b4-creating an integrated patient navigation model

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Creating an Integrated Patient Navigation Model through Hospital, Health Plan and Community

Collaboration

June 24th, 2014Catholic Health Assembly

Presented By: • Rosemary Younts ‐ Director, Community Benefit

Dignity Health Sacramento Service Area

• Ashley Brand ‐Manager, Community BenefitDignity Health Sacramento Service Area

• Kelly Bennett Wofford – Executive DirectorSacramento Covered

Agenda

• Dignity Health Overview

• Understanding of the Sacramento Region

• Developing Need using Emergency Department Data

• Creating Meaningful Collaboration

• IT Integration

• Patient Navigator Program Overview & Outcomes

• Challenges Experienced

• What’s Next

• Q&A

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Dignity Health• Founded in 1986 and headquartered in San Francisco

• 5th largest hospital provider in the nation; largest in California

– Over 40 hospitals and care centers serve California, Arizona and Nevada communities

• Changing to meet the needs of a dynamic new health care environment

• Mission, however, remains steadfast

– We are committed to further the healing ministry of Jesus, dedicating resources to:

• Delivering compassionate, high‐quality, affordable health services• Serving and advocating for our sisters and brothers who are poor

and disenfranchised; and • Partnering with others in the community to improve the quality of life

• “Hello Humankindness”

– http://www.youtube.com/watch?v=asYUiWJrfQg

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Our Topic: Patient Navigation Program

• Is an expression of our mission

– Responds to the health care needs of the underserved

– Creates access to regular, affordable quality care

– Brings hospitals, health insurers and community nonprofit partners together in a collaborative effort that is groundbreaking for our region

• Is aligned with goals of the Affordable Care Act

– Improve quality of care

– Coordinate care

– Reduce costly Emergency Department admissions

– Lower health care costs

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Concept for Patient Navigation Model Not Complex

Establish a medical home for underserved patients who admit to Emergency Departments for non‐urgent care, coordinate their care, provide other needed social support services, and follow their progress

• The devil, however, is in the details … IT, legal, privacy/security, partner relations, emergency department space, process, protocols, etc…

• Learning objectives we hope to accomplish:

1. Understand how to analyze Emergency Department data to demonstrate the need and basis for patient navigation

2. Develop evidence‐based system of outcomes measurement and evaluation

3. Develop implementation strategy, including process flow, cost‐benefit analysis, and template of key hospital leaders and community partners core to the project team

4. Understand the need for, and value in, building collaborations between multidisciplinary partners, including providers/provider networks, health plans and community‐based partners

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To Understand Need, Must Understand Community

• Our community is Sacramento, California • Home to 4 Dignity Health Hospitals

Mercy Hospital Folsom Methodist Hospital of Sacramento

Mercy General Hospital Mercy San Juan Medical Center

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Snapshot of Sacramento County

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• Sprawling urban/suburban area; 995 square miles

• 7 incorporated, 29 unincorporated cities• 1.4 million residents• 17% of all residents live below FPL• 1 in 4 residents are uninsured or Medi‐Cal‐insured

• Only now beginning to recover from recession

• Population is ethnically diverse

Caucasian ‐ 46.7%

Hispanic ‐ 21.2%

Asian / Pacific Islander ‐ 15.2%

African American ‐ 11.5%

American Indian ‐ 2.2%

Multi‐Racial ‐ 3.3%

Sacramento Region

The State of Sacramento County’s Safety Net

• Sacramento County’s safety net characterized as weak and fragmented

– Only 5 Federally Qualified Health Centers and Look‐Alikes

– All are young, financially fragile, and have historically operated in silos with minimal outreach in the community

• County’s public health programs/services have been decimated

• One of 2 counties in state with Medi‐Cal Geographic Managed Care

– Short list of providers and no system of care coordination

• California has one of lowest Medi‐Cal reimbursement rates, making it hard to attract providers

• Without change, region’s safety net will reach full capacity before 2016

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Hospitals Filling Monumental Gap

