successful social and financial outcomes for complicated patients

This presentation will:

Chronicle the process of development and implementation of the project by community stakeholders.

Identify and share how barriers were addressed.

Present outcome data after one year of operation.

After attending this presentation participants will be able to:

Identify two key components of community outreach that successfully engages individuals at high risk for multiple emergency room visits.

Identify two key components for a successful partnership between emergent health care system and the substance use disorder treatment system.

Identify return on investment to communities supporting community outreach projects, financially and in terms of improved healthcare outcomes.

Mercy Hospital reached out to community partners in 2010 asking for assistance in meeting the needs of individuals presenting to the hospital’s emergency room repeatedly who due to their substance use disorders, mental health disorders and/or co-occurring disorders were not able to successfully access and engage in community-based services to address needs.

A wide array of community stakeholders were invited to attend meetings to help develop and implement a number of initiatives related to the health and well being of the communities served by Mercy Hospital in Cadillac, Michigan. Anyone who had an interest was allowed access to these meetings. A sampling of stakeholders involved included:

Community Mental Health NMSAS (the regions Substance Use Disorders Coordinating Agency) Public Health Catholic Human Services (a provider of both SUD and Mental Health services

in the area) Representatives from the area Homeless Coalition Clergy Wexford/Missaukee ISD Mercy Hospital - Medical Social Workers, Nurses and ER staff

Issues of concern to the community that were discussed during the coalition meetings were:

homelessness poverty mental illness substance use public transportation medical care of low income indigent individuals and families school attendance/truancy

Of particular concern to the coalition was the lack of coordination of care for individuals who frequented the hospital emergency room for issues that could and should be handled in a Primary Care setting. Care Coordination occurs routinely for individuals who have commercial insurance providers, but rarely occurs for uninsured or under-insured individuals and families. The coalition decided to concentrate efforts in this area and were able to secure funding for the Community Outreach Practitioner in October 2011.

Costs to families 75% domestic violence 50% homicide Productivity Child abuse 20% of all suicides

Suicide and substance abuse and; Suicide and mental illness (particularly depression) 90% of people who die by suicide have a mental illness 

or substance abuse disorder. 

Mission: To improve the care to people with mental health and substance use disorders. 

Vision:  To provide an informed, coordinated, comprehensive community system of services for individuals with mental health and/or substance use disorders. 

Goal:  Establish a bridge from the ED to community for clients/patients to interface with community services or establish community services resulting in improved mental stability and/or longer periods of sobriety and reduced inappropriate accessions of ED services. 

Results/Accomplishments: Interagency collaboration. Establishment of resource lists for the ED and local providers.  NMSAS funding for a Community Health Worker (practitioner –

CHP) secured.  Community Benefit Ministry support for CHP for the poor.

Outcome Evaluation: 20% of patients contacted without a medical home will have a PCP. 50% of appointments are kept.  Appropriate health utilization:  reduction in inappropriate ED visits.  Medication compliance. Demonstrates knowledge change.

Process Evaluation: Numbers contacted.  Numbers served.

Improve care transitions. Reduce preventable hospital admissions. Reduce readmissions. Avoidable ED visits. Improved problem solving; stable mental health, improved 

quality of life. Sobriety, not using for longer periods of time.

Referrals  105

Number served   66

Provider contacts  971

Number of referrals provided 418

Medication assistance  23

Transportation assistance  23

Co‐pay assistance  6

42

24

0

5

10

15

20

25

30

35

40

45

Inhouse ‐ 64% Community ‐ 36%

47

15

405101520253035404550

Co‐Occurring71%

Primary MentalHealth  23%

Primary SubstanceAbuse  6%

Female ‐ 58%

Male ‐ 42%

Homeless ‐ 22%

Pregnant, just gave birth ‐ 6%

2

15 16

2926

116

0

5

10

15

20

25

30

35

18‐202%

21‐2514%

26‐3015%

31‐4028%

41‐5025%

51‐60  11% 61 andolder 6%

Face to face/phone contacts

Case coordination

Empathic listening

Modeling

Motivational interviewing

Advocacy

Validation

51% had a Primary Care Provider

24% obtained with Community Outreach Practitioner

5% pending

15% dropped out/moved 

5% unable to obtain

Kept healthcare appointments ‐ 73%

Medication compliance 56% ‐ compliant 19% ‐ zero prescriber Unaffordable 13% ‐ non‐compliant 13% ‐ unknown

SUD 65% ‐ annual average not using 28% ‐ still using 11% ‐ unknown

Year‐to‐date = 132

Examples of “Appropriate Healthcare Utilization” include:   Medical and psychiatric appointments kept. Free clinic utilized. Medications obtained through outpatient provider. Accessing homecare services. Detox accessed through SA treatment provider. Emergency MH services accessed through CMH.

89 x 650 = $57,850  Utilization of a primary care provider, urgent care or 

specialist instead of the Emergency Room. Procurement of necessary medications, especially 

psychotropics. Meeting with patients in crisis and developing a stabilized 

plan. Utilization of public dental clinics for urgent needs. Pursuit of residential substance abuse treatment. Sustained sobriety and/or mental health stability 

resulting in reduced ED/IP visits. Referrals to Mercy Homecare and/or Hospice.

Year‐to‐date = 148

“Demonstrated Knowledge Change” refers to behaviors indicative of increased knowledge/understanding regarding the availability of healthcare and community resources, and/or of improved self‐care with regard to medical, MH and/or SA diagnoses. 

Northern Michigan Substance Abuse Services

Catholic Human Services