Complex Care

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Complex Care

Care Neighborhood

CHCN’s intensive case management program helps high-risk, high needs patients prevent unnecessary hospitalizations by focusing on addressing the social determinants of health.

How Do We Do It?

Care Neighborhood Care Plan

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.

Care Neighborhood Care PlanCHCN’s social worker and nurses provide added support to our health centers so that patients get the right care at the right time.

Delivering Results

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. Support from our health plan partners means that we will have 12 Community Health Workers in our 8 health centers by June of 2016, building our capacity to support more than 800 medically complex patients annually.

CHCN is partnering with Welkin Health to develop a platform to enable better care for our most vulnerable patients. Health 2.0 and Technology for Healthy Communities – with support of the Robert Wood Johnson Foundation – has awarded a grant to allow CHCN and Welkin Health to create a complex case management digital tool to improve health outcomes for underserved populations. Read more

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.