• Safety net is dependent upon Emergency Departments

• Emergency Department visits by uninsured and Medi‐Cal‐insured for non‐urgent care have more than tripled over past 5 years

• Today, over 50% of all patients seen and treated in our Emergency Departments admit for basic primary care needs

– Almost 70% are Medi‐Cal or uninsured

– This represents nearly 47,000 patients annually

– In 2013, unreimbursed Medi‐Cal expense alone for the 4 hospitals was over $103 million

• Demand for care continues to grow with implementation of the Affordable Care Act in a region where access is a priority health issue

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Changes with Health Care Expansion Through the ACA

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Emergency Departments as Only Source of Care

• Research tells us Emergency Departments are suboptimal for patients in need of routine care

– Designed for rapid, short‐term treatment of acute illnesses and injuries

– No continuity of care

– Patients with non‐urgent needs have low priority

– ED physicians do not have a relationship with patients, lack complete records, face constant interruptions and distractions

– No means of patient follow‐up

• Emergency Department also an expensive alternative for primary care

– Cost to treat primary care 3 to 5 times higher than in a physicians office or community clinic

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Utilization Trends Spurred Pilot Program

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• Established Community Health Referral Program through small grant award in 2011

• Despite limitations of pilot, outcomes held promise

– 3,000 patients assisted over 2.5 years

– 80% of those assisted received referrals and/or appointments with Primary Care Provider

– 60% of those assisted attended their appointment

• Felt strongly that an expanded model incorporating direct in‐person assistance in the Emergency Department would dramatically improve effectiveness

– Baseline data needed to build a business case for taking the pilot full‐scale

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How We Sold the Program: Demonstrating the Need Through Data

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Number % Number %

# of ED Visits 195,911 0% 202,185 0%

Unduplicated Patients 127,265 0% 129,851 0%

# of ED Visits (D=C4) 99,658 51% 105,821 52%

Unduplicated Patients (D=C5) 72,424 57% 76,700 59%Visits between the hours of 8am‐5pm

(D=C7) 48,827 49% 52,499 50%

# of ED Visits (D=C7) 42,704 43% 45,938 43%

Unduplicated Patients (D=C8) 15,470 21% 16,817 22%

# of ED Visits (D=C7) 8,887 9% 9,432 9%


# of ED Visits (D=C7) 30,220 30% 34,910 33%


≥2 ED Vistis for Primary Care (D=C7) 14,295 14% 17,099 16%

Unduplicated PTs w/≥2 ED Vistis (D=C8) 5,234 7% 6,168 8%

# of ED Visits (D=C7) 18,030 18% 18,496 17%




# of ED Visits (D=C7) 10,071 10% 8,502 8%




Self‐Pay (including Pending

Financial Aid)

