IMPROVING OUR CLIENTS WHOLE HEALTH THROUGH DATA-INFORMED CARE MANAGEMENT
|
|
|
- Oswin Garry Porter
- 8 years ago
- Views:
Transcription
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
Provider Manual. Section 18.0 - Case Management and Disease Management
Section 18.0 - Case Management and Disease Management 18.1.1 Introduction 18.2.1 Scope 18.3.1 Objectives 18.4.1 Procedures Case Management 18.4.1-A. Referrals 18.4.1-B. Case Management Mercy Maricopa Acute
Lessons on the Integration of Medicine and Psychiatry
Lessons on the Integration of Medicine and Psychiatry Edward Post, MD, PhD Associate Professor of Internal Medicine, University of Michigan VA Health Services Research & Development Center of Excellence,
Fixing Mental Health Care in America
Fixing Mental Health Care in America A National Call for Measurement Based Care in Behavioral Health and Primary Care An Issue Brief Released by The Kennedy Forum Prepared by: John Fortney PhD, Rebecca
Integrating Data to Support Care Management Transformation
Integrating Data to Support Care Management Transformation The Washington State Experience David Mancuso, PhD Director, Research and Data Analysis Division Washington State Department of Social and Health
Idaho Health Home State Plan Amendment Matrix: Summary Overview. Overview of Approved Health Home SPAs
Idaho Health Home State Plan Amendment Matrix: Summary Overview This matrix outlines key program design features from health home State Plan Amendments (SPAs) approved by the Centers for Medicare & Medicaid
MedStar Family Choice (MFC) Case Management Program. Cyd Campbell, MD, FAAP Medical Director, MFC MCAC June 24, 2015
MedStar Family Choice (MFC) Case Management Program Cyd Campbell, MD, FAAP Medical Director, MFC MCAC June 24, 2015 Case Management Program Presentation Overview CM Programs Disease Management Complex
Care Coordination. The Embedded Care Manager. Presented by Thomas Decker, MD Mary Finnegan, BSN, M.Ed
Care Coordination The Embedded Care Manager Presented by Thomas Decker, MD Mary Finnegan, BSN, M.Ed Goals of Care Management The goals of care Management are consistent with the Triple Aim: Improve population
CRITICAL SKILLS FOR OPTIMUM PATIENT CARE: Care Coordination and Health Literacy
Thursday, August 20, 2015 CRITICAL SKILLS FOR OPTIMUM PATIENT CARE: Care Coordination and Health Literacy Contributors to the Presentation: Steven A. Estrine, PhD, President & CEO Loan Mai, PhD, Director
Population Health Management Program
Population Health Management Program Program (formerly Disease Management) is dedicated to improving our members health and quality of life. Our Population Health Management Programs aim to improve care
Managing Care for Adults With Long-term Medical Illnesses. A Review of the Research
Managing Care for Adults With Long-term Medical Illnesses A Review of the Research Is This Information Right for Me? If you meet all of the following, this information is for you: You or someone you care
Person-Centered Nurse Care Management in Home Based Care: Impact on Well-Being and Cost Containment
Person-Centered Nurse Care Management in Home Based Care: Impact on Well-Being and Cost Containment Donna Zazworsky, RN, MS, CCM, FAAN Vice President: Community Health and Continuum Care Carondelet Health
Care Coordination in. the Health Home Program A benefit available to high risk Medicaid beneficiaries. Northwest Regional Council 1
Care Coordination in the Health Home Program A benefit available to high risk Medicaid beneficiaries Northwest Regional Council 1 Northwest Regional Council Develops and advocates for a comprehensive and
Mental Health & Substance Abuse Services
Mental Health & Substance Abuse Services Services Overview The Adult Behavioral Health (ABH) Department provides Mental Health and Substance Abuse services to clients who meet criteria for either Substance
October 22, 2014 Jill M. Gregoire RN, MSN Quality Assurance/Clinical Operations Director Indian Stream Health Center Colebrook, NH
October 22, 2014 Jill M. Gregoire RN, MSN Quality Assurance/Clinical Operations Director Indian Stream Health Center Colebrook, NH Why Stratify Risk for Your Patients? NCQA s Patient-Centered Medical Home
Dr. Anna M. Acee, EdD, ANP-BC, PMHNP-BC Long Island University, Heilbrunn School of Nursing
Dr. Anna M. Acee, EdD, ANP-BC, PMHNP-BC Long Island University, Heilbrunn School of Nursing Overview Depression is significantly higher among elderly adults receiving home healthcare, particularly among
Integrating Behavioral Health and Primary Health Care: Development, Maintenance, and Sustainability Cici Conti Schoenberger, LCSW, CAS Behavioral
Integrating Behavioral Health and Primary Health Care: Development, Maintenance, and Sustainability Cici Conti Schoenberger, LCSW, CAS Behavioral Health Provider Sunshine Community Health Center Why Integrate?
