Summit Explores Best Care for Superutilizers

Published on December 7, 2016 by

How do we truly address patient needs? Build a team for support? Identify the right care for the patient in front of us?

Recently, Maine Community Care Teams (CCTs) confronted these questions with national experts at QC’s final Superutilizer Summit in Freeport. Attendees included teams from each of the Community Care Teams, Maine Quality Counts staff, Patient Centered Medical Home teams, Health Home teams and health care leaders from State government.

Community Care Teams recognize that many patients have needs and barriers to care that can reach beyond the capacity of even the most robust primary care physician practice. CCTs are multi-disciplinary, community-based, practice-integrated care management teams that work closely with the Patient Centered Medical Home (PCMH) Pilot practices to provide enhanced services for the most complex, most high-needs patients in the practice.

Lauran Hardin kicked off the day with an innovative presentation called Carrying People.  The Director of Cross Continuum Transformation for the Camden Coalition and the National Center for Complex Health and Social Needs, Lauran described a unique and very effective way to capture and deliver care. It’s built on a model that looks at the medical needs/system/mental health/social needs and uses a quadrant mapping to identify needs, risks and the team. She starts with a ten year chart review!

Local and national experts filled out the day with a wide range of presentations that explored clinical, social and operational factors at play in caring for complex patients. In one of the more revelatory sessions, CCTs submitted in depth case studies to a full panel of experts that offered a 360 degree view of patient needs and service options. There were lots of “ahas” and comments like “I hadn’t thought of that” that we love to hear!

Local presenters included Alison Ashley, LCSW, Beacon Health, Marco Cornelio, MD, Health Access Network, Felicity Homsted, PharmD, BCPS, Penobscot Community Health Center Ellen Randall, CHW, CHES, Androscoggin Home Care & Hospice, and Kathleen Webster RN, PMHNP, PMHCNS, MaineGeneral Health.

The Summit drew to a close with a fast but furious presentation by Lisa Letourneau, QC Executive Director, that offered great sense making and clarification of the upcoming payment reform changes and how practices and systems can navigate through the sea of enormous change. Rhonda Selvin, QC Medical Director, joined Lisa to reminded us to take the time to celebrate the work that has been done so far and add the element of self-care in order to maintain and support it going forward.

And finally, we acknowledged the wonderful work of Helena Peterson whose dedication to supporting, organizing and inspiring Maine’s CCTs has been instrumental in their success.  The Summit was her final support to the CCT initiative and we at Quality Counts owe her a debt of gratitude for her excellent leadership and commitment.

CCT summit 2016

Pictured: Carter Wilson, Camden Coalition, Helena Peterson, Maine Quality Counts, Rhonda Selvin, Maine Quality Counts, Lauran Hardin, Camden Coalition, Kaiya Harris, Camden Coalition, Dr. Steve Martin, Barre Family Health Center, and Dr. Marco Cornelio, Health Access Network.




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