Fee for Service (FFS) and Share

of Cost (SOC) Medi‐Cal

Geographic Managed Care

(GMC) Medi‐Cal TOTAL

Overall ED Visits

FY 11‐12 FY 12‐13

Visits to ED for Primary Care

Payor Mix for Visits to ED for Primary Care

Total ED Visits

ED Visits for Primary Care

≥2 ED Vists for Primary Care

≥5 ED Vistis for Primary Care

Capturing ED Utilization Data

• Obtaining Emergency Department utilization data to demonstrate deed

– Work with Patient Registration Department and IT

– Develop a report template to capture data elements

• Obtain list of discharge diagnosis codes that identify non emergent diagnoses

• Import codes into ED template to capture all visits for non‐emergent needs

• Sort data to demonstrate need

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Name DOBAdmtDate

AdmtTime

DschDate

DschTime

DschICD9

Dsch DiagDesc

Admt Reason

InsName

Attend DR Phone Sex Race Acct# M/R_# Address City St Zip

P ati en t N um er ica l V alu e Ag e Ad m t_D at eA dm t_ Ti me D sch _D at e Ds ch_ Tim e D sch _I CD 9P rim a ry C ar e Ds ch_ Di ag _De sc Ad mt _R ea son In s_N am e1 17 6 /2 5/2 01 3 1 801 6/ 25/ 20 13 1 820 2 40 9 #N /A GO IT ER NO S TH YR OID P RO BLE M TH RO AT SW E LLI NG M EDI ‐CA L 2 56 2 /1 2/2 01 3 1 106 2/ 12/ 20 13 1 401 71 94 6 JO INT P AIN ‐L /LE G BIL AT KN EE PA IN X 7 M O NT HS SE LF PA Y 3 34 2 /1 7/2 01 3 1 835 2/ 18/ 20 13 14 78 06 0 FE VE R N OS CH ES T H UR TS CH ILL S H EA D HU RT S H EA VY CH ES M EDI ‐CA L 3 34 8/ 7/2 01 2 2 054 8 /7/ 20 12 2 118 37 23 0 CO NJ UN CT IV ITIS N OS BIL ,PI NK EY E M EDI ‐CA L 4 57 3/ 6/2 01 3 1 727 3 /6/ 20 13 2 150 95 90 1 #N /A HE AD IN JU RY UN SP EC IFI ED FEL L D O WN H I H EA D 1 50 0 O N CO NR ET E D IZZ Y M EDI CA RE 4 57 6 /2 2/2 01 3 1 646 6/ 24/ 20 13 1 415 43 81 3 #N /A LA TE EFF C VD ‐DY SA RT HR IA STR O KE M EDI CA RE 5 2 5 /1 9/2 01 3 2 158 5/ 19/ 20 13 2 237 3 82 9 OT ITI S M ED IA NO S EA R P AI N SE LF PA Y 6 37 11 /2 8/2 01 2 429 1 1/2 9/ 20 12 1 004 2 98 9 #N /A PS YC HO SIS N OS CO NF US ED M EDI CA RE 6 37 3/ 1/2 01 3 117 3 /1/ 20 13 1 846 7 80 1 #N /A HA LL UC INA TI ON S AL OC M EDI CA RE 7 67 6 /1 3/2 01 3 1 601 6/ 13/ 20 13 1 933 5 99 0 UR IN TR AC T I NF ECT IO N NO S ME D REF ILL M EDI CA RE 7 67 7 /1 3/2 01 2 1 352 7/ 13/ 20 12 1 621 5 99 0 UR IN TR AC T I NF ECT IO N NO S UT I M EDI CA RE 8 17 9/ 7/2 01 2 2 125 9 /8/ 20 12 130 8 40 9 SP RA IN SH OU LD ER /AR M NO S RIG HT SH O UL DER P AIN P LA YIN G FO OT BA LL SE LF PA Y 9 78 3 /1 7/2 01 3 111 3/ 17/ 20 13 308 55 09 0 #N /A UN ILA T ING U INA L H ER N IA HE RN IA