HealthCare Partners of Nevada. Heart Failure
HealthCare Partners of Nevada Heart Failure Disease Management Program 2010 HF DISEASE MANAGEMENT PROGRAM The HealthCare Partners of Nevada (HCPNV) offers a Disease Management program for members with
Caring for depression
Caring for depression Aetna Health Connections SM Disease Management Program Get information. Get help. Get better. 21.05.300.1 B (6/08) Get back to being you How this guide can help you Having an ongoing
How To Help Veterans With A Mental Health Diagnosis
RIGHT CARE RIGHT TIME RIGHT PLACE DEBORAH HARRIS-COBBINAH RN, MSN, CNS, NP, BC Faculty Disclosure Deborah Harris-Cobbinah, MSN, ANP,MHCNS,BC Conflict of Interest: None Employer: Dept. of Veterans Affairs
Bi-Directional Integration: What Degree of Integration is Needed for Success Linking Indiana Integration Principles to National Models
Bi-Directional Integration: What Degree of Integration is Needed for Success Linking Indiana Integration Principles to National Models What Degree of Success is Needed from the Affordable Care Act Perspective?
Project Objective: Integration of mental health and substance abuse with primary care services to ensure coordination of care for both services.
Domain 3 Projects 3.a.i Integration of Primary Care and Behavioral Health Services Project Objective: Integration of mental health and substance abuse with primary care services to ensure coordination
Chapter 18 Behavioral Health Services
18 Behavioral Health Services INTRODUCTION The State of Arizona has contracted the administration of the AHCCCS mental health and substance abuse services program to the Arizona Department of Health Services
CCNC Care Management
CCNC Care Management Community Care of North Carolina (CCNC) is a statewide population management and care coordination infrastructure founded on the primary care medical home model. CCNC incorporates
Population Health Solutions for Employers MEDIA RESOURCES
Population Health Solutions for Employers MEDIA RESOURCES ABOUT MISSIONPOINT MissionPoint s mission is to make healthcare more affordable, accessible and improve the quality of care for our members. MissionPoint
Chronic Care Management Model
Chronic Care Management Model And, it s history and evolution in Washington State Melissa Schafer RN, BSN, CCM Part of Washington s journey toward cost savings October 2001, ADSA Mobility Project 2002,
SECTION VII: Behavioral Health Services
OVERVIEW Behavioral Health Services (mental health and/or substance abuse services) are covered for all members except those enrolled in family planning services only. Care1st manages the delivery of select
Financing integrated Healthcare in Washington
Financing integrated Healthcare in Washington as of: April 23. 2012 E & M Codes CPT Code 99201-99205 99211-99215 Est. Pt Diagnostic Code May be used only with physical Federally Qualified Health Centers
Integrating Self Management Supports in Primary Care
Integrating Self Management Supports in Primary Care Support for this product was provided by a grant from the Robert Wood Johnson Foundation in Princeton, New Jersey, 2009 Objectives: To describe key
CHAPTER 17: HEALTH PROMOTION AND DISEASE MANAGEMENT
CHAPTER 17: HEALTH PROMOTION AND DISEASE MANAGEMENT HEALTH SERVICES AND PROGRAMS The Plan s Health Promotion and Disease Management Department seeks to improve the health and overall well-being of our
Effective Care Management for Behavioral Health Integration
Effective Care Management for Behavioral Health Integration Title: Effective Care Management for Behavioral Health Integration A process improvement initiative focused on improving mental health outcomes
El Rio Community Health Center
Integrated Primary Care Behavioral Health Services El Rio Community Health Center 79,000 individuals served - 16 clinic locations 3 different types of BH integration projects Fully Integrated PCBH Program
Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Coventry Health and Life Insurance Company Commercial Lines of Business
Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Coventry Health and Life Insurance Company Commercial Lines of Business Quality Management Program 2012 Overview Quality Improvement
CARDIOLOGIST What does a cardiologist do? A cardiologist is a doctor who specializes in caring for your heart and blood vessel health.
YOUR TREATMENT TEAM CARDIOLOGIST What does a cardiologist do? A cardiologist is a doctor who specializes in caring for your heart and blood vessel health. To become a cardiologist, a doctor completes additional
Major Depressive Disorders Questions submitted for consideration by workshop participants
Major Depressive Disorders Questions submitted for consideration by workshop participants Prioritizing Comparative Effectiveness Research Questions: PCORI Stakeholder Workshops June 9, 2015 Patient-Centered
Community Care Collaborative Integrated Behavioral Health Intervention for Chronic Disease Management 307459301.2.3 Pass 3
Community Care Collaborative Integrated Behavioral Health Intervention for Chronic Disease Management 307459301.2.3 Pass 3 Provider: The Community Care Collaborative (CCC) is a new multi-institution, multi-provider,
An Integrated, Holistic Approach to Care Management Blue Care Connection
An Integrated, Holistic Approach to Care Management Blue Care Connection With health care costs continuing to rise, both employers and health plans need innovative solutions to help employees manage their
IRG/APS Healthcare Utilization Management Guidelines for West Virginia Health Homes - Bipolar and Hepatitis
IRG/APS Healthcare Utilization Management Guidelines for West Virginia Health Homes - Bipolar and Hepatitis CHANGE LOG Medicaid Chapter Policy # Effective Date Chapter 535 Health Homes 535.1 Bipolar and
5/6/2014. Physiologic Monitoring Tools & Use with Patients with Chronic Health Conditions. Objectives. The Issue at Hand
Physiologic Monitoring Tools & Use with Patients with Chronic Health Conditions Kelly Brittain, PhD, RN Assistant Professor MCRH-Nursing Grand Rounds May 8, 2014 Objectives 1. Summarize previous research
CHAPTER 535 HEALTH HOMES. Background... 2. Policy... 2. 535.1 Member Eligibility and Enrollment... 2. 535.2 Health Home Required Functions...
TABLE OF CONTENTS SECTION PAGE NUMBER Background... 2 Policy... 2 535.1 Member Eligibility and Enrollment... 2 535.2 Health Home Required Functions... 3 535.3 Health Home Coordination Role... 4 535.4 Health
Oregon Standards for Certified Community Behavioral Health Clinics (CCBHCs)
Oregon Standards for Certified Community Behavioral Health Clinics (CCBHCs) Senate Bill 832 directed the Oregon Health Authority (OHA) to develop standards for achieving integration of behavioral health
Telemedicine in Physical Health and Behavioral Health
Telemedicine in Physical Health and Behavioral Health Collaborative Care Summit April 16, 2015 Shabana Khan, MD Assistant Professor of Psychiatry Western Psychiatric Institute and Clinic University of
Community Health Program Outpatient Care Management Program
Community Health Program Outpatient Care Management Program Beverly Dowling Assistant Vice President Community Health Network Office of Health Policy and Legislative Affairs The University of Texas Medical
Understanding. Depression. The Road to Feeling Better Helping Yourself. Your Treatment Options A Note for Family Members
TM Understanding Depression The Road to Feeling Better Helping Yourself Your Treatment Options A Note for Family Members Understanding Depression Depression is a biological illness. It affects more than
Healthy Coping in Diabetes Self Management
Healthy Coping in Diabetes Self Management Support for this product was provided by a grant from the Robert Wood Johnson Foundation in Princeton, New Jersey, 2009 Objectives Describe the relationship among
Member Health Management Programs
Independent Health s Member Health Management Programs Helping employees manage their health. Helping you manage your costs. Independent Health s Member Health Management Programs A Comprehensive Approach...
El Rio Community Health Center. Integrated Primary Care Behavioral Health Services
El Rio Community Health Center Integrated Primary Care Behavioral Health Services 1 El Rio Community Health Center Mission Improving the health of our community through comprehensive, accessible, affordable,
Johns Hopkins HealthCare LLC: Care Management and Care Coordination for Chronic Diseases
Johns Hopkins HealthCare LLC: Care Management and Care Coordination for Chronic Diseases Epidemiology Over 145 million people ( nearly half the population) - suffer from asthma, depression and other chronic
MODULE 11: Developing Care Management Support
MODULE 11: Developing Care Management Support In this module, we will describe the essential role local care managers play in health care delivery improvement programs and review some of the tools and
Department of Human Services Health Care Reform Review Committee Representative George Keiser, Chairman March 19, 2014
Department of Human Services Health Care Reform Review Committee Representative George Keiser, Chairman March 19, 2014 Chairman Keiser, members of the Health Care Reform Review Committee, I am Julie Schwab,
PAYMENT INNOVATIONS SUPPORTING BEHAVIORAL HEALTHCARE DELIVERY IMPROVEMENT. NGA July 2015
PAYMENT INNOVATIONS SUPPORTING BEHAVIORAL HEALTHCARE DELIVERY IMPROVEMENT NGA July 2015 My Background Medicaid Director Previously DMH Medical Director 20 years Practicing Psychiatrist CMHCs 10 years FQHC
DELIVERING VALUE THROUGH TECHNOLOGY
DELIVERING VALUE THROUGH TECHNOLOGY Mark Nelson, MD - EMR Physician Champion Krishna Ramachandran - Chief Information and Transformation Officer Karen Adamson - Director, Epic Clinical Applications DuPage
Integrating Behavioral Health and Primary Care. Overview
Integrating Behavioral Health and Primary Care Department of Family Medicine & Public Health Sciences Overview 1) Healthcare system & spending 2) Why behavioral health? 3) Patient-Centered Medical Home
Health System Strategies to Improve Chronic Disease Management and Prevention: What Works?
Health System Strategies to Improve Chronic Disease Management and Prevention: What Works? Michele Heisler, MD, MPA VA Center for Clinical Practice Management Research University of Michigan Department
Tribes and the Health Home Program 01/20/2015
Tribes and the Health Home Program 01/20/2015 Yolanda Lovato, DSHS Health Home Stakeholder Engagement Manager Marietta Bobba, DSHS Planning and Program Development Manager Health Home Program History Created
Community Care of North Carolina. Statewide program for managing Carolina Access recipients
Community Care of North Carolina Statewide program for managing Carolina Access recipients Key Goals Improve access to, quality of, and coordination of care for Carolina Access Medicaid patients. By doing
Module 5: Bill s Search for Lois
COMPANION GUIDE Module 5: Bill s Search for Lois Tips for facilitators: Watch the Module 5 DVD prior to the training so that you can anticipate questions and identify supplementary materials needed for
Ohio s Community Behavioral Health Center Health Homes: A New Service Delivery Model
Ohio s Community Behavioral Health Center Health Homes: A New Service Delivery Model 1 C E N T E R F O R E V I D E N C E - B A S E D P R A C T I C E S A T C A S E W E S T E R N R E S E R V E U N I V E
RN Care Manager Assessment: The 4 Domains
RN Care Manager Assessment: The 4 Domains Access to Care Experience with Provider(s) Getting Needed Services Coordination of Care Medical Home / Services Risk Medical Neighborhood Social Support Home Environment
Behavioral Health Rehabilitation Services: Brief Treatment Model
Behavioral Health Rehabilitation Services: Brief Treatment Model Presented by Allegheny HealthChoices, Inc. 444 Liberty Avenue, Pittsburgh, PA 15222 Phone: 412/325-1100 Fax 412/325-1111 April 2006 AHCI
Collaborative Care Tips for Sustainability. Virna Little, PsyD, LCSW r, SAP The Institute for Family Health NYS Collaborative Care Initiative
Collaborative Care Tips for Sustainability Virna Little, PsyD, LCSW r, SAP The Institute for Family Health NYS Collaborative Care Initiative Teamwork Applies to Billing Too!!! Combine with other initiatives
Home Health Care: A More Cost-Effective Approach to Medicaid in Illinois Illinois HomeCare & Hospice Council December 2010
Home Health Care: A More Cost-Effective Approach to Medicaid in Illinois Illinois HomeCare & Hospice Council December 2010 As the Illinois Legislature prepares to act on the future of Medicaid, it is important
Are mental health nurses equipped with the knowledge to effectively manage the physical health of their service users?
Are mental health nurses equipped with the knowledge to effectively manage the physical health of their service users? Dr Hussain Al-Zubaidi George Eliot Hospital Trust Dr Shahnaz Hassan Coventry and Warwickshire
RN/Care Coordinator Roles In the Integrated Health Home
RN/Care Coordinator Roles In the Integrated Health Home Nancy Delanoit, Taralyn Tranmer May 2014 The Magellan ICN, IHH site care coordinators and managed care nurses work together in a partnership to improve
Advancing Health Equity. