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WelcomeThe National Cooperative Agreement on
Advancing Team-Based Care
WEBINAR 6: Complex Care Management in Primary Care
May 5th, 2016
Presented by the the Community Health Center, Inc. & the MacColl Center for Health Care
Innovation
SpeakersFrom MacColl Center for Health Care Innovation, Group Health Research Institute:Ed Wagner, MD, MPH, Director Emeritus Brian Austin, Deputy DirectorKatie Coleman, MSPH, Research Associate
From Daughters of Charity Health CentersRobert Post, MD. Chief Medical Officer Roslyn Arnaud, RN, Chief Nursing OfficerGrace Mena, RN, RN Care Manager/QI Coordinator
From Community Health Center, Inc.:Margaret Flinter, APRN, PhD, Senior Vice President & Clinical Director Kerry Bamrick, MBA, Senior Program Manager
LEARNING COLLABORATIVE APPLICATIONS NOW OPEN!
o Participation in the Learning Collaborative is FREE for health centers.
o 9-month intensive learning collaborative provided by CHCI, it’s Weitzman Institute and partners
o Team Based Care or Post-Graduate Residency Program
How to apply?-Visit www.chc1.com/nca -PDF of the application is available on
our website -Applications due May 20th
Learning Objectives:1. Participants will be able to describe the features that
distinguish effective care management programs.
2. Participants will be able to describe ways that expanded care team members can work with core team members to provide seamless, non-fragmented care to patients.
Get the Most Out of Your Zoom Experience• Send your questions using Q&A function in Zoom• Look for our polling questions• Live tweet us at @CHCworkforceNCA and #primarycareteams and
#HRSAnca • Recording and slides are available after the presentation on our
website within one week• CME approved activity; requires survey completion • Upcoming webinars: Register at www.chc1.com/nca
A Team Approach to Complex Care Management
Learning from Effective Ambulatory Practices
MacColl Center for Health Care InnovationGroup Health Research Institute
May 5th , 2016
Ed Wagner, Director Emeritus Katie Coleman, Research Associate | Brian Austin, Deputy Director
The Key Functions Of Excellent Primary Care
What is a “complex” patient?
• American Geriatrics Society--Persons whose conditions require complex continuous care and frequently require services from different practitioners in multiple settings.
• Robert Wood Johnson Foundation--Patients … with multiple chronic conditions, frequent hospitalizations, and limitations on their ability to perform basic daily functions due to physical, mental and psychosocial challenges.
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The challenges of caring for the patient with multiple chronic conditions
• Limited evidence base – complex, older patients excluded from trials, growing
evidence of poorer outcomes when treated according to disease-specific guidelines.
• Added care complexity – multiple guidelines, multiple registries, difficult co-
morbidities such as psychiatric disorders and substance abuse
• Polypharmacy • Multiple physicians and a poor care coordination culture and
mechanisms.
Percent of patients reporting problems in careby number of doctors seen
Base: Adults with any chronic conditionPercent reported any errors in past 2 years*
Data collection: Harris Interactive, Inc.Source: 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.
What do Patients with Chronic Illness Need to Optimize Outcomes
• Drug therapy and medication management that gets them safely to therapeutic goals. MEDICATION MANAGEMENT
• Effective SELF-MANAGEMENT SUPPORT so that they can manage their illness competently.
• Preventive interventions at recommended times. PLANNED CARE/POPULATION MANAGEMENT
• Follow-up tailored to severity, and more intensive management for those at high risk. CARE MANAGEMENT
• Timely, well-coordinated services from medical specialists and other community resources. REFERRAL MANAGEMENT
But, the multi-problem problem patient likely increases the need for:
• Full implementation of the patient-centered medical home.
• Primary care clinicians willing and able to be accountable for their care.
• Greater sharing (interactive communication*) of care planning and care management between primary and specialty care.
• Clinical care management services integrated with primary care
• More assertive and effective care coordination.
* Foy et al. Ann Int Med 2010; 152:247-258
Care for Patients with Complex Health Care Needs
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Care Management
Logistical
Logistical
Logistical Clinical Monitoring
Care Coordination
Clinical Follow-up Care
Medication managementSelf-management Support
©MacColl Institute for Healthcare Innovation, Group Health Research Institute 2011
Clinical Monitoring
ComplexityLow High
Are care manager interventions effective for multi-problem patients?