PA IN M EDI CA RE 10 66 4 /2 8/2 01 3 827 4/ 28/ 20 13 1 232 78 90 0 AB DO M INA L PA IN, UN SP EC IF STO M AC H PA IN V OM IT ING M EDI CA RE 11 32 4/ 7/2 01 3 1 348 4 /7/ 20 13 1 453 9 23 3 CO NT US IO N O F FIN GE R INJ UR ED H AN D F IN GE R SE LF PA Y 12 84 5 /2 5/2 01 3 208 5/ 25/ 20 13 539 85 20 1 #N /A SU BA RA CH NO ID HE M ‐N O C OM A SU BD UR AL AN D SU BA RA CH OID S /P FA LL M EDI CA RE 13 94 2/ 1/2 01 3 459 2 /4/ 20 13 1 628 78 00 9 #N /A AL TER AT IO N/ CO NS CI OU SN ES S DE LIR IUM M EDI CA RE 14 92 1 2/ 2/2 01 2 1 929 12 /6/ 20 12 1 603 8 05 4 #N /A FX LU MB AR V ER TEB RA ‐C LO SE LO W BA CK PA IN , L2 FR AC TU RE , D EM EN TI A, SE LF PA Y 15 68 8 /2 0/2 01 2 1 050 8/ 20/ 20 12 1 607 V 681 #N /A ISS UE RE PE AT PR ES CR IPT NO SE BL EE D/N EE DS R EFI LL M EDI CA RE 15 68 8 /2 6/2 01 2 1 029 8/ 26/ 20 12 1 412 79 09 2 #N /A AB NO RM A L C OA G PR OF ILE BR US ING B LEE DI NG AR O UN G I NJ ECT IO N AR EA M EDI CA RE 15 68 9/ 6/2 01 2 858 9 /6/ 20 12 1 147 59 97 0 HE MA TU RI A N O S NO DE BL EE DS X2 W KS M EDI CA RE 16 37 1 1/ 7/2 01 2 943 11 /7/ 20 12 1 054 61 17 1 #N /A MA ST OD YN IA R S ID E B RE AST P AIN SE LF PA Y 17 81 1 0/ 5/2 01 2 807 10 /5/ 20 12 830 84 5 #N /A CL OS TRI DI UM DI FF ICI LE TO OT H P AI N DI AR RH EA M EDI CA RE 17 81 1 0/ 9/2 01 2 809 10 /9/ 20 12 1 316 78 90 6 AB DO M INA L PA IN EPI GA ST RI EP IGA ST RIC P AIN , D IA RR EA H M EDI CA RE 18 93 4/ 6/2 01 3 1 355 4 /6/ 20 13 1 641 79 09 2 #N /A AB NO RM A L C OA G PR OF ILE RE CH ECK M EDI CA RE 18 93 8/ 3/2 01 2 1 752 8 /3/ 20 12 2 332 7 80 4 DI ZZI NE SS AN D G ID DI NE SS DIZ ZY M EDI CA RE 19 3 1 /2 7/2 01 3 1 908 1/ 27/ 20 13 2 201 78 06 0 FE VE R N OS FEV ER C OU GH X1 DA Y SE LF PA Y 19 3 10 /1 0/2 01 2 2 007 1 0/1 0/ 20 12 2 022 4 65 9 AC UT E U RI NO S FEV ER SE LF PA Y 20 31 8 /1 5/2 01 2 2 119 8/ 15/ 20 12 2 327 78 65 2 PA IN FU L R ESP IR AT ION HE AR T P AL PIT AT IO NS SE LF PA Y 20 31 8 /1 6/2 01 2 1 622 8/ 16/ 20 12 1 813 78 65 0 #N /A CH ES T P AIN N OS INF EC TIO N IN LU NG S, CP SE LF PA Y 21 18 1/ 3/2 01 3 1 411 1 /3/ 20 13 1 627 6 82 6 CE LLU LIT IS OF LE G PA IN SE LF PA Y 22 2 4 /3 0/2 01 3 1 542 4/ 30/ 20 13 1 612 3 82 9 OT ITI S M ED IA NO S EA RA CH E F EV ER M EDI ‐CA L 22 2 5 /1 2/2 01 3 2 232 5/ 12/ 20 13 2 346 37 20 0 AC UT E C ON JU NC TI VIT IS NO S FEV ER S OR E T HR OA T M EDI ‐CA L 23 53 7/ 7/2 01 2 510 7 /7/ 20 12 1 357 78 65 0 #N /A CH ES T P AIN N OS CH ES T P AIN SE LF PA Y 24 82 9/ 6/2 01 2 1 239 9 /6/ 20 12 1 411 9 22 1 #N /A CO NT US IO N O F CH EST W AL L MV A/ BA CK PA IN M