BACKGROUND:University of Texas Medical Branch, a major academic medical center, with four hospitals with four emergency departments, currently serving as anchor for a Medicaid 1115 and receiving funds for medicaid eligible-, which will end in 2021 wants to develop a system wide care delivery model based on the Medicaid Health Home across their health system to combat ED over user in the Medicaid population. The university has multiple primary care clinics, an integrated electronic medical record system, and a robust community health program ,with doctors, social workers, case managers, and community health workers, that could provide a team based approach and follow the patients identified, Medicaid or Medicaid eligible patients with 4 or more ED visits in a calendar year, or 2 or more in a quarter, for an ED super user health home program to provide and coordinate the care delivery model of the Medicaid Health Home, which has been shown effective in lowering cost and reducing ED use in Medicaid patients , as well as improving patient outcomes
Instructions- use the lessons learned from the Iowa Qualitative Medicaid Health Home Study to Develop a Plan for Change using Kotter’s 8 steps for University of Texas Medical Branch to implement a care delivery model utilizing their community health department, that has nurses, doctors, social workers, and community health workers than manage and provide a team based care deliver approach, based on the 6 essential elements of the Medicaid health home, for Medicaid ED super users with 4 or more visits in a year, or 3 or more in quarter, identified across the University of Texas Medical Branch, to provide an evidenced based cost effective approach to improve outcomes for Medicaid eligible and Medicaid ED super users
Please include graphics (kotter’s 8 steps, any relevant charts, grids)
