Care Management Approach for People Who Are at High Risk

Transcription

1 Care Management Approach for People Who Are at High Risk Presented by: Ann Larsen RN, CDE Care Manger - Herefordshire Clinic/Trainer Care Management Plus June 11, 2013

2 Welcome! Type questions into the Questions Pane

3 Patient-Centered Primary Care Institute History and Development Launched in 2012 Public-private partnership Broad array of technical assistance for practices at all stages of transformation Learning Collaboratives Website ( Webinars & Online Learning Ongoing mechanism to support practice transformation and quality improvement in Oregon

4 PCPCH Model of Care Oregon s PCPCH Model is defined by six core attributes, each with specific standards and measures Access to Care Be there when we need you Accountability Take responsibility for us to receive the best possible health care Comprehensive Whole Person Care Provide/help us get the health care and information we need Continuity Be our partner over time in caring for us Coordination and Integration Help us navigate the system to get the care we need safely and timely manner Person and Family Centered Care Recognize we are the most important part of the care team, and we our responsible for our overall health and wellness Read more:

5 Acknowledgements and Introduction Based on a presentation delivered through the Comprehensive Primary Care Initiative (CPCI) Funding from CMS through AIR Previous funding from The John A. Hartford Foundation, AHRQ, NLM, and the Gordon and Betty Moore Foundation Initial development at Intermountain Healthcare Ann Larsen, RN, CDE - Care Manager at Intermountain Healthcare and trainer for Care Management +

6 Rather than continuing to fish people out of the river, why do we not look up at the bank of the river and ask: Why are they falling into the river in the first place?

7 Steps to risk stratification Who are our patients? What risk technique will we use? How will we track risk status? How will we work with patients at higher risk?

8 Model of Care Management Plus Over 250 clinics Referral - For any condition or need - Focus on certain conditions Care management Care manager - Assess & plan - Catalyst - Structure Technology - Access - Best Practices - Communication Evaluation - Ongoing with feedback - Based on key process and outcome measures Larger infrastructure: Electronic Health Record, quality focus

9 Care Management Step 1: Who will provide CM services? Step 1.1 New staff or reassignment of responsibilities Create or modify job description Step 1.2 What clinic resources and CM skills are needed? Space, supplies, support, resources, training Step 1.3 How will it work? Implementation plan with team planning to adjust work flow Step 2.1 Risk stratification Use algorithm or other process to identify high risk Step 2.2 Who receives CM? Prioritize high risk group, others? List of patients who have received care mgt services Step 2.3 Indication of progress Care plans, tracking, feedback to providers

10 How to Identify/Stratify Registry Poly-pharmacy 6 or medication in age >65 Multiple Chronic Illnesses Paired Diseases Substance Abuse 2 or More ED visits in 90 Days Readmissions to In Patient with in 30 days Diagnosis of Cognitive Impairment Falls

11 Risk Stratification & Incentives Must Be Tied to Complexity Most intense (e.g., Homeless, Schizophrenia) < 1% of population severe illness, low function, poor health Intense Complex illness Multiple chronic diseases Other issues (cognitive, frail elderly, social, financial) 5-10% of population multiple chronic or moderate-severe illness Mild-moderate Well-compensated multiple diseases Single diseases 40-50% of population Low risk (usual preventive care) Remainder of clinic

12 Risk Stratified Patients Basic Team/PCP Review and Identify High Risk Intermediate Simple Algorithm Populations Complex Complex Algorithm Tied to complexity scores (stage IV CHF)

13 Team Review Identify Whom to Target Proactive Asking a Patient How They Feel is Predictive Individual s Assessment of Self Poor Fair Good Excellent

14 Patient Centered Care/ High Risk Patients Primary Care Setting Team Based Care Individualized/Customized Daily Interface with Provider Care Coordination across settings and Providers Treat the whole Patient and Family Collaborative Goal Setting Prevention/Wellness/Independence Does the Patient have Support????

15 Risk Stratified Intervention Strategies Low Risk Groups Telephone Classes Intermediate One on One (and above) Intensive Care Management ENGAGE the TEAM One on One Appointment w/provider Home

16 Team Primary Care Physician Care Manager Health Advocate Mental Health Provider Social Worker Clinic Staff Other healthcare providers (cardiologist, dietician) Community (NAMI) WORK TOGETHER TO PROVIDE THE BEST CARE

17 Patient-Centered Care Relationships Based on Respect and Trust Team Patient Care Manager Physician

18 Care Manager Role Advocate Educate Build Relationships/Teams Facilitate Team Communication Plan, Prioritize and Organize Plans of Care Proactive and Personalized Primary Care

19 Care Manager Detective Identify Barriers/Problems Salesman Benefits/Value of Health Coach Educate and Support

20 Care Manager Assessment Start with the Patients Greatest Concern Identify Barriers/Fears/Stressors Stage of Grief Readiness to Change Importance/Confidence Family Pattern Profile Depression

21 Care Manager Assessment Cognition Functional Ability Learning Styles Health Literacy Cultural/Social Issues

22 Health Coaching Self management support (Health Coaching) is more than patient education. It involves providing patients with the knowledge, skills and confidence they need to become active participants in their care. Tom Bodenheimer MD Care Management + Advisory Board Nationally known for work on Medical Home

23 Patient Coaching Shared Decision Making/Collaborative Goal Setting Customize/Individualize Intervention Motivate them to Seek Proper Treatment Maintain Healthy Boundaries Identify Resources Teach Self-Management Skills Teach Patient When to Call Back Empower patients to Take Charge of their Illness for a Lifetime ULTIMATELY IT IS THE PATIENTS DECISION REGARDING LIFESTYLE CHOICES

24 Patient Engagement Patient Engagement enhances adherence to therapy Motivational Interviewing = Engagement The More Proficient the MI the More Engagement Patients are Experts in Themselves What help do you feel you need? Ask: What is your Goal? What can we (Provider, Care Manager) do to help you with your goal?

25 Motivational Interviewing A New Way of Interacting with Patient and Families Change Talk When the Patient Begins to Talk Themselves into Change Asking the Right Questions Open Ended Questions How What Tell Me More EXPLORE

26 MI Open Ended Questions Greatest Question/Concern? Biggest Fear? What do you think is wrong? What is your biggest roadblock? What is the most difficult thing about managing your illness? What does it meal to you to (take insulin)? What have you learned from your illness?

27 Do you have other concerns that we haven t discussed?

28 Like a River Roll with it, find a new way to talk to them

29 Handouts & Links Access this webinar recording and other Institute webinars: (also included in post-webinar )

30 Build a Bridge From where the patient is to where he/she wants to go

31 Summary What Patients with Chronic Illness Need Effective treatment (clinical, behavioral, supportive) Information and support for self-management Systematic follow-up and assessment Tailored interventions Coordination of Care Across settings and providers It s not if you ll have a job in ten years, it s how that job will change and how you will adapt to it.

32 Questions? Type questions into the Questions Pane

33 Closing Please fill out the survey after this presentation you can send us additional questions Webinar materials can be retrieved from our website, Additional questions?