in-reach program elizabeth keck, msw, lgsw allina health - owatonna hospital may 19, 2014...
TRANSCRIPT
In-Reach Program
Elizabeth Keck, MSW, LGSW Allina Health - Owatonna Hospital
May 19, 2014
Participants:1-866-639-0744, no code needed
In-Reach Program In-Reach Program Coordinating Multiple Service Providers
Rare Presentation
Partnership between: South Central Human Relations Center Steele County Human Services South Country Health Alliance Owatonna Hospital-Allina Health Systems May 19th
2014
Objectives of the Program
Process for Identifying and Engaging Patients
Common Patient Profile Patients are generally between the ages of 20 and 40 years of
age. Diagnosed or undiagnosed anxiety, depression, or substance
abuse. Chief complaint related to physical symptoms related to
depression or anxiety (i.e. HA, SOB, palpitations, etc) Majority are on public assistance (but not ALL) Majority either have or have had a mental health adult case
worker Often are disconnected primary care physician Need assistance before qualifying for the Human Service or
Mental Health Services as recommended in their discharge instructions/plan from ED
Many have issues with transportation, housing, food, and medications which is often not addressed in their ED stay
Often times patients mental health treatment providers are not aware of their emergency department visits that relate to their mental health symptoms.
How is Health Care Coordination different from typical hospital
social worker role?
Health Care Coordinator Tasks
Patient Name: John Doe Owatonna Clinic MRN: 20-520-879 Owatonna Hospital MRN: 10099999 Date of Birth: 01/01/1900 Date of Plan: 2/9/2011 Goal of Care Plan: Mr. Doe will reduce overall usage of the Emergency Department and have a reduction in overall symptoms. Living Arrangements: Mr. Doe lives in his own apartment. He does not have a lot of contact with his family. He does engage with his neighbors on fairly regular basis. Mr. Doe lives on Social Security Disability. He uses the SCAT bus for transportation as needed. He sometimes has trouble getting to and from appointments when the SCAT bus is full. County Involvement: Mr. Doe has an adult mental health case manager, Sara Jane. Mrs. Jane can be reached at 507-455-9999. Mr. Doe’s financial worker at this time is Deb W. Deb provides SCAT tickets so Mr. Doe can get to and from his medical appointments. Mr. Doe’s health insurance provider SCHA has a nurse that provides care coordination services for Mr. Doe. Her name is Patty Hocking and she can be reached at 507-455-8115. Mrs. Hocking assists with arising medical needs and concerns as necessary. Psychiatric Care: Mr. Does’s psychiatrist is Dr. Peace at the Human Relations Center. Mr. Doe sees Dr. Peace once every three months unless issues arise. Mr. Doe carries a diagnosis of Major Depression and Anxiety Disorder NOS. Mr. Doe also has an ARMHS (Adult Rehabilitative Mental Health Services) worker Patty Sunshine. Mrs. Sunshine goals with Mr. Doe include learning coping skills for managing his anxiety, maintaining his apartment, and learning to deal with difficult people. Mr. Doe is not seeing a therapist at this time but has engaged in this service in the past. Family Physician: Mr. Doe’s primary care physician is Dr. Doolittle at the Owatonna Clinic. See attached note about care plan Dr. Doolittle, Dr. Peace and Mr. Doe created.
The Program Data
1. Patient Survey upon closure of case.
2. Pre and Post Questions Survey
Billable Service2011-Successful legislative effort-payment
guidelines imbedded in the HS Omnibus Bill (Sec. 45. Minnesota Statutes 2010, section 256B.0625)
Billing expected to be in 15 minute increments at community health worker hourly salary.
MS 256B.0625 subd, Covered Services; Medical Service Coordination.
Bill 80 hours within a calendar year.Can not have two overlapping 60 day
occurrencesCriteria is 4 visits in 3 months.
Upcoming RARE Events….
Stay tuned for the next RARE Mental Health Webinar: New York Office of Mental HealthDr. Molly FinnertryJune 26, 2014 (Noon-1pm)
Future webinars…
To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact:
Kathy Cummings, [email protected]
Jill Kemper, [email protected]