While discussions about the social determinants of health are featuring more prominently in the nation’s current health policy conversation, many organizations, like the Camden Coalition, have been working for years to understand and address this intersection. In the spirit of reflection and continuous learning, we thought it was timely to share the story of the Camden Coalition’s 15-plus years developing a care model that is centered around both health and social complexity.
This piece, “Phase 2 of the Camden Core Model: Using healthcare hotspotting to find patients and adjusting the model to suit patient needs (2012-2013),” is the second in a four-part series that describes the phases of the Camden Core Model as we addressed challenges and tested new solutions. Read all four sections together in this brief.
The second phase of our care management work continued to focus on home and community visits.
Our ultimate goal was to reduce hospital admissions by supporting the patient in finding ways to best manage their health conditions, engage in preventive care, and develop a stable relationship with primary or specialty care. We sought to appropriately navigate patients away from the hospital and address psychosocial factors. Some important changes we made during this time include:
Refining the healthcare hotspotting process
In this second phase, we refined our healthcare hotspotting process and began to strategically use Camden Coalition HIE data to refine our patient selection process by instituting a triage methodology. This real-time patient identification was a unique component of our approach at the time, given that most other approaches used retrospective claims data to identify patients.
Camden Coalition staff reviewed all admissions at local hospitals to find patients who, based on our experience, were more likely to be in need of the kind of care management that the Camden Coalition offered. We started using the criteria of high hospital usage coupled with social and medical complexity. Specifically, we sought to mitigate hospital use by delivering care management only to patients who presented with both medical and social complexity, including two or more chronic conditions and two or more additional barriers that might include: polypharmacy; lack of social support; housing instability; active drug use; physical disabilities; language barriers; and mental health conditions. At this point in time, some referred to these patients as “super utilizers” or “frequent flyers.”
During this period, we became much more effective at identifying patients who might benefit from care management and navigation services and excluding patients that we knew would not benefit from our intervention. Our exclusion criteria became patients living in a nursing home or assisted living facility, since these patients receive all of their care at their facility; individuals experiencing dementia or Alzheimer’s because patients with these conditions do not have the capacity to care for themselves or participate fully in the intervention; and those receiving intensive care management services from another agency. We also excluded patients with certain diagnoses such as cancer because the diagnosis itself would drive most of the patient’s hospital visits. This daily triage process continues today at the Coalition.
Using the Health Care Innovation Award to test changes to our approach
These were the early days of getting ready for Affordable Care Act implementation, and our experience was that most primary care offices were not set up to support the patients that we brought to them. Although most clinicians we interacted with were committed to caring for our population of clients, they were operating in practices that did not have the care management or social work support needed to address their patients’ level of medical and social complexity. In addition, the financial model for primary care still left clinicians with very little time for patients. Treating complex medical needs was difficult to do in a single appointment, and addressing social needs in that same appointment was nearly impossible. The financial model of primary care continues to be a major challenge for our patients and their hard-working clinicians.
Amidst the buzz of “healthcare homes” and the promise of new resources for primary care, we sought to develop a strategy to navigate patients to a permanent relationship with primary or specialty care and graduate patients from our intervention after some of their most immediate social needs were addressed. We received support through a Health Care Innovation Award from the Center for Medicare and Medicaid Innovation (CMMI) to test a shorter-term intervention, modified to last an average of 90 days and scaled to serve up to 800 people in a 3-year period. We wanted to limit the number of weeks that our Care Team engaged with patients because longer engagements did not seem to increase the likelihood of creating stable connections to primary and specialty care. Our Care Team made it clear to patients that this was a short-term intervention designed to help them meet their goals and was not a permanent care management model. The premise of the short-term intervention was that navigating back to health care was an important aspect of meeting our patients’ needs.
The Health Care Innovation Award also allowed us to expand our staffing. We created a second Care Team so we could serve more patients and better attend to their needs. Each Care Team included an RN or LPN paired with a community health worker. The two teams were supported by a social worker and housing specialist who provided their expertise as needs arose. The RNs and LPNs were responsible for engaging patients while they were in the hospital, and the full Care Team served patients after discharge.