Pediatric Complex Care Management

Transcription

1 Pediatric Complex Care Management Kristen Foose RN, BSN, CPN Objectives Disclosure of Conflict Participants will gain an understanding of the impact that pediatric care management has had on the patients, families and healthcare providers. be able to describe the benefits of care coordination and the importance with complex children. gain an understanding of what outpatient care managers do and their importance. be able to identify the gaps in healthcare prior to care management. I have no relevant financial relationships with the manufacturer(s) of any commercial products(s) and/or provider of commercial services in the CME activity. I do not intend to discuss commercial products or services and unapproved/investigative uses of a commercial product/device in my presentation. OSF HealthCare System OSF HealthCare System Acute care hospitals 11 Heart hospital 1 Children s hospital 1 OSF Medical Group locations 75 OSF Locations not including hospital 108 Clinic site locations 193 Prompt care sites 13 Employs more than 667 physicians and mid-level providers operating in eight LLC corporations and in more than 80 office sites OSF HealthCare owns an extensive network of home health services known as OSF Home Care Services and also owns OSF Saint Francis, Inc., comprised of healthcare-related businesses, and OSF Healthcare Foundation, the philanthropic arm for OSF Healthcare System and OSF Home Care Services

2 The Communities We Serve Other OSF HealthCare Facilities OSF Saint Anthony s Health Center 8 OSF Mission OSF Vision In the spirit of Christ and the example of Francis of Assisi, the Mission of OSF HealthCare is to serve persons with the greatest of care and love in a community that celebrates the gift of life. Embracing God's great gift of life, we are one OSF Ministry transforming health care to improve the lives of those we serve. Every patient, every person, every time. 11 History of Care Management Started the pediatric program in 2010 Expanded into two other offices in 2012 and additional pediatric care manager hired Now in several offices and regions with a total of five RN care managers, one social worker and two health coaches and continuing to expand Care Transformation Advisory Committee 11

3 Care Management Team Focus Statement Why Care Management? The Care Management Team promises to foster and support the OSF Mission by using an interdisciplinary team approach to help patients and their families achieve the highest possible functioning levels so they can be part of their communities. We will foster and support each other by challenging and encouraging our co-workers to use their individual, unique strengths, skills and talents to build a cohesive team to care for our patients. This is a shared commitment to transforming health care as a culture that cares. Fragmented healthcare system System is hard for parents to navigate Lack of communication Barriers to coordinating care Difficulty with transitioning care Alex s story Care Management Team approach Planning and coordinating the physical, mental, and social needs of a patient to help improve their health and maintain their independence This entails managing, referring, and coordinating health and social services Team consists of Care Manager Social Worker Health Coach

4 Complex Care Managers Complex Care Manager Qualifications Bachelor s of Science in Nursing (BSN) degree required Registered Nurse with an Associate s degree will be required to complete a BSN within 5 years of hire date with completion of such requirements no later than 2020 Three to five years of experience caring for patients with progressively increasing responsibility Care Management certification as appropriate for adult or pediatric within 3 years of hire. A Complex Care Manager is a health care provider, typically a nurse, who works as a member of the patient s care team, providing holistic, longitudinal care to a panel of patients Care Managers are advocates who help patients/parents understand their current health status, what they can do about it and why those treatments are important Complex Care Manager Complex Care Manager Guide patients/parents and provide cohesion to other professionals in the health care delivery team, enabling their clients to achieve goals more effectively and efficiently Work together with and the primary care physician to assist in the care of the patient Assess, plans, implements, coordinates, monitors, evaluates interventions and develops a comprehensive plan of care for each patient Coordinate care Assess medical/social needs Educate and engage Support Smooth transition of care Patient advocate Create care plan Proactive monitoring of patient Accessing community services Communicate with all involved Close follow up Transitions Social Worker Social Worker Qualifications Bachelor s degree in Social Work from a school or program accredited by the Council on Social Work Education is required; Master s degree in Social Work preferred Will obtain a license for social worker degree with in three years Care Management certification as appropriate for adult or pediatric within 3 years of hire Responsible for identifying, assessing, planning, coordinating, implementing, monitoring and evaluating options and services across the continuum of care for individuals in assigned case load Health care services are coordinated on behalf of the patient to promote the delivery of care at the appropriate level of care which will optimize clinical outcomes and satisfaction with services

5 Social Worker Heath Coach Addresses both the patients bio psychosocial status as well as the state of the social system in which care management operates Develops and maintains a therapeutic relationship with the client Assists the patient's with systems that provide services, resources, and opportunities Co-manages patients with the Complex Care Manager if patient has both social and medical needs Qualifications: Associate s degree in health education, health promotion or equivalent Two years of experience in clinical, counseling or health care setting caring for patients with chronic, complex illnesses (adult experience for adult and pediatric experience for pediatric) adult and/or pediatric care management experience preferred. Broad knowledge of chronic illness and medical and community resources required Health Coach Has own panel of patients Complex Care Manager manages new patients for a minimum of 90 days, and if stable will then transition to the health coach Promote disease management, preventative care and wellness Coordinates, monitors, and follows up with patient to ensure patient they are working toward the comprehensive plan of care and care goals Performs ongoing communication and works to promote quality of care Care Management Helping patients manage their health, maintain their independence and improve their quality of life Managing, referring and coordinating health and social services MONITORING FOLLOW-UP CONNECTING COORDINATING COMMUNICATING connecting to community resources Monitoring Follow-up Monitor and keep tract of appointments and testing Ensure that patients get seen with their PCP if sick for continuity of care Monitor immunizations and preventative testing to ensure that they are completed Weekly calls on new patients for one month Monthly check in calls/care plan updates See patient in office when they come in