EDI CA RE 25 1 1 /2 0/2 01 3 1 159 1/ 20/ 20 13 1 401 4 65 9 AC UT E U RI NO S FEV ER C OU GH SE LF PA Y 26 27 4/ 7/2 01 3 1 715 4 /7/ 20 13 1 745 78 90 6 AB DO M INA L PA IN EPI GA ST RI PH YS C M EN TA L I SS UES SE LF PA Y 27 30 3/ 3/2 01 3 1 130 3 /3/ 20 13 1 539 78 90 0 AB DO M INA L PA IN, UN SP EC IF AB D P AI N M EDI ‐CA L 28 88 4 /1 9/2 01 3 1 022 4/ 19/ 20 13 1 423 4 35 9 #N /A TR AN S C ER EB ISC H EM IA NO S SLU RR ED S PEE CH M EDI CA RE 29 30 1 /2 6/2 01 3 1 113 1/ 26/ 20 13 1 600 78 90 3 #N /A AB DO M INA L PA IN RT LW Q UA RLQ P AI N SE LF PA Y 30 81 3 /1 7/2 01 3 1 319 3/ 19/ 20 13 2 145 4 35 9 #N /A TR AN S C ER EB ISC H EM IA NO S L U PP ER EX TE RM ITY W EA KN ES S M EDI CA RE 30 81 9/ 4/2 01 2 1 249 9 /9/ 20 12 1 030 41 07 1 #N /A SU BE ND O AM I/1 ST EP ISO D E GA ST RO IN TE STI NA L B LE ED WI TH CH ES T P AI N M EDI CA RE 31 20 7/ 6/2 01 2 1 659 7 /6/ 20 12 2 040 53 08 1 ES OP HA GE AL RE FLU X AB DO M INA L P AI N SE LF PA Y 32 1 9 /2 0/2 01 2 2 041 9/ 20/ 20 12 2 116 77 98 9 PE RIN AT AL CO N DIT IO N NE C CIR CU M CIS ED 6 D A YS AG O, DO ES NT LO OK RI GH T SE LF PA Y 33 38 4 /1 2/2 01 3 1 003 4/ 12/ 20 13 1 038 7 10 0 #N /A SY ST LUP U S E RYT HE M AT OS IS LU PU S F LA RE SE LF PA Y 33 38 5 /2 0/2 01 3 1 335 5/ 20/ 20 13 1 621 71 94 6 JO INT P AIN ‐L /LE G L K NE E P AI N SLI PP ED OF F S TE P SE LF PA Y 34 24 6/ 5/2 01 3 2 216 6 /6/ 20 13 106 7 29 1 MY AL GI A A ND M YO SI TIS NO S WE AK NE SS CH IL LS NA US EA VO M ITI NG DI AR RH EA SE LF PA Y 35 49 12 /2 8/2 01 2 2 007 1 2/2 8/ 20 12 2 132 53 9 HE RP ES ZO ST ER NO S BA CK PA IN W ITH R ASH M EDI CA RE 36 44 2 /2 2/2 01 3 929 2/ 22/ 20 13 1 238 V 872 #N /A HA ZA RD CH EM C ON TA CT N EC CH EM IC AL EX PO SU RE SE LF PA Y 37 1 1 /2 5/2 01 3 1 538 1/ 25/ 20 13 1 920 78 06 0 FE VE R N OS FEV ER S ICK SE LF PA Y 37 1 12 /1 1/2 01 2 2 248 1 2/1 1/ 20 12 2 341 5 53 1 #N /A UM BI LIC AL HE RN IA BE LLY BU TT ON N OT HE AL ED SE LF PA Y 38 62 5 /3 0/2 01 3 1 656 5/ 30/ 20 13 1 905 71 94 6 JO INT P AIN ‐L /LE G KN EE PA IN RI GH T M EDI ‐CA L 39 21 10 /1 0/2 01 2 1 023 1 0/1 0/ 20 12 1 152 78 90 6 AB DO M INA L PA IN EPI GA ST RI STO M AC H IS H UR TI NG SE LF PA Y 40 10 3 /1 5/2 01 3 1 617 3/ 15/ 20 13 2 001 78 65 0 #N /A CH ES T P AIN N OS CH ES T H UR TS VO M ITIN G BI T O F P AI N SE LF PA Y 41 61 2 /1 0/2 01 3 521 2/ 11/ 20 13 1 330 5 95 0 AC UT E C YS TIT IS LET HA RG Y REC EN T STE M I D M2 HY PO TH YR OI DIS M SE LF PA Y 42 53 9 /3 0/2 01 2 1 329 9/ 30/ 20 12 1 852 25 00 0 DM 2/ NO S UN CO M P N SU BLO O D S UG AR H IGH M EDI CA RE

