Focus On Research July 2013

Focus on Research:

Decreasing Utilization & Improving Health via REaCH

Christina Milano, MD
Christina Milano, MD
 Erin Kirk
Erin Kirk

By Christina Milano, MD, and Erin Kirk, Clinic Quality Control MAnager, Family Medicine at Richmond

The REaCH (Richmond Engagement and Community Health) Team at Family Medicine at Richmond is a multi-disciplinary group that is attempting to reduce repeat hospitalization and emergency department use among high-cost, high-acuity adult Medicaid patients. Our innovation is one of five community-wide activities being funded by the Health Commons grant, a $17.3 million grant awarded by CMS to the community partners who have formed the new coordinated care organization, Health Share of Oregon (HSO). The 5 community-wide activities being funded by the grant include: 

  • Outreach: Helping patients overcome barriers to health.
  • Hospital-to-Home: Improving Transitions to outpatient care
  • Mental Health: Connecting patients to community resources
  • ED Navigators: Providing patients with pathways to the right care
  • Discharge: Standardizing hospital discharge practices

The REaCH Team is a cohort of the Outreach arm of the project. Our fundamental goal is to reduce the total cost of care and/or hospital and ED utilization for a subpopulation of HSO members who have experienced recent high “potentially avoidable” utilization while improving their experience of care and indicators of health. We have a targeted reduction of -9.2% in total cost of care over the three years of this intervention. Our team consists of two nontraditional outreach workers, a social worker, a care coordinator, a pharmacist tech, a pharmacist and a physician lead. We huddle daily and weekly to review current inpatient censuses throughout the Portland metro area, identifying new candidates for referral to the program, updating one another on the progress of currently engaged patients and brainstorming novel approaches for meeting our goals. Our care coordinator also provides daily discharge coordination to all of our Richmond patients currently admitted to OHSU.

When REaCH Team members become “engaged” with a patient who is currently or historically demonstrating patterns of high utilization (adults who have had at least 6 or more ED visits or one non-obstetric inpatient hospital admission in a year), they pursue the following REaCH objectives: 

  • Engage and mentor targeted members toward an optimal relationship with a primary health home.
  • Facilitate the connection between targeted members and beneficial community resources.
  • Educate and coach targeted members to improve health literacy, condition-specific self-management skills, and activation in wellness.
  • Coordinate services and communication between various providers of services with or on behalf of members.

Concrete interventions have included attendance at specialty and PCP appointments; pharmacy home visits for medication reconciliation and reduction; pharmacy-instigated opportunities for enhanced continuity; security of housing, food and social services; facilitated enrollment in inpatient detox programs; lunch visits and walks in the Japanese Garden; coordination of peer-wellness relationships; remote support via text messaging and a myriad of other “non-traditional touches” that are not typical of healthcare.

We are early in the innovation, and pleased to report that preliminary review of utilization data for Richmond clinic HSO members engaged with our outreach workers for greater than 3 months looks promising. A few key early “pilot” cases have been particularly compelling, including the experience of a Richmond patient profiled by Oregon Public Broadcasting in the this article.

Looking toward the future, we are partnering with HSO to determine what process measures will best demonstrate our progress, and seek to optimize integration of our work with the two other Health Commons Grant funded teams at OHSU: C-Train in the inpatient setting and New Direction in the Emergency Department.