6 Connecting Coordinating Advocate for patient and assist them in getting the services they need Answer questions and help explain what is going on and why things are needed Discuss services and resources Assist in transition issues Coordinate coverage with insurances Coordinate referrals Coordinate with home health/home nursing Facilitate coordination between physicians and specialists Coordinate all appointments and testing Communicating Communicate the needs of the patient to all that are involved Care plan is accessible to all specialists, hospital staff and parents to ensure continuity of care Collaborate and ensure that all specialists notes are received Ensure that the parents are receiving the communication they need to care for their child Communicate the plan of care It is the simple things Referral Process Predictive risk assessment tool Hospital referral Doctor/staff referral

7 New Enrollment New Enrollment Intake process: Meet with parent/patient in person or complete over the phone Discuss Arrival needs Challenges Goals Diet Equipment School Specialists Dentist Risks Therapies Living situation MyHealth Community Resources Weekly calls for a month Monthly calls for updates Care plan updates monthly, sooner if any new changes Care Plan Care Plan Individualized care plan established for each patient. Goals are identified Needs are identified Care plan is shared with patient Care plan is able to be viewed by all (outpatient/inpatient) Updated monthly or as needed Goals Challenges/barriers If something goes wrong To do Care manager s action items Diet/nutrition Current medications Care team Upcoming health maintenance Care managers impressions Hospital Admissions Hospital Discharges Receive notification if a care managed patient is hospitalized Utilize and communicate with case management in the hospital Will attend care conferences if appropriate Receive a hand off when patient is discharged from the inpatient case manager Follow up call done with in 24 hours of discharge Work weekend and holiday hours to be able to follow up on discharges in a timely manner Medication reconciliation Follow up appointments Address needs and concerns Assure all equipment delivered

8 Payton Payton Costello syndrome Transitional cell carcinoma of the bladder Currently 15 years old Transitioning to adult care Transition plan Begin discussion of transitioning between years of age Develop transition plan of care Work with adult care manager and transition patients to them MD to MD hand off Social worker plays a large part in the transition process in assisting with guardianship, insurance etc. Adult primary care Adult specialty care Adult dental care Schedule doctor appointments Refill my medications/supplies Know my medications/treatments and why I take them Describe my medical condition and understand the disease process and hoe to manage the disease Describe and understand my specific diet Consent for medical care Guardianship options Plan for education Plan for employment/work Plan for independent living Plan for transportation Plan for finances/money management Paying for medical care SSI Financial decisions Parent/patient testimonies Provider testimonies I do not have to repeat myself and tell the long history of my son each and every time I call the office. Care is streamlined and my care manager understands and knows what is going on and can get us the help that we need. You have helped us think through sticky situations and assist us in solving the situation. You have been our rock, and helped us through the hardest time of our life. You supported, advocated and assisted us through so much. You are very valuable and we appreciate your services more than you will ever know. You get to the meat of the problem. I do not need to spend 15 minutes explaining what the history of my child is before we get to the problem. This is very valuable. You are like a Walmart, one stop shopping, you have and know it all about our son. You bring the team together, organize and prioritize and help me when I am crashing and need to talk. You make my life easier, period. I am able to have a knowledgeable, go to person who understands the patient and can assist in times of need. You are my go to person for everything for the care managed kids. You are easy to get a hold of and you know exactly what is going on with all the kids, otherwise I am calling random nurses that do not understand complex kids. Central contact for families, patients, and other providers to communicate needs with. You know and understand the complexity of the child. Referrals, therapies, and appointments are easier and can be done through you. You have the flexibility to meet families at non standard times and can even come to the hospital. Much more thorough explanations of testing and results, very valuable to the parents and patients. Centralized person for a complex kid... you are HUGELY VALUABLE.

9 Questions Resources Evans, M. (2015). Demand grows for care coordinators. Health Services Administration. 45 (13). Kelleher, K., Cooper, J., Deans, K., Carr, P., Brilli, R., Allen, S., Gardner, W. (2015).Cost saving and quality of care in a pediatric accountable care organization. Pediatrics. 135 (3). Taitsman, D. (2015). Medicaid managed-care patients face hurdles in getting care. Modern Healthcare. 45 (1). Venegas, M., Zubarew, T., Pacheco, F., Besoain, C., Paula, V., Velarde, M..Reinoso, A. (2015) The transition process from pediatric to adult services: perspectives from adolescents with chronic diseases. Journal of adolescent health. 56 (2). Wong, C., Chan, F., Wong, F., Wong, E., Huen, K., Yeoh, E., Fok, T. Transition care for adolescents and families with chronic illnesses. Journal of Adolescent Health. 47 (6).