Bringing the Partners Together

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Represents groundbreaking collaboration for Sacramento region

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About Sacramento Covered

Sacramento Covered is a community based non‐profit organization getting people covered and connected to health

care services throughout the Sacramento region.

Organizational History

• Founded in 1998 as a collaborative initiative between four local health systems

• Program was launched to expand local participation in Medicaid and SCHIP, among children and pregnant women

• Cover the Kids reached over 50,000 children with coverage and access to care

• In 2012, expands to serve adults and is re‐branded as Sacramento Covered

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Comprehensive Services

• Outreach

• Education

• Enrollment

• Utilization

• Retention

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Program Overview

• New ED Patient Navigator Program builds on successful pilot demonstration

• Includes 6 navigators

• Purpose is to assist underserved patients who admit to the EDs for primary care in connecting/reconnecting with PCPs, community clinics, and other social support services

• Goals are to:

1. Ensure patients can access appropriate primary care

2. Decrease dependence on EDs for primary care

3. Reduce uncompensated care expense

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Information Technology Integration

• MS4 ‐ Electronic Health Records (EHR) used by Patient Registration in the Emergency Department to capture demographics of patients utilizing the ED.

• Cerner – EHR used by ED clinical staff to capture medical activities that occur in the hospital. The system houses all hospital medical records

• MobileMD ‐ Health Information Exchange (HIE) system used to communicate with providers outside of the hospital. It is a secure web‐based system that allows for sharing of medical records that meet HIPAA standards.

• Health Plan Provider Portals – Access to obtain information regarding with whom patient is assigned to for primary care

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Identification of Target Population

• Focuses on Medi‐Cal insured and uninsured as target population

• Majority of patients are identified by Patient Registration prior to discharge and directed to navigators

– All patients sign a consent form prior to receiving assistance

– During registration, uninsured and underinsured patients are asked if they need assistance with establishing a Primary Care Provider or reconnecting with their assigned if Medi‐Cal‐insured managed Medi‐Cal.

• Answering yes triggers Patient Registration to connect patient with navigator

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Patient Navigators:

• Establishes immediate rapport with patients in ER

• Provides follow up to ensure that patients connect to primary care physician

• Build collaborative relationships with clinics contacts

• Support patients in mitigating access barriers (i.e. transportation, health coverage, language)

Role of the Patient Navigator

Case Model

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Program Services

• Navigators provide direct patient assistance, which includes:

– Determining patient’s assigned Medi‐Cal PCP

– Making timely follow up appointments with PCP

– Helping uninsured get established at a community clinic

– Connecting patients to additional community resources

– Educating patients on current health plan coverage

– Enrolling patients in Dignity Health’s no‐cost chronic disease programs

• Navigators conduct reminder calls prior to scheduled appointments

• Transportation is arranged on a case by case if needed

– Navigators schedule taxi pickups for patients

• Navigators follow up after appointment to confirm attendance and ensure patient is pleased with their care.

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From left to right: Adriana Sandoval, Eva De La Cruz, Gabriela Fredrickson, Silvia Dominguez, Joseph Garcia

• Experienced with with target populations• Come to us from community‐based nonprofits, clinics and health plans• Culturally competent/ bilingual• Tenacious and patient

Meet our Navigators

Management Oversight

• Management and analysis of all data elements

• Organize quarterly meetings with all partners at management level

• Develop audit process of systems utilized by PN’s to meet Dignity Health compliance requirements

• Ensure all new employee hospital requirements are met for all PN’s

• Develop orientation for PN’s that encompasses all partner organizations

• Facilitate hospital core team meetings quarterly

• Constant internal communication with hospital senior leadership

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Program Data

• Emergency Department utilization analyzed bi‐annually using data compiled through Patient Registration System

o Provides ability to track large trends

o Navigators are able to see high utilizers through MS4 and are tailoring their conversations accordingly

