Carol Plotkin, LICSW, Executive Director for the
Collaborative Outreach and Adaptable Care at Hallmark Health (COACHH) program
, presented to the HPC's Quality Improvement and Patient Protection (QIPP) committee on June 22, 2016 to discuss the COACHH program's efforts to intervene on the opioid epidemic at a local level. In CHART Phase 2, Hallmark Health identified three target population cohorts: patients with ten or more ED visits in the last 12 months; ED patients requiring a Narcan reversal; and obstetric patients with a substance use disorder (SUD). Hallmark Health seeks to reduce ED utilization as a primary aim, with secondary aims to increase post-ED contact with patients following an opioid overdose and provide at least one contact per week for obstetric patients with SUD.
In an effort to improve care for COACHH patients, the team - comprised social workers, community health workers, physician consultants, a nurse practitioner, and a pharmacist - endeavors to de-medicalize treatment for its target population, provide longitudinal interventions (versus episodic), and push, rather than pull, support and interventions to patients. Nearly all COACHH services are provided outside of the hospital in the community. Target population patients are contacted within 48 hours of discharge, receive weekly phone calls and/or home visits, and are delivered services that are tailored to individual patient needs.
Early findings reveal that both clinical and social drivers lead to inappropriate hospital utilization, including SUD, serious and persistent mental illness, chronic pain, social isolation, poverty, and poorly coordinated care. Many patients within the target population do not use acute care services solely for medical issues; rather, patients may visit the ED as a means to social engagement or to meet basic needs (e.g., food, shelter, hygiene). Ms. Plotkin referred to the process of understanding and meeting these needs as "thawing treatment freeze;" the COACHH team encourages Hallmark Health clinicians to eliminate preconceived judgements about patients and their courses of treatment to inspire creativity and, in turn, improved support and interventions. Rather than playing "kick the can" with patients with social or medical complexity, the COACHH team takes the necessary ownership of these patients to increase appropriate utilization of services and improve care.
With the help of highly engaged staff and leadership and community support, the COACHH program is making strides to reverse the system failure experienced by these patients and improve the quality and efficiency of care delivered. QIPP committee members and HPC staff were pleased to learn about the important work being done by the COACHH team at Hallmark Health System. Ms. Plotkin's presentation can be found