Program Overview

The MAX series is an independent program offered by Care Compass Network and facilitated by qualified MAXny facilitators as part of the DSRIP program. The Lourdes MAX program addressed high utilizers by having a multi-disciplinary team to meet and create focused plans and goals. The team created a high utilizer Care Pathway where they created a list of high utilizers and assessed their needs. Then a case manager or social worker would link them to services that may address their needs outside of the inpatient clinic. The high utilizers are followed up with and monitored over time. The social worker and case manager were placed in the clinic since many of these high utilizers needed access to palliative or community services. The top 3 drivers of utilization were fear/feeling overwhelmed, self-efficacy confidence, and lack of family/ caregiver or community.

Program Goals

The goals of the program were to reduce high utilizer inpatient admissions by 35% when compared 90-days pre vs. post hospital utilization and to establish partnerships to integrate services across the care continuum.

Learnings

Care Managers and Social Workers are needed that can identify and link high utilizers with community and palliative services, and following up with high utilizers is a good way to ensure they are still accessing services.

Collaborating across departments and with partners outside of the Lourdes Hospital system made it easier for the patient and for the social worker to connect them to services.

Organization and Structure: The team had workshops to determine what was and was not working to best address high utilization of hospital services. The group created diagrams such as the high utilizer care pathway to map out what needed to be addressed.

The team generated daily lists of admitted patients who met the high utilizer criteria in order to conduct targeted interventions and wrap around the patient, assessing the drivers of utilization (root cause of frequent hospital use, often non-clinical in nature) and connecting them with the appropriate resources to address the drive of utilization rather than the presenting symptoms leading to their admission in the hospital.

Download the Lourdes Inpatient MAX Series Shared Learnings to see the program results.