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.
Our Lady of Lourdes Memorial Hospital participated in another MAX Series led by Emily Balmer and June Mohammed, both Project Managers at Care Compass Network. The Lourdes action team focused on the Emergency Department (ED) with a goal to reduce admissions by 10%. “The Lourdes ED action team was very diverse,” says Emily Balmer. “We had an ED Health Coach, Nurses, Health Home Nurses, Social Workers, and leadership. It’s really interesting watching them collaborate together. They don’t have the opportunity to come together often because they work in separate roles. Bringing them together, they really enjoyed that.”
The action team first focused on establishing an assessment for high utilizers to better understand why they are coming in to the Emergency Department. Along with this they worked to develop protocols for high utilizer referrals as well as determining who would make up the care team and how it would function.
For the second workshop, the action team delved in deeper, working to connect and refer high utilizers to appropriate programming in outpatient services. The team looked at the Lourdes GPS Program which is housed within Lourdes at Home. This program is a navigation service for patients who do not qualify for Medicaid Health Home services. Before the MAX Series, collaboration between this program and the Emergency Department did not exist, despite the program being successful in helping patients get the services they need.
The team worked to ensure closed loop communication was happening between care team members, helping to improve warm handoffs and provide an increased patient experience. This also helps ensure appropriate care is being given after the patient leaves the Emergency Department. The action team also developed a plan where their social workers would be providing ED high utilizers with problem solving therapy when appropriate. This therapy, administered at the primary care office, develops and improves problem solving skills.
The Lourdes action team finished their third and final MAX Series workshop at the end of 2018. After putting their action plans into play, the team is continually working on process improvement, with final results expected at the close of their series in February 2019.