Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. Eastern Maine HomeCare Patient-Centered Health Home Project -- Community Care Teams

10/29/2013

CCTs are multidisciplinary, community-based care teams that provide support for the most complex, high-risk, high-need and/or high cost patients served by the PCMH Pilot Sites. The CCT assists patients overcome barriers to care, improve health compliance and outcomes, and reduce avoidable ED use and hospital admissions. The CCT managers are Licensed Clinical Social Workers, the teams include MSWs, RNs, and pharmacy students who work out of the EMHC office. They are actively engaged with community partners including the Area Agency on Aging, Local Healthy Maine Partnerships, and Bangor Public Health.

There are approximately 800 EMHS patients in this CCT program with a variety of challenges that impact their health outcomes and utilization such as mental health conditions, substance abuse, frequent ED use, medication compliance, or psychosocial concerns (e.g., senior housing issues, transportation issues). While dedicated to specific PCMHs, the CCT receives referrals from various sources including care managers at the PCMH, EMHC and hospital. They also identify potential patients be regularly analyzing data from the hospital EHR and HIN looking for individuals who have been in the ED and had multiple ED visits, individuals with complex conditions (medical and/or behavioral health co-morbidities) and targeting based and payer.

The following list provides an example of the type of criteria used to identify potential patients for the program:

  • Two or more ED visits for chief complaint that is readily identified as non-emergent;
  • Transitions of care;
  • History of medication non-compliance; and
  • Two or more chronic illnesses or one chronic illness with a co-morbid behavioral health diagnosis.

CCTs use the document remotely to the primary care setting EHR. The CCTs develop an individualized treatment plan and are working on getting the plan on HIN. One of the challenges for the CCT is the lack of a centralized record -- they must log into multiple systems to conduct their work, which is time consuming. A project is in development to allow the CCT information to flow into HIN.

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