Kaiser Permanente of Ohio

Transcription

1 Kaiser Permanente of Ohio Chronic Disease Management Program March 11, 2011 Presenters: Amy Kramer and Audrey L. Callahan 1

2 Objectives 1. Define the roles and responsibilities of the Care Managers in the Chronic Disease Management Program at Kaiser Permanente and of the Care Coordinators at MetroHealth Medical Center 2. Identify documentation expectations required of Care Managers and Care Coordinators to facilitate accurate reporting functions to track populations of patients 3. Identify and explore other tracking systems utilized in the Greater Cleveland Area (group discussion) 2

3 Kaiser Permanente Ohio Mission Statement Kaiser Permanente exists to provide high quality, affordable health care service to improve the health of our members and the communities we serve 3

4 Care Management Roles RN Care Manager Clinical Pharmacist RN Population Care Management Allied Physicians Assistants Nurse Practitioners 4

5 RN Care Manager Office based RN responsible for chronic disease management of patients referred from the Office Providers Referrals are generated from Tapestry which is an electronic referral management tool in EPIC Responsible for other clinical activities in the Medical Office 5

6 Clinical Pharmacists Office based clinical pharmacists responsible for chronic disease management of patients referred from the Office Providers Serves as a drug information resource to the team Responsible for Medication Therapy Management (MTM) and participates in other clinical pharmacy clinics 6

7 RN Population Care Management Centralized team of RNs based in the Population Care Management Department which is external to the Medical Offices Focus is on cardiovascular risk reduction in diabetic patients with an A1C<7.5 Responsible for Health Education classes for the region 7

8 Care Management Swim Lanes 8

9 Care Manager Responsibilities The highest risk diabetics with A1C>9 are assigned to RN Care Managers for closer monitoring and education in the Medical Offices The moderate risk diabetics A1C are assigned to Clinical Pharmacists with the focus on telephonic medication titration in collaboration with the PCP in the office 9

10 Cont Care Manager Responsibilities The large volume of diabetic patients with A1C<7.5 are assigned to the RNs in Population Care Management where there is less need for intensive clinical monitoring but more need for generalized focus on other cardiac risk factors The Allieds are responsible for patients with CAD without DM and manager their care both with telephonic and face-to-face visits 10

11 Patient Assignments A report is generated by PCM analyst monthly of new diabetics and diabetics with an A1C that has changed The PCM analyst places the patients in the appropriate Care Manager InBasket in the Care Management Tracking Tool (CMTS) The Care Managers are distributed patients based on medical office location and PCP 11

12 Care Management Workflow The Care Manager assigned to the patient is responsible for tracking the patient in CMTS A chart review in EPIC is completed with recommendations for a prescribed plan of care which is submitted to PCP All care gaps are reviewed as a part of the patients total care Care Managers track the patients until they reach the identified clinical goals Once the patient reaches goal or declines care, they are placed in a Maintenance Mode in CMTS 12

13 Care Management Tracking System (CMTS) Online tool from Pharmacy Analytical Services in Kaiser California User access assigned and once access obtained, available from any Kaiser computer Used for disease management monitoring for: Diabetes CAD Asthma

14 Care Management Tracking Tool 14

15 CMTS Patient List 15

16 CMTS Patient List 16

17 CMTS Patient List 17

18 CMTS Inbox Features

19 Care Management Reports Care Manager Touch Report (from EPIC) CMTS Report Dashboard Chronic Disease Report 19

20 Touch Report Lists the absolute numbers of encounters done by each care manager Useful for baseline productivity Time of encounter not taken into account No ability to attach outcomes to these numbers

21 Care Manager Detail Clinical Pharmacist 21

22 Care Manager Detail - Allied 22

23 Care Manager Detail Population Care Manager 23

24 Care Manager Detail RN Care Manager 24

25 Care Management - Facility Detail 25

26 Dashboard 26

27 Chronic Disease Report 27

28 Advantages/Disadvantages of CMTS Advantages: Reporting capabilities Accountability on individual level Centralized ability to assign and track patients Disadvantages: Double documentation with medical record Separate system to log into during busy days 28

29 Follow-up Actions Meet with Office Based Teams Meet with individual Care Managers Collaborate with Advance Care Management Committee and Quality Executive Sponsors 29

30 30

31 Questions 31

32 MetroHealth Hospital Patient Center Medical Home Role of the Care Coordinator 32

33 Patient Centered Medical Home Patient centeredness refers to health care that establishes a partnership among practitioners, patients, and their families to ensure that decisions respect patients wants, needs, and preferences and that patients have the education and support they require to make decisions and participate in their own care. Institute of Medicine Envisioning a National Healthcare Quality Report 33

34 34

35 Case Management Disease Management Care Navigation Referral of Patients Providers (PCP) Providers (other) Other Sources (FC, SW, PSR, ED, self) Health risk assessment/ appraisal -Review Care Coordinator Reports - New Enrollees Rpt Review DM, HTN & HF reports for diagnosed patient s health measures Perform Outreach: Reminders to patients with HM due or clinical need. Initiate by Call or Contact either from or to patient. Including acute care outreach Initiate Case Coordinate follow-up or other needs and provide information Create Case in Tapestry & Review Chart (incl Problem list, ED Utilization, Show Rates) Contact Patient/Family (Phone, Letter, Nurse Visit) Create Initial Case Management Plan (incl Goals & Frequency of Contacts) Monitoring Function to add when staffing level permits Yes Need Case Open? No Monitor for patient follow up/ compliance Provide support to patient who is self -managing Intervention Educate Patient (Plan & Disease) Coordinate Access & Utilization Self Management Support Revise Plan as needed Close case Monitor Patient Adherence to Treatment Plan Not Done Final updates to case notes Complete Calls, Letters, Nurse Visits, and Interdisciplinary Referrals/Consults (as needed) Evaluate patient status to plan Done 35

36 Case Management Case Manager for High Risk patients: Chronic Disease; Inappropriate Utilization (repeat ED use); Medical Non-compliance; High degree of complexity Chronic disease self management education and support (telephonic, letters, in office) Serves as the liaison between the patient and the PCP (Epic in-basket messages, routing encounter messages, interdisciplinary team meetings) Assist with adherence to treatment plan (chart review for outstanding orders, health maintenance, referrals, specialty follow ups) 36

37 Tools used for CM Tapestry 37

38 CM Tools 38

39 In-Basket Alert: Review is Due 39

40 Tracking Patient Progress in Tapestry 40

41 Disease Management Proactive disease management of identified patient populations within the medical home patient panel through monitoring of specified clinical and utilization activities and initiating targeted patient outreach and follow-up based on these activities. Diabetic Population, Heart Failure Population, and Hypertension Population 41

42 Reports in Reporting Workbench 42

43 Diabetes Workbench Report 43

44 Care Navigation and Acute Care Follow up Coordinates use of clinical and ancillary resources within and outside of the MetroHealth System to achieve treatment goals specified in patient care plan assist with scheduling; making referrals inside and outside MetroHealth system; identifying and eliminating barriers to accessing care (transportation, health care coverage, Rx coverage, etc.) Use of Workbench report to provide outreach to patients who had recent ED, inpatient, or urgent care visit to assure appropriate and timely follow up care. 44

45 Acute Care Workbench Report 45

46 QUESTIONS? 46