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Sonoma Care Collaborative Patient Recruitment Algorithm
First Steps
March 23, 2016
Recruitment: Algorithm Overview• Primary Care Provider Buy‐In & Roll‐Out• Marketing Plan• Sonoma County Adult & Aging Services• Data and PCP entry points• Clinic Care Manager (CCM)
Assessment• Inclusion/exclusion• Referral to services
• Home Visiting Care Manager (HVCM)‐Action Assessment
• Motivational Interviewing• Referral to services
• Psychiatry• MDT
Participants review the case and trajectory Treatment planning Referral to services
• Relapse prevention
Decrease Depression
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Roll‐Out
• PHC establishes a Collaborative Care Model of Elder Depression Care PHC hired Social Worker Case Manager (CCM) Psychiatric Consultant appointed Physician Champion selected MDT and program management team established
• Sonoma County Adult and Aging (SCAA) SCAA hired Home Visiting Care Manager (HVCM)Weekly PHC/SCAA admin/innovation meetings occurred
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Primary Care Provider Buy‐In
• Primary Care Provider Training Roll out of program at Primary Care All‐Provider meeting Description of empirical evidence, goals, referral process and work flow Provider panels reviewed‐inclusion/exclusion/depression in general Patients who might have depression and meet criteria were flagged
• Referral Process Developed Referral process established through eCW
• Care Managers and Operations attend on an ongoing basis Team meetings QI meetings Operations Meetings Team Huddles
• Warm hand offs and scheduled Consults referred by PCPs
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Marketing Plan
• Developed Flow/Recruitment Algorithm chart to share with PHC’s collaborative team Communications plan regarding patient’s care How patients will be engaged in care if there are multiple points of entry How and when family members will be engaged
• Developed “Post Card” summarizing the Sonoma Care Collaborative program• Literature available on each team and at the front desk
• Press Releases: Sonoma County Gazette Radio Spot Univision TV spot Plan May “mental health month” video for our website
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Sonoma County Adult & Aging Services• The Human Services Department Adult and Aging Services Division provides assessment and support in‐home, coordinated with treatment in primary care to older adults with depressive symptoms.
• Utilizing the evidence based Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors) intervention strategy, PHC patients receive support and greater access to care through in‐home services and referral to community resources.
• Sonoma County has provided leadership and program management to facilitate a social worker (HVCM) and supervisor to be embedded in the PHC clinical teams and MDT, leading to innovation, improved care and better outcomes.
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Sonoma Care CollaborativeElder Depression Care Team: Treatment Algorithm
ACO/EHR Data
CCM or Operations schedules
appointment with PCPFlagged for warm
hand off
PCP will contact CCM for warm hand off
If CCM is not available a referral will be made through
eCW
CCM schedules patient appointment
Patient does not meet criteria:• PCP notified via TE• Referred to other Services
Available Services:• Follow up visits with PCP• Psychiatry• Patient Navigator Assistance• Referral to Community
Resources• Psychotherapy• Education regarding
depression management• Behavioral Activation
through Healthy IDEAS
CCM: Clinic Care ManagerHVCM: Home Visiting Care ManagerLCM: Lead Care ManagerTE: Secured messaging
In Out
Primary Care VisitScreening/Introduction
to Program
CCM screens patient using PHQ‐9, GAD‐7, and rules out Dementia/ Bipolar/Psychosis
HVCM & CCM collaborate to develop an initial care plan and LCM identified
Psych Consult/med review occurs with CCM and HVCM
weekly
If program criteria is met, patient signs consent and is enrolled in Elder Depression Care Program. TE is sent
to the PCP informing them the patient will be part of the Elder
Depression Care Program
HVCM is notified of new patient. Home visit is scheduled and assessment completed
• Patient improves• PHQ‐9 < 10 Relapse Prevention
MDT Depression Continues
Regular Patient appointment scheduled with PCP
MDT Participants:Clinic Care ManagerHome Visiting Care ManagerPCP ChampionHVCM Supervisor Director of MH/BH ServicesClinical GeropsychologistMH/BH Team ManagerProject Manager
LCM Coordinates care and tracks progress
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Acronyms
Clinic Care Manager ‐ CCM Home Visiting Care Manager ‐ HVCMLead Care Manager ‐ LCMSecured Messaging ‐TEChief Medical Informatics Officer – CMIOeClinical Works – eCW – Electronic Medical Record
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Actuarial Data Mining and PCP visits for
DepressionOur Data Miner and CMIO created a list of all patients over 65
These were sorted by medical provider panel
Each medical provider reviewed their list and reflected on who might be appropriate for the program
Separately, the original data set was cross referenced with diagnoses of depression
This was not used as the sole method due to the under diagnosis of depression in the elderly
The Clinic Care Manager in a coordinated effort with operations, schedules targeted visits with the PCP to review depression
The visits are scheduled at a time when the CCM can be available for a warm hand off
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Primary Care Visit
In the course of a normal primary care visit…The PCP suspects or diagnoses depression
1. PCP introduces the program to the patient
2. Alerts medical assistant/flow coordinator and MH operations to contact CCM for warm hand off
If CCM is not available then a referral is made and TE sent to CCM to schedule an intake with patient.
