Universal encounters represent face-to-face visits and some highly intensive telephonic interactions. It is important to track these encounters as they reflect the amount of work and degree of complexity required to serve the OAHR client population. OAHR serves medically fragile clients with multiple medical and psychosocial co-morbidities. Our clients are generally referred to us because they have very high needs that are outside of the scope of conventional medical case management. Our clients are often psychosocially unstable upon intake. Our work with them requires a high degree of “touch” with frequent contact, follow-up, linkage, coordination, and healthcare provider communication from the outset. As our work proceeds and we are able to strengthen support structures, ideally our clients’ conditions stabilize and the intensity of “touch” can be reduced. However, it is not possible to predict how many encounters will be necessary in order to achieve this type of stabilization. Numbers of encounters may fluctuate depending on multiple caseload factors such as longevity/duration, available healthcare and community resources, medical decompensation, client engagement, etc. OAHR tracks this number as a reflection of work volume and productivity.  This quarter, the increase in number of universal encounters reflects the gradual expansion of our caseloads, leading to an increase in the number of face-to-face encounters.

Clients, caregivers, healthcare providers, community-based organizations, behavioral health clinicians, APS, etc.

To serve the OAHR client population of medically fragile older adults it is essential that our nurses customize the intensity and frequency of “touch” to address each client’s unique and specific needs rather than setting any hypothetical benchmarks. Each client requires a different number of visits according to the nurse’s assessment and the client’s/caregiver’s ability to engage and participate in efforts to build improved systems of support.

Continue to track the number of universal encounters generated in order to understand and reflect the effort and time required to serve the needs of this complex population. Tracking encounters as a reflection of effort, workload, and productivity may become more challenging because we anticipate having to reduce face-to-face encounters with high risk clients when COVID-19 community transmission is high. Additionally, with the end of the official State of Emergency in February, our ability to generate universal encounters through telehealth visits will be limited.  Moving forward we will look at ways to provide effective service even more creatively in order to ensure that we are serving the needs of clients who struggle with telephone communication while prioritizing their health and safety.