Care Neighborhood is CHCN’s intensive case management program that helps high-risk, high needs patients connect to local community resources and prevent unnecessary hospitalizations by focusing on addressing the social determinants of health.
How Do We Do It?
CHCN’s data-driven approach combined with our clinical expertise allows us to identify the patients who are most at-risk of hospitalizations. Using claims information, we detect early on which patients have the highest likelihood of hospitalizations in the upcoming year, and are most likely to benefit from Care Neighborhood. CHCN assigns Community Health Workers at our health centers to reach out to and link with patients at their clinic visits, their homes, in the hospital—wherever the patient would like to meet. Patients and their Community Health Workers generate plans focused on care goals.
CHCN’s Care Neighborhood social workers and nurse provide added support to our health centers so that patients get the right care at the right time.
CHCN’s Care Neighborhood approach has demonstrated positive returns on investments including: decreased hospital re-admission rates, improved use of integrated behavioral health, decreased ER use, improved Hgb A1c and more. With support from our health plan partners, we had 12 Community Health Workers in our 8 health centers by the end of 2017, building our capacity to support more than 800 medically complex patients annually. Care Neighborhood successfully continued to demonstrate total cost of care savings per member per month and received additional support from our health plan partners in 2018 to grow gradually from 12 to 20 Community Health Workers.
Care Neighborhood Technology
Care Neighborhood uses a cloud-based tool called Welkin as the program’s case management platform. Data is pulled from the health center electronic records, claims, and real time inpatient authorization and RN notes and presented to the Community Health Workers in Welkin. On the case management platform, Community Health Workers can review patient’s records and document their notes, care plan goals and assessments and track their progress with patients in Care Neighborhood. Lastly, Care Neighborhood uses Tableau, a data visualization program, to present Care Neighborhood progress. Tableau pulls data from Welkin and demonstrates the growth of Care Neighborhood over time, and progress with the Care Neighborhood eligible population on an individual CHW level and on the larger programmatic level.
Care Transitions When Patients Are Hospitalized
CHCN’s work does not end with our health centers’ four walls. When our patients are hospitalized, hospitals alert CHCN’s nurses who authorize hospital stays. Because CHCN is notified of the admission much earlier than the health center primary care physicians, we are able to proactively coordinate with hospitals to ensure smooth discharge planning for our patients. CHCN helps patients to connect with the appropriate resources when they leave the hospital. CHCN nurses are linked with nurses on-site at our health centers, further ensuring smooth follow up to get patients back into Primary Care.