• Through MobileMD, able to track readmission rates for all patients assisted by navigator at all 4 hospitals

o Data analyzed quarterly

o Navigators notified of patients readmitting , allowing them to provide additional follow‐up services as needed

• Navigators have limited access in EHR system, allowing them to document when follow‐up appointments are scheduled

• All data is shared with hospitals

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Quantitative Program Outcomes

• Persons Served (8/6/2013‐4/30/2014) ‐ 2999

• 2371 Appointments scheduled with Primary Care Providers

– 79% of patients have a follow up appointment scheduled

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Insurance Type Count of Patients % of Total Appts Scheduled

Blank 9 0.3% 2

Blue Cross GMCP 219 7.3% 156

CMISP 11 0.4% 3

Emergency Medi‐Cal 79 2.6% 72

Health Net GMCP 402 13.4% 270

Medi‐Cal 437 14.6% 373

Medi‐Cal Share of Cost 19 0.6% 14

Molina GMCP 120 4.0% 94

Molina LIHP 50 1.7% 39

Other 63 2.1% 36

Pending Financial Assistance 1147 38.3% 935

Self‐Pay 443 14.8% 377

Grand Total 2999 100.0% 2371

Quantitative Program Outcomes

• Appointment Show Rate

– 62% (669/1075) of all patients contacted attended their appointments and 10% (112/1075) rescheduled.

– Identify challenges with show rate for target population

• Readmissions

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Sacramento Service Area

Hospital # of Unique Patients

(FY12‐13)

Patient Navigation # of

Unique Patients (YTD:

8/6/13‐4/30/14)

ED Visits for Primary Care 76,700 2,999

≥2 ED Vists for Primary Care 45,938 497

Readmission Rate for Primary Care 60% 17%

Qualitative Program Outcomes

• True collaboration established with sharing of data and engagement from all partners

• Establishment and/or strengthening of relationships with local Community Health Centers

• Ability to articulate barrier trends experienced by patients

• Development of collaborative meetings between health plans, hospitals, and Individual Provider Associations (IPA’s)

• Continuous feedback loop to improve program

• Hospital staff engagement

– Ongoing education and communication of program outcomes

– Quarterly meetings with hospital core team

– Support from all hospital senior level management

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Challenges During Implementation

• Sharing of information through multiple systems

– Working with health system IT to provision navigators

• Engaging hospitals

• Establishing reporting mechanisms and appropriate data elements to capture desired outcomes

• Orientation and training of patient navigators

• Challenges with non‐clinical contract employees being placed inside ED

– Available space in Emergency Departments

• Ensuring target population is being served

• Accessibility of patients to obtain information following services

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What’s Next

• Working with IT to implement a Population Health Management System

– Moving from spreadsheets to management of data through one system

• Replication of program across other Dignity Health Hospitals

• Creating awareness within county level and across managed care health plans

• Establishment of goals and expectations for Navigators

– Development of priorities

– Analyze case loads

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“…Patient Navigator Silvia Dominguez was very kind, helpful and professional. Since I am unemployed and without insurance, she offered all kinds of information and resources for help.”

“ …We had spent two weeks attempting to locate a doctor in this area (with no success). After approximately 30 minutes, she had accommodated all our needs for our 3 year old to our 30 year old. I cannot express the relief and assurance I felt after leaving her office. She was polite, concerned and very authentic in her line of work. It felt as if she was providing services for her own family…”

“…Mr. Garcia is awesome with the work he does to help any patient who needs his guidance. Mr. Garcia is always found to very respectful, caring and understanding, always the professional, always ready to help. In fact, our family could have not asked for more from Mr. Garcia, and he left our family with us feeling a greater sense of ease, and that is something that we needed very much!...”

Patient Feedback

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Thank YouContact Information:

• Rosemary YountsDignity Health Community Benefit [email protected](916) 851‐2731

• Ashley Brand

Dignity Health Community Benefit Manager

[email protected]

(916) 851‐2005

• Kelly Bennett‐Wofford

Sacramento Covered Executive Director

[email protected]

(916) 414‐8336

b4-creating an integrated patient navigation model

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