Implementing Care Management for Complex Patients

Transcription

1 Implementing Care Management for Complex Patients Timothy Ferris, MD, MPH SVP, Population Health Management, MGH, MGPO and Partners HealthCare Ohio Perinatal Quality Collaborative September 28, 2015

2 Thinking about the challenge Identification Reach/engage Find opportunities for improvement Intervention Realized Improvement (measured frequently!) Adapted from J Eisenberg JAMA

3 Study of 18 successful care management programs Study domains Patient Selection and Engagement Team Structure Key Resources Primary Care Integration Care Manager Scope of Work/Key Tasks Information Technology Integration Training Outcomes Hong CS, Abrams MS, and Ferris TG. Toward Increased Adoption of Complex Care Management. N Engl J Med 2014 (8); 371:

4 Program methods for patient selection Quantitative Quantitative vs Qualitative Multi- vs Uni-dimensional Risk prediction High-utilizer tracking Event-triggered identification Referral (provider or patient self referred) Qualitative Identifying impactable patients Motivation/readiness 4

5 Patient engagement Importance of primary care integration Face-to-face interactions (critical!) Early successes Motivational interviewing Longitudinal relationships Traits of the CM Hire the right people Detective skills Trust building 5

6 Care management team structure Tight Team Structure all on same payroll Variable team structure CMs predominantly RNs Other team members Resource specialist/sw Pharmacists Health Coaches Behavioral Health specialists Support Staff Loose Team Structure virtual team 6

7 Critical care management resources Ties to inpatient facilities/eds Communication with inpatient CMs Embedded CMs at hospital sites Ties to community-based agencies Home health agencies Elder resource centers Community centers Social service agencies 7

8 Primary care integration Tightly Integrated Variable integration Loosely Integrated Enhancing integration Co-location Face-to-face interaction EMR access Building trust Educate clinicians on CM Role Who owns the CM? Health system, payer, practice CM s as change agents 8

9 Care manager scope of work Case loads range Depends on training/resources Stratification and innovative IT allow more patients per care manager Touches Frequency twice weekly to monthly Types telephonic, office, home Face-to-face contact varies CM needs to build trusting relationships with both the patient AND the physician CM/practice ratio matters also 9

10 Care manager key tasks Comprehensive assessment Individualized care plans Health coaching/self-management support Care coordination/navigation With Hospitals/EDs, SNFs/Rehabs, Specialists, VNA, behavioral health, and community resources Address barriers to access/care Patient advocacy/activation 10

11 IT functionality Limited advanced care management IT infrastructure Data availability for risk prediction Population management functionality Task assignment capacity QI functionality Referral tracking Core IT needs for CM activities: Accurate, updated contact information Real time notification of high risk events Accurate chronic disease data and up-to-date medication/problem lists EMR access 11

12 Training Classroom didactics paired with on-the-job training Motivational interviewing cited as most important skill Other training elements include: disease focused training, care management protocols, IT systems Skills that can t be taught matter Being a detective and innovator (Creative Solutions) Ability to build trust 12

13 Emerging themes Building strong relationships with BOTH patients and primary care teams is critical Patient-centeredness is critical Particularly informal assessment of patient motivation/readiness to change Working in multi-disciplinary teams addresses needs of complex patients & allows CMs to work larger case loads A good CM doesn t do everything Allocating the CM resource to high-yield activities and addressing mutable issues is critical IT infrastructure can greatly enhance CM efficiency 13

14 Thinking about the challenge Identification Reach/engage Find opportunities for improvement Intervention Success requires high performance at every resister Realized Improvement (measured frequently!) Adapted from J Eisenberg JAMA