Over the last two years, Care Compass Network (CCN) has conducted several Medicaid Accelerated eXchange (MAX) Series in conjunction with local health systems to redesign the way care is delivered for the state’s most vulnerable patients. In earlier article “‘Mad’ MAX Comes to the Southern Tier”, we provide further detail on the process for the MAX Series.
United Health Services (UHS) was one of 4 health systems involved in the MAX Series workshops with CCN. The concentration for the UHS MAX Series was on the Emergency Department. “The UHS team was very resilient,” notes Juned Mohammed, Project Manager and MAX Facilitator at Care Compass Network. “Perseverance is the key with this team. Even with their IT systems not talking to each other, they found a way to communicate manually. It was amazing to see how the team coordinated that.”
The first focus of the action team was to examining complex case high utilizers by creating a team to care for them and developing a process by which to provide care, including a care plan. Determining the location that the care plans would be stored within the department and how they would be accessed, improving care coordination. The team also focused on educating staff on the high utilizer pattern at UHS in order to achieve increased referrals and determine if high utilizers were being seen within the rest of the health system.
During their second workshop the action team examined the possibility of creating opiate and anxiety care pathways as these were the most common issues for high utilizers. The team met with the Emergency Department staff to better understand what the exact focus point would be and what subject matter experts were needed to create these care pathways. The action team also focused on additional ways to further educate their patients on the services available to them, such as the Nurse Direct hotline.
Since not all needs of high utilizers are clinical, the action team also used the second workshop to focus on building community partnerships, with a goal to create case conferencing with several community-based organizations (CBOs). The UHS team developed partnerships with Catholic Charities of Broome County, Fairview Recovery Services, including specific departments within their own healthy system.
The final workshop focused on increasing referrals for high utilizers through different strategies. The first strategy the team created was to have Behavioral Health Navigators meet with patients before and after a discharge to connect them with the appropriate services. Another strategy the team created revolved around intensive follow-up at 7 14, 21 and 30-day intervals after a discharge. Following up helped determine if the patient is improving and gauging if the patient was likely or unlikely to return to the Emergency Department. Long term intensive follow-up would continue until the staff felt the patient no longer required assistance.
“UHS achieved really great success in terms of reducing [Emergency Department] utilizations,” notes Mohammed. The UHS action team had a goal to reduce admissions by 10%, which was established by the state. After the conclusion of the MAX workshops, the action team had a 30% reduction in admissions.