• Care manager interventions improve outcomes in diabetes, depression, bipolar disorder, CHF, etc.
• TEAMcare study suggests effectiveness across conditions.• But a recent meta-analysis* suggests that only patient
satisfaction is improved across studies—not health or costs.
But interventions are very different!
*Stokes et al. PLoS One. 2015; 10(7): e0132340. Published online 2015 Jul 17.
Care management is a function not a person
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Providing follow up, clinical management, and self-management support to patients outside of clinic visits.
Services and intensity of services vary with the severity of the
illness.
Some aspects provided by a staff
person for lower risk patients and by a
nurse or nurse-led team for high-risk
patients.
Works best when the care manager:
• Is an integral member of the practice team
• Has social work support• Can influence drugs• Has a clinical support
structure.
How do effective practices provide follow-up and care outside the office?
• Core teams, care managers, and referral coordinators regularly monitor patients between visits.
• Follow-up can range in intensity from periodic status checks by telephone or e-mail (MA) to active care management (RN).
• Higher risk patients (poor disease control, frailty, recent hospitalization, etc.) receive regular follow-up (monitoring) AND active care management from RN care manager and/or social work. Referral coordinators and community workers help patients get the services they need, and ensure that providers get desired information.
One LEAP Clinic’s Approach to Hospitalized Patients: Primary Care Assuming Accountability!
• Use risk stratification (Modified LACE* tool) to determine who makes the Hospital F/U call.– HIGH Risk-Call is made by RN, automatic referral to Care
Management, F/U visit with PCP in 2 to 3 days– MODERATE Risk-Call is made by RN or MA Health Coach, automatic
referral to Care Management, F/U visit in clinic within 3 to 5 days– LOW Risk-Call made by MA Health Coach, F/U visit in 7 days. MA
Health Coach makes a “touch base call” in a week after F/U
One LEAP clinic’s answer: The Expanded Team Huddle• One hour once/week• All clinic staff attend: front desk, pharmacy, MA, behavioral
health consultants, etc• Clinician selects & presents patient (chart open on EMR
projected on screen)• Front desk staff, health coach, and MA who live in community
asked what do they know?
What can be done if you don’t have a nurse?
Building a Care Management Capacity
1. Think about care management as a function or program, not a person.
2. Shift RN roles toward care management.3. Decide which patients to refer to CM.4. Establish relationships with key hospitals to identify and co-
manage recently hospitalized patients.5. Create protocols, standing orders, and standard workflows,
etc. to guide CM work.6. Develop a support structure for care managers:
1. To discuss challenging problems.2. To assist with psychosocial issues.
www.improvingprimarycare.org
Resource Spotlight #1
Resource Spotlight #2
Resource Spotlight #3
www.improvingprimarycare.org
Daughters of Charity Health Centers
Complex Care Management in Marillac Community Health Centers
Roslyn Arnaud, Robert Post, Grace Mena
The Daughters of Charity have provided compassionate health care in New Orleans for 180 years. After the sale of Hotel Dieu Hospital in 1992, the Daughters transitioned their efforts, establishing a community health ministry known today as Daughters of Charity Services of New Orleans.
The Transformation to Consumer-Driven Healthcare
Daughters of Charity Services of New Orleans offers primary and preventive health services that address the needs of the total individual – body, mind, and spirit.
Our nine health centers are conveniently located in various geographic region of the greater New Orleans area. Most of our health centers are located near bus lines. We provide care for chronic illnesses such as asthma, cardiovascular disease, diabetes, and depression. Women's health, behavioral/mental health, dental, optometry, pharmacy, podiatry and Women, Infants and Children (WIC) services are also available at select health centers.
We are a proud member of Ascension Health, the nation’s largest Catholic and non-profit health care system. Our mission, similar to that of other Ascension Health ministries, is to improve the health and well-being of our community and to be a presence of the Love of Jesus in the lives of all we serve and with whom we partner.
