IMPROVING OUR CLIENTS WHOLE HEALTH THROUGH DATA-INFORMED CARE MANAGEMENT
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1 IMPROVING OUR CLIENTS WHOLE HEALTH THROUGH DATA-INFORMED CARE MANAGEMENT Laurie Alexander, Ph.D., Alexander BH Consulting Melba Mannell Whatcom Counseling & Psychiatric Clinic Laura Sureepisarn Compass Health
2 The panelists 2 Laura Sureepisarn Adult Extended Care Manager, Compass Melba Mannell Nurse Care Manager, Whatcom CPC Laurie Alexander Consultant, Alexander BH Consulting
3 For today s workshop 3 Overview of care mgmt & WCMHC s pilot program Case studies Lessons learned Key resources Q&A
4 4 Data-Informed Care Management Overview of Care Management & the WCMHC Pilot Program
5 Healthcare spending & chronic illness 5 A high percentage of health care expenditures are associated with a small proportion of the population. Health care spending for people with 5 or more chronic conditions is 17 times higher than for people with no chronic conditions. Average Per Capita Spending by # of Chronic Conditions $2,573 $5,062 $7,381 $16,819 $10,091 $ # of Chronic Health Conditions Care management of patients with complex health care needs Bodenheimer, & Berry Millett, RWJF Policy Synthesis, December 2009
6 Care mgmt can help 6 Reduce costs while improving quality for people with multiple chronic conditions In medical & MH/SU settings Critical option for MH/SU centers, especially given the early mortality gap Care management of patients with complex health care needs Bodenheimer, & Berry Millett, RWJF Policy Synthesis, December 2009 Morbidity and Mortality in People With Serious Mental Illness, NASMHPD, 2006
7 How it all fits together 7 Jarvis, 2011
8 The health home 8 Care mgmt is a core competency of highperforming MH/SU providers wishing to participate in health homes & ACOs Health home Integrated care Care team Care mgmt Jarvis, National Council, 2011
9 What is care management 9 Care management assists patients in managing their conditions more effectively. The goals of care management are: To improve patients functional health status, To enhance coordination of care, To eliminate duplication of services, To reduce the need for expensive medical services, & To increase patient engagement in self-care Care management of patients with complex health care needs Bodenheimer, & Berry Millett, RWJF Policy Synthesis, December 2009
10 Care mgmt in practice 10 Identify patients most likely to benefit. Assess the patients risks and needs. Develop a care plan together with the patient/family. Teach the patient about the diseases and their mgmt Coach the patient/family on how to respond to worsening symptoms to avoid hospitalization. Track how the patient is doing over time. Revise the care plan as needed. Bodenheimer, & Berry Millett, RWJF Policy Synthesis, December 2009
11 Case mgmt vs. Care mgmt 11 Case management typically involves assisting patients and families in navigating the health care and social service systems Linking focus Care management comprises a broader set of longer-term services that includes medical management and assistance in navigating the system Clinical focus Care management of patients with complex health care needs Bodenheimer, & Berry Millett, RWJF Policy Synthesis, December 2009
12 A targeted intervention 12 Identifying patients most likely to benefit is key. Care management is most effective when targeted to people with multiple disease conditions, who are at high-risk for costly care People who are high-risk / high-utilizing Care management of patients with complex health care needs Bodenheimer, & Berry Millett, RWJF Policy Synthesis, December 2009
13 The WCMHC pilot 13 DSHS Transformation grant funding 12-month pilot: Columbia River, Compass, Comprehensive (Klickitat), & Whatcom Required elements: Washington Community Health Council Include an RN on the project team Use PRISM to select participants and identify their community contacts Use the PAM to assess patients level of activation Implement a registry for program participants
14 PRISM 14 DSHS/RDA created this secure database of adult Medicaid clients (Pilot sites submitted lists) PRISM provides Medicaid claims data: Encounters at area ERs, primary care, etc. Medications & diagnoses Risk score based on the complexity of the client s diagnostic picture and level of health care utilization The data-informed piece of the program
15 Patient Activation Measure (PAM) 15 Insignia Health s PAM gauges the knowledge, skills and confidence needed to manage one s own health and health care. It predicts health care outcomes, including medication adherence, ER utilization, and hospitalizations.
16 PAM s 4 levels of activation 16 4 levels of patient activation: 1) No involvement in care 2) Building knowledge & confidence 3) Starting to take action 4) Maintaining active behaviors
17 Learning community structure 17 June 2010 kick-off meeting, with training on PRISM and PAM Monthly all-team calls, with trainings on special topics and review of team data 6-month and 12-month learning congresses In-person opportunity to reflect on work to date and share lessons learned
18 18 Data-Informed Care Management Case Studies: Compass Health
19 The Compass team 19 Laura Sureepisarn, Comprehensive Community Support Services Manager Registered Nurse as the Care Manager Crisis Services Manager OP Clinical Director Data Integrity Specialist Medical Director
20 Nurse care manager s role 20 Review the client s medical history Use PRISM to assess risk factors, including: Inpatient utilization ER utilization and reason for visit Medical providers serving client Medications and pharmacies utilized If completed, the Long Term Care assessment by HCS
21 Nurse care manager s role (cont.) 21 Assist with PAM completion and development of health care goals and action plan Offer support, patient education, and problem solving around client s medical conditions and goals during regularly scheduled meetings Accompany client to medical appointments Support client in communicating health care needs, questions, and concerns Assist with interpreting doctors orders and lab results
22 Nurse care manager s role (cont.) 22 Routinely meet with agency clinical staff to coordinate the care plan and share the client s defined goals and progress achieved Participate in intensive case management team to facilitate coordination of care and information sharing
23 Case manager s role 23 Work closely with the care manager to support the client s defined health care goals, which are integrated into the MH care plan Help define community resources and health care benefits available for clients
24 Success story: 37-yr-old woman 24 Single mother of 3, with the following diagnoses: Bipolar disorder Personality disorder NOS Attention deficit disorder Chronic liver disease Migraine headaches Rare inflammatory disorder Client selected into program due to high ER utilization PRISM showed 21 visits thru June 2010, most rated as nonemergent
25 Success story: Actions taken 25 A month after being offered the program, she accepted Initially client missed several appointments with CM Engaged in care after numerous outreach contacts by CM Initial goals included: Losing weight Going to school and getting a job Stable housing Having children returned to her care
26 Success story: Actions taken (cont.) 26 Care management interventions: Monitoring weight at each visit Discussing the role of exercise and weight loss Reviewing exercise regime, eating patterns, and dietary habits Supporting lifestyle changes Confidence-building activities, such as maintaining eye contact, speaking directly to strangers, and paying attention to her posture and body language
27 Success story: Outcomes 27 PAM level rose from a 2 to a 3 in 7 mos. Confidence rating in Goal Setting & Action Plan increased from 5 to 8 in 8 mos. Significant changes were achieved with lifestyle, eating habits, and exercise regime (e.g., She lost 50 lbs) She completed community college coursework and started an externship. ER utilization went from 21 visits a year (prior to care management) to 8 visits for the year ending April 2011.
28 28 Data-Informed Care Management Case Studies: Whatcom CPC
29 The Whatcom team 29 Melba Mannell, RN: Project Coordinator Jessica Hofer, RN: Care Manager Kathleen Daughenbaugh: Clinician, Group Coordinator, IOP consultant Linda Ford: Adult Teams Manager, including IOP Fredrick Sears: Emergency Case Manager Dean Wight: Executive Support
30 Nurse care manager s role 30 Select potential clients from PRISM list Discuss with team Finalize participant list Do face-to-face interviews with clients Offer CM services Administer PAM Coordinate care with Clinic prescriber, therapist, case managers PCP, medical specialists in community
31 Nurse care manager s role (cont.) 31 Attend adult team meetings to discuss CM clients (Teams include therapists and case mgrs) Educate adult teams on health issues How to respond to abnormal health indicators (e.g., blood sugar) How to support clients contact with other health providers How to incorporate other health goals into treatment plans
32 Case manager & therapist roles 32 Care mgmt team has 2 levels Core project team identified earlier Regular OP and IOP therapists and case managers whose clients are in the project. Assigned case managers are either primary or secondary to a given client (depending on whether a therapist is also assigned)
33 Case mgr & therapist roles (cont.) 33 Case managers accompany clients to health appointments as appropriate Both case managers and therapists support client participation in health care, including: Consistent vitals monitoring (e.g., BP, blood sugar) When to seek a physician appointment Preparing for appointments and communicating with physicians Adherence to physician instructions
34 Success story: 47-yr-old man 34 Program criteria met: In the top 10 on PRISM risk score for previous year 50 EMT trips in previous 4 months 4 hospitalizations Significant health concerns Referral from PCP in community Cardiac history / heart attack / stent Mental health Major depressive disorder Generalized anxiety disorder Initially resistant: Refused to enter ARNP office, grandiose, labile, anxious, combative, verbally abusive, suicide plans
35 Success story: Actions taken 35 Nurse care manager conducted initial screen and connected client to additional team members: Assigned IOP case manager Seen 3-4 times weekly Built relationship with family Assigned psychiatric ARNP RN and ARNP in close contact with PCP Medication change Prescribed atypical antipsychotic (vs. benzodiazepine) Assigned therapist Fostered relationship with team Client felt heard Addressed anxiety issues, given tools to cope
36 Success story: Outcomes 36 Client and family moved into town from remote rural area Better access to health providers Taking meds as prescribed Exercises regularly by walking; Has lost weight Developed hobby Bird watching and feeding More connected to family No EMT calls in last 8 months No hospitalizations
37 Success story: Key lessons 37 Gain clear vision of the client s particular needs in all areas of health Reduce psychiatric symptoms in order to make participation in overall care more effective Atypicals were key in this case Establish a relationship where client feels her/his issues are heard clearly, respected Coordinate with external caregivers and support systems
38 38 Data-Informed Care Management Initial Results & Lessons Learned
39 Caveat: It takes time to get results 39 Research shows that care mgmt is effective, but it takes time (>12 months) to realize positive quality outcomes WCMHC pilot sites are almost at the 12-month mark Care management of patients with complex health care needs Bodenheimer, & Berry Millett, RWJF Policy Synthesis, December 2009
40 Team data summary 40 An up-to-date data summary will be provided to attendees at the workshop
41 Whatcom s PRISM risk score findings 41 Client # Aug '10 Mar '11 Change / % Change (76% drop) (63% drop) (58% drop) (44% drop) (36% drop) (44% drop) (43% drop) (39% drop) (65% drop) (41% drop) (50% drop) Mean (52% drop) Note: Sample size is small, and data have not been analyzed for statistical significance.
42 Lessons learned 42 Discussion with Laura & Melba: What has been helpful in making the pilot a success? What have been the biggest challenges? What advice would you have for a center just starting a program like this?
43 43 Data-Informed Care Management Key Resources
44 Care mgmt resources 44 RWJF Policy Synthesis on care mgmt for people with complex health care needs ( Stanford Self-Management Programs ( Patient-Centered Primary Care Collaborative ( Patient Activation Measure ( Druss et al. (2010) PCARE Study (
45 CONTACT INFORMATION Laurie Alexander, Ph.D. Melba Manning Laura Sureepisarn
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