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Clinic Care Manager(Vicki)
Meets with Patient
Screens for Exclusion Criteria Bi‐polar Dementia Psychosis
Screens for Inclusion Criteria Depression (PHQ‐9>10)
Notifies the PCP
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Services Include
And others that become apparent as the need arises
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IN/OUT
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Clinical Care Manager determines if the patient meets inclusion criteria
IN
Patient meets criteria: Patient signs consent Is enrolled in Elder Depression Care
Program! TE is sent to the PCP informing them the
patient will be part of the Elder Depression Care Program
Referred to appropriate services
OUT
Patient does not meet criteria: PCP notified via TE Referred to other services
Home Visiting Care Manager (Diane)
Notified of newly enrolled patientHome visit is scheduledIn‐Home assessment is completed including:
Psychosocial assessment Functional assessment Environmental safety Social support Legal financial assessment Initiates Healthy IDEAS Referral to services
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Initial Care Plan
CCM and HVCM (Vicki and Diane)
Meet in person or virtually/telemedicine Discuss patient’s needs Make appropriate referrals Update eCW Update CMTS Send TE to psychiatrist Send TEs to any appropriate
member of the team
Lead Care Manager is identified to coordinate care and track compliance.
Referral to services
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Psych
Psychiatric Consultant Receives TE Reviews chart Makes medication
recommendations Contacts PCP Referral to services
CCM, HVCM and psychiatrist meet weekly as separate MDT
Appropriate actions are taken (see above) Referral to services
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Lead Care ManagerTracks Progress
Reviews chart
Looks at recent encounters
Contacts patient on a regular basis
Sends TEs to any appropriate entity
Tracks PHQ‐9 scores
Tracks inclusion criteria
Tracks overall wellbeing
Refers to services
Preps case for MDT
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Positive Feedback Care Cycle
MDT members Meet weekly Review each patient
Think together about treatment plan Adjust, advance and evolve plan
Refer to servicesLead Care Manager continues to track progressIf depression continues:The patient continues to be tracked and reviewed on a weekly basis to:
Optimize care coordination Treatment planning Access to services
22
MDT Participants:
Clinic Care ManagerHome Visiting Care ManagerPCP ChampionHVCM Supervisor Director of MH/BH ServicesClinical GeropsychologistMH/BH Team Manager‐OperationsProject Manager
23
Access to Services
At every point in the flow of treatment the patient has the opportunity to be referred for services that are assessed to be appropriate by:
Any individual member of the team The MDT
Communication optimizes:
Treatment planning and Referral to services
24
Graduation
When the patient improves: PHQ‐9 < 10 Behavioral observations show
decrease in symptoms
Lead Care Manager identifies patient for Relapse Prevention
MDT reviews Relapse Prevention
Patient is informed and engaged in Relapse Prevention
25
Questions?
Thanks!
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