Our Mission
Integrated Team Care
Patient’s Desires & Needs
PatientPanels
Outcome and ResultsMeasures
PopulationRegistries
Open Access
Primary Care Team
Care Management
MD/MANP/MACare Coordinator
Nurse CMBH CMPharmD
PROACTIVE TREATMENT
Project Collaboratives
PATIENT CENTRIC SERVICES
Continuous Quality Improvement
Continuous Quality Improvement
Adapted from David Dorr, MD, Care Management Plus
Complex Care Team• Nurse Care Manager
– Intensive Case Management– High Risk Patients
• Behavioral Health Consultants– Immediate consultations– Focused on outcomes
• Other Members of the Team– Clinical Pharmacists – Established CHD
Complex Care Team• Referrals
– Poor Control – Chronic Illness (Care Managers use the Clinical Event Manager in the EMR)
– ED/IP Utilization– Coordination of Care – home health, hospice– CNS Barrier – Neurologic, Behavioral, Substance– Perceived Risk by Primary Care Team
Other Responsibilities – Care Managers• Abnormal Cancer Screen Tracking• Hepatitis C Patients• CMS Chronic Care Management• NCQA – PCMH• Clinical Resource to Medical Assistants• Clinical Staff Training• Quality Assurance
– Medical Assistant Chart Audits
Community Health Center, Inc.
Foundational Pillars1. Clinical Excellence- fully Integrated teams,
fully integrated EMR, PCMH Level 3
2. Research & Development- CHC’s Weitzman Institute is the home of formal research, quality improvement, and R&D 3. Training the Next Generation: Postgraduate training programs for nurse practitioners and postdoctoral clinical psychologists as well as training for all health professions students
CHC Profile:•Founding Year - 1972•200+ delivery sites•130k patients
What is Complex Care Management?Complex Care Management is the deliberate organization of patient care activities and sharing of information with the main goal of meeting patients' needs and preferences in the delivery of high-quality, high-value health care (AHRQ, 2015).
At CHC, Complex Care Management includes:• CCM Tools: Dashboard, Scorecard, Structured Templates, Standing
Orders• Project ECHO Complex Care Management• Dedicated Education Unit
***CHC Ratios are 1 RN per 2 provider panels
• Goal: to improve the quality and coordination of care delivered to our most complex patients
• Patients: identified through dashboards either by hospital admissions, high ED utilization, chronic illness (uncontrolled or 4+) or individually by a care team member
• Consent: patients consent to be enrolled in CCM• Essential elements of the role:
• Transition Care (ie. hospital to home)• Medication Reconciliation• Having patients set their own goals and work with the care
team to meet them• Individualized Care Plan • Monitoring and adjustment of treatment regimens
• Discharge: once goals are met, transition is complete, care plan is fully implemented, or patient opts out
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Reason for Complex Care Management
• Basic Demographics (Age, Gender)• Smoking status• Clinical Markers (A1c, recent BP)• Important Dates (CCM start/end date, last PCP visit, last BH visit)• Self Management (last date self management goal set or MI done)• Any Actions Due? (Subject of the action and due date)• Patient Engagement (Portal Enabled?)
Scorecard Creation• Enrollment Data (Ever & Current)• HTN & DM Control Rates• Transition Contact• Coming Soon! Self-Management Goal Tracking
Additional Actionable Dashboard Data
Project ECHO Complex Care Management First session on 9/24/15 Duration: 2 hours; 1 didactic and ~2 cases All 12 sites involved – Approx. 33 nurses Faculty consists of:
Nurse Practitioner and Nurse Executive Homecare Nurse Medical Provider Pharmacist Behavioral Health Provider Complex Care Management Specialist and
Certified Diabetes Educator Registered Dietician and Certified Diabetes
Educator Access to Care Coordinators
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- Support for further developing the role of the CCM- Diverse Faculty Expertise- Improve Nurse self-efficacy/ leadership- Improve collaboration across all disciplines and supporting agencies- Increase interactions with nursing colleagues - Improve educational experience for students
8/25/2015
Goals of Project ECHO CCM
Q & A, Discussion
RemindersSign up for our next webinar in this series:
Achieving Full Integration of Behavioral Health and
Primary CareThursday, May 19th, 3–4 p.m. EST
Dissolving the Walls: Clinic Community Connections
Thursday, June 2nd, 3-4 p.m EST
Complete our survey!
Sign up at www.chc1.com/NCA