discussed. The subcommittee spends considerable time discussing how to improve the HUB’s referral form to make it more useful to providers.
After lunch, Emily drives to a primary care clinic to meet a patient, along with his behavioral health specialist and primary care provider. Fostering connections between high-utilizer patients and primary care providers is paramount to the HUB’s work. “Getting the patient to the primary care provider’s office is often a significant success,” says Emily. “We need to be willing to celebrate these steps with the patient.”
The patient, Emily, the behavioral health specialist, and the primary care provider discuss the next steps. They review findings from a survey the patient previously took using the Patient Activation Measurement tool.10 This tool measures patient engagement in care as well as self-management capabilities. Together, they develop the patient’s action plan based on his self-identified goals. “Everybody has a potential solution,” Emily notes after the visit, “but the real solution has to come from the patient. He needs to tell us how we can make the plan work for him. We can tell him that we want him to be healthy, but ultimately he needs to have some control.”
After leaving the office, Emily gets a call from a patient who she has been working with for a couple of months. Despite being well connected with a primary care provider, the patient has been in the emergency department between 20 and 30 times in the past month. Emily says the patient calls the emergency department “her comfort zone.” After the call, Emily wonders, “What is she getting in the emergency department that she is not getting at home or from her primary care provider? She’s stuck in this behavior pattern and has created a community that’s inappropriate for what she needs.”
Emily has connected this patient with Project Able, and the patient is writing in a diary to try to identify “triggers” that send her to the emergency department. Emily asked the patient to call her the next time she felt the urge to go to the emergency department and Emily would accompany her on the visit. That call came today. Emily heads out the door to meet the patient at the hospital and takes a further step in trying to break this patient’s cycle of inappropriate emergency department use.