Page 5 - Christiana Care Focus

Patients with complex needs are often high users of acute health services. This population comprises fewer than 10% of all patients but accounts for more than 20% of all hospital visits.
“This kind of coordinated care for patients with complex medical and non-medical needs benefits everyone,” Dr. Lang said. “By helping them to overcome their barriers to health and more effectively manage their behavioral health and chronic medical conditions, we help them to live the healthy lives they want to live. At the same time, we are helping them to prevent the need for emergency care or hospitalization, which means that we are potentially reducing their
Tcost of care.”
he Center for Hope and Healing team will coordinate all medical, behavioral health and community resources and will connect with
participants regularly for an average of nine months to ensure compliance or to break down additional barriers.
The program is built on a successful pilot funded by the Delaware Health Care Commission. The pilot also indicated improvements among patients in adhering to preventive health measures, such as mammograms and immunizations.
The seven-member Center for Hope and Healing team offers:
• Expeditedappointmentsforpsychiatric care and behavioral therapy.
• Controlofchronicmedicalconditions, wellness physical exams and preventive care.
• Comprehensiveevaluationofsocial determinants of health and interventions leveraging community, state and federal resources.
• Homevisitstoimprovetheunderstand- ing of social determinants of health.
• Flexibilityforhoursandlocationof care — when and where care is needed, including out in the community outside of traditional weekday office hours.
Where they need us
Flexibility will be key, said Dr. Bohner. If a patient struggles with severe anxiety and is not ready to leave his house, Dr. Bohner may send a community health worker to form a relationship with him. Video visits or secure texting will allow them to communicate un- til the patient is ready to travel to the office.
Ifayoungwomanhastotakeabustoan appointment at Wilmington Hospital and arrives 30 minutes late, the team will find a way to see her. If a patient is too sick to come into the office, the center’s nurse might go to the shelter where the patient is staying.
The team also focuses on what the patient wants to accomplish. If a patient wants to get his diabetes under control, but is not yet ready to seek treatment for substance abuse, the team is not going to send him away, said Dr. Bohner.
“We’re certainly going to chat about the substance abuse, but we are going to help
| Cover Story him based on his goals and where he is now,”
she said. “To get someone to a place where he is ready to stop a substance use disorder, I need to first build a trusting relationship.”
Once services are in place to support sustainable health and the patient demonstrates skills to access and manage medical, behavioral and social health needs, the center will transition the patient back to his or her primary care provider.
Amy Marston, MPH, corporate director, Behavioral Health, said the program is designed to make patients feel comfortable and welcome.
“We are their support system and we will meet them where they need us -- in our practice, out in the community, in their car, at their place of worship.”
Treating social health needs matters just as much to us as treating medical needs, said Marston. “This is going to change lives.” 
Left to right: Kristin Achuff, practice manager, Outpatient Behavioral Health; Cassandra Rogers, MSW, LCSW, behavioral health consultant; Jennifer Arriaga, CNMA, senior medical assistant; Naiyma Hawkins, MSN, RN, PCCN, RN, care manager; Diane Bohner, M.D., MS, FACP, clinical lead for Complex Care and medical director for Carelink CareNow Special Populations; Louis Bab, BS, CADC, CCDP, community health worker; Tannisha Hutchinson, LCSW, senior social worker. Not pictured: Amy Marston, corporate director, Behavioral Health.
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