Connect4 Patients CCCM Primary Care Community. Presented By: Veronica Mansfield, DNP, APRN, AE-C, CCM Kit McKinnon, MBA, BSN, RN, CDE, CCM

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1 Connect4 Patients CCCM Primary Care Community Presented By: Veronica Mansfield, DNP, APRN, AE-C, CCM Kit McKinnon, MBA, BSN, RN, CDE, CCM September 17, 2015

2 Objectives: Describe innovative care management for common and prevalent chronic illnesses and contributing lifestyle habits Discuss community population health partnerships current and future Understand care management cost reduction models across the continuum current and future

3 What are the chronic disease management programs available at CCCM? A. Asthma, Diabetes & Smoking Cessation B. Fit for Kids, Diabetes & Heart Failure C. Asthma, COPD, Diabetes, FFK, HF & Smoking Cessation 81% 19% 0% A. B. C.

4 What are the CCCM programs that are available to homecare patients? A. MNT Wound Management 69% B. DSMT C. MNT Home D. Little Air Home 23% E. 1 & 2 only F. 1, 3 & 4 0% 8% 0% 0% A. B. C. D. E. F.

5 Which disease management program is available using IVR (Interactive Voice Response) technology? A. Diabetes Education B. Smoking Cessation C. Heart Failure D. Fit for Kids 54% 31% 15% 0% A. B. C. D.

6 Center for Chronic Care Overview 1 st NCQA accredited hospital based disease management program in the US Provide disease management services since th NCQA accreditation 2015, 2012, 2009, 2006 & programs: Asthma, COPD, Diabetes, Fit for Kids, Heart Failure & Smoking Intervention Approximately 650 new patients are served annually 48 hour post discharge triage interventions are provided to 100 patients monthly (about 20% of total hospital discharges) Partner with patients to improve self management & Quality of Life Adjunct resource to practitioners to improve patient engagement, meet quality measures and pay for performance goals

7 CCCM: Mobility and Access Middletown - Marlborough - Shoreline Asthma Management Adult & Pediatric Outpatient Asthma Care Program Little AIR/Home Family Medicine Asthma Education Asthma Inpatient Diabetes Care Diabetes Education: Individual and Group Classes Diabetes Disease Management Diabetes Inpatient CHC - Rent a CDE Contract Medical Nutrition Therapy (MNT) MH Employee MNT MNT in the Home Diabetes Wound MNT Fit for Kids Medical Nutrition Therapy (children and families) Heart Failure Program Heart Failure Inpatient Heart Failure Outpatient Care Management Smoking Intervention Smoking Intervention Outpatient Service Rewards to Quit Smoking Intervention Inpatient Service COPD Program COPD Inpatient COPD Outpatient Care Management

8 Center for Chronic Care Management GOALS: Increase access to care by targeting highly vulnerable populations Demonstrate improvement in clinical, economic and QOL indicators for enrolled participants by focusing on patient goals Act as an adjunct to primary care practices, hospitalists and specialists through utilizing evidence based guidelines Improve coordination of services Integrate community resources to meet the needs of patients and practitioners 8

9 Center for Chronic Care Management The Foundation - Based on Wagner Model: Nurse Led Certified Disease Experts Interprofessional Collaborative and Adjunctive 9

10

11 Incorporating an Integrative Chronic Care Model into Daily Practice Fundamentals of all programs based on Nationally Recognized Evidence Based Guidelines Focus is patient centered and collaborative Patient driven individualized goals established Emphasis is on patient self-management and independence Enhances patient s quality of life 11

12 Patient Care Toolkit Interview skills (motivational interviewing) Teaching and Training (teach-back) Assessment and care planning (critical thinking) Specialty consultations (Endocrine, Pulmonary, Cardiology, etc.) Symptom management (zones) 12

13 Symptom Management Asthma COPD Diabetes Heart Failure

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18 Community Partnerships

19 Medical Nutrition Therapy (MNT) Home Visit CCCM and Homecare partner to provide diabetes nutrition education to high risk patients Patients to be seen by Registered Dietician/Certified Diabetes Educator in the home Patients transition to outpatient diabetes education and support once successfully discharged from homecare 19

20 Criterion for Medical Nutrition Therapy (MNT) Referral A diagnosis of diabetes A1C range greater than 7.0 Treatment intensity increase from oral meds to insulin Many diet questions that homecare clinician can not answer Knowledge deficit as assessed by homecare clinician Hospitalization for: 1. Acute complications of diabetes 2. Recent DKA or HHNK 3. ED or hospitalization for hypoglycemia *A diagnosis of CKD: GFR (Stages III, IV, V). (Staging as determined by documentation in hospital discharge or history and physical) 20

21 Diabetes Wound Care Initiative Partnered with Outpatient Wound Center to improve wound healing using a multidisciplinary approach MNT is an appropriate treatment for diabetic foot wounds used as adjunctive medical treatment Criteria: Diabetes with Wound 21

22 Readmission and ED Visit Reduction Initiative Post 48 hour Hospital Discharge Automated Phone Call via IVR (Interactive Voice Response Technology) CCCM developed question sets and triage protocols CCCM provides triage support based on trigger alerts to patients 7 days per week Provide process improvement suggestions based on actionable data 22

23 CCCM - In Pursuit of the Triple Aim* Improve the health of the population of chronic care patients Enhance the experience and outcomes of the patient Reduce per capita cost of care for the benefit of communities (* Institute for Healthcare Improvement Triple Aim)

24 State and National Impact Diabetes Control Plan Committee Member of Connecticut Association of Diabetes Educators (CADE) Asthma Regional Council of New England CHA Asthma Initiative AHRQ Innovation Model

25 Asthma Care Partnering with the Patient and Family Patient empowerment - meeting patients where they are and positively influencing cultural, environmental and lifestyle issues that impact health CCCM and Homecare are partnering to provide asthma education to high risk patients Patients are seen by APRN, Certified Asthma Educator (AE-C) in the center Next patients are then referred to homecare for environmental assessment by a specially trained homecare RN Continued follow up reinforcement and support of asthma plan by specially trained Community Health Worker Program originally funded through CMS Innovations Grant 25

26 Heart Failure Disease Management Program Heart Failure Disease Management via automated phone call (IVR) Developed question sets and triage protocols to identify decompensating patients and trigger alerts Developed triage intervention protocols to address patient alerts Automated calls made 48 hrs post discharge, 7 days post and 21 days post 26

27 Starting Conversations: Examples of Care Coordination & Transition Collaboration DAPR Tool Initiation HF Patient Transitions COPD Wrap Around Care Diabetes Care and Management Collaboration Telemonitoring services

28 NEW COPD Program Roll Out of COPD Care Management across the continuum - January 2015 Utilize CCCM nurse experts to see patients at inpatient bedside (survival skills) Transition patients to appropriate level of care Goals: Reduce readmissions by 2.4 patients per month Increase Screening and Spirometry for early detection and intervention 28

29 COPD Outpatient Care Management Who Should Be Referred? Stage 3 or Stage 4 (based on GOLD guidelines) Newly diagnosed Self-management barriers Transition from a higher level of care (SNF, homecare, acute care or pulmonary rehab)

30 Future Explorations Population Health Management - New Models CareLink Engaging patients through connectivity - Partnering with PCP s and Technology to I.D. chronic disease in it s earliest stages to slow progression and improve self-management Primary Care Partnering with PCP s and Specialists to target chronic disease at all stages to improve QOL and lower cost 30

31 CCCM s Targeted Results A motivated, educated patient with fewer hospitalizations/ed visits, better clinical outcomes and improved quality of life 31

32

33 CCCM Team

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