Care Coordination Lessons Learned From ATR
Problems Recovery Plans- Not standardized Referrals for other identified needs? Discharge process too close to discharge? Discharge process unique to providers? Programs lack resource/connections? Programs do not see themselves as a part of the care continuum? No accountability?
A Shared Definition Care Coordinator assists recipients in gaining access to necessary care and medical, behavioral, social, and other services appropriate to their wellness needs promotes sound and appropriate use of resources Etc………………………
Clear role Definitions Clinician: • Orients client to ATR requirement for treatment engagement • Assesses and recommends next level of care • Creates a referral and establishes an intake appointment for the client Care Coordinator: • Confirms client understanding of the required referral • Obtains all needed information about the referral • Identifies and resolves with client any obstacles related to the referral • Checks with client to confirm that appointment was kept • Ongoing monitoring of treatment progress, troubleshooting, etc.
Relationships in the Project Regional Area Coordinators (RAC) –Manage on Regional level Client utilizes RecoveryNet resources to enhance and stabilize recovery Care Coordinators (CC) – Manage on the client level
Recovery Plans No standard definition . Problem oriented- strengths/resources One size fits all Clients left to make the connection...or not Clinical tool vs. client tool
A Recovery Plan • What is the plan? (Goals, objectives, strengths, obstacles, actions or steps) • What are the crisis intervention and relapse prevention plans • Are there action steps in the plan that care coordination can assist with? (i.e. transportation, gap services, vital documents, etc) • What appointments are needed?/ Who’s making the appointment?
Clear Functions/Process One time, face-to-face or telephone* interview with ATR client conducted prior to discharge from residential treatment program : (Requires 3-5 days notice from portal) Purpose: • Engage the client in Care Coordination • Insure that Care Coordinator has information needed to coordinate care and client understands the program • Explain the purpose and process of care coordination • Establish contact schedule • GPRA 6 month follow-up appointment
Next Steps • Establishes contact schedule and details (where to call, who to call if.., etc. ) • How to contact care coordinator • Agenda for next contact (what services have been accessed, obstacles, successes, needs, etc.) • Schedule 6 month follow-up GPRA appointment (give client appointment slip)
Care Coordinator is: Recovery Champion Overseer of Recovery Resources Community Resource Connection Obstacle Mover System Changer GPRA Getter
A Care Coordinator is Not: The Clinician Crisis Intervention Available 24/7 Psychiatrist Doctor Mother Best Friend
Know What You Want What are we looking at in the short term? Time interval between referral and intake/length of pending status Number of in-person vs. telephonic intakes Client voucher burn rates Billing patterns Number of closed cases Enrollment in recommended level of care GPRA Follow-up Rates
Effecting Change What are we looking at in the long term? • Rate of client readmissions to intensive levels of care. • Extending treatment episode to support chronic disease model.