Systems-based learning

1. High Utilization in the Context Homelessness Carolyn Junior, BSc Biology and Katharine Royer, BSc Biology, MSc Medical Genetics Health Coaches with the Camden Coalition of Healthcare Providers; Camden, NJ • Background • 915 individuals were homeless in Camden County in 2012 • John was transitionally housed (considered homeless), living in a one bedroom apartment with two other adults prior to our intervention • Patient Information • Income: $210 in General Assistance • $200 in Food Stamps • Insurance: Medicaid Package G (Out-Patient/ Under- Insured) • Systems-based learning • Driving Diagnoses: • Seizure Disorder • Hypertension • Anxiety & Depression • Insulin Dependent DM • Psychosocial Stressors: • Homelessness (2009) • Lack of Family Support • Poor Medication Adherence • Intermittent Drug Use The Intervention Medical Mental Health Housing John is a 44 year old, father of three girls. He has worked as a professional wrestler, a mail carrier, and a truck driver. A trucking accident in 2007 left him unemployed & eventually homeless. Patient Utilization Estimated Total Hospital Receipts > Pre-Intervention: **$41,118 – Seizures and/or DKA > Post-Intervention: **$35,200 – Suicide Attempt ** This estimate cost data was compiled using The Camden Health Information Exchange (HIE) • Medicine Reconciliation • Provider Follow-up: • > Primary Care Ortho, Podiatry, PT/OT, Dentistry, Nephrology, Neurology, • Provider Follow-up: • > Psychiatry • Coalition Accompani-ment • Day program • Medically ill, Chemically Addicted (MICA) • Accompany to Board of Social Services • Emergency Housing • > Motel • > Shelter • Permanent Housing • > CSPNJ support Acknowledgements Collaborative Support Programs NJ The Community Health Law Project Center for Medicare and Medicaid Innovations Care team Jason Turi (RN, MPH), Angel Mitchell (LPN) Raquel Medina (LPN), Sharine Eliza (Health Worker), Bill Nice (Intervention Specialist), Kelly Craig (CMMI Director), Carolyn Junior & Katharine Royer (Health Coaches) • MEASURABLE OUTCOMES • Decrease in Patient Risk Score: • > Initial (Day 0) : 12 out of 24 • > 30 days: 9  1/12/13 • > 60 days: 11  2/12/13 Timeline of Patient’s Hospital Utilization Inpatient Intervention Begins ED Visits June 2012 Oct. 2012 Jan. 2013 May 2012 July 2012 Aug. 2012 Sept 2012 Nov 2012 Dec. 2012 Feb. 2013 Mar. 2013