Case Management and HomeBASE Plus:

Point Person: Amy Royals, MSW, LCSW, CCM

The Duke Outpatient Clinic has gone through several iterations of planning and developing an intensive case management program for our highest need patients. Now called “HomeBASE Plus”, (previously known as homeBASE and HIDOC), the program is a collaboration between nurse case managers, nurse practitioners, social workers, and physicians. The program has successfully redirected care out of the emergency departments and back to the clinic for numerous patients.

HomeBASE Plus reduces ED utilization and admissions via better connection to coordinated primary and specialty care, with a focus on better health coping in our patients. We also created new capacity to care for these patients acutely on-site at DOC.

• Eligibility criteria for HB+: patient has made 6 or more Emergency Department visits in a 3-month period, with some ongoing use of the ED OR 6 or more Emergency Department visits in the last year with 3 leading to hospital admissions
• Primary contacts: Valerie Keck NP is the primary clinical lead for the HB+ program with support from Gregory Brown, MD (MedPsych Attending), Amy Royals is the Ambulatory Case Manager, and Jan Dillard & Elissa Nikolopoulos are the clinical social workers
• How to Refer: send the patient’s name, MRN, and short blurb about your concerns to Elissa Nikolopoulos, Amy Royals, or Jan Dillard via email or In basket and the patient will be discussed in the Monday Big Pool Meeting to determine next steps.

The Duke Outpatient Clinic has gone through several iterations of planning and developing an intensive case management program for our highest need patients. Now called “HomeBASE Plus”, (previously known as homeBASE and HIDOC), the program is a collaboration between nurse care managers, nurse practitioners, social workers, and physicians. The program has successfully redirected care out of the emergency departments and back to the clinic for numerous patients.

Big Pool Meeting: DOC’s main avenue to refer patients for complex case mgmt.

• At Big Pool, led by Elissa Nikolopoulos, patients are discussed in a multidisciplinary one-hour weekly meeting.
• This population level approach still has a granular, patient-specific methodology that allows identification of diverse treatment recommendations for multiple patients within an hour-long weekly meeting
• Patients are identified by high-risk pools but anyone can refer a patient to be reviewed
• How to Refer: send the patient’s name, MRN, and short blurb about your concerns to Elissa Nikolopoulos, Amy Royals, or Jan Dillard via email or In basket

Other Care Management options:

Duke Connected Care and DukeWELL:

• Duke Connected Care (DCC) is an accountable care organization (ACO) operated by the Duke Population Health Management Office (PHMO) that manages population health for patients with no insurance and those with traditional Medicare, a number of Medicare Advantage plans, some commercial insurance plans, Duke Select/Duke Basic and Medicaid. DukeWELL is a free care management program that assists in providing DCC’s care management https://dukewell.org/who-we-serve
• Eligibility: Look for the “DukeWELL: Y” notation in the patient’s chart. This is located in the left hand side banner in the
• How to Refer: in the orders field, place an “ambulatory referral to Duke Well”. DukeWELL or DCC may also proactively identify a patient and contact you for input on potential opportunities to improve
• Services include:
  • Free RN and Pharmacy Tech home visits (limited to DCC Medicare patients)
  • Care coordination
  • Patient outreach and engagement
  • Appointment reminders and coordination
  • Transportation assistance
  • Medication access assistance
  • Skilled nursing facility transition coordination
  • Coordination with Duke Home Health and Hospice
  • Quality measure gap closure (may include outreach to patient and/or provider)
  • Telephonic RN disease management education and coaching
  • Virtual specialist and clinical pharmacist rounds (geriatrics, CKD, Cardiology, Palliative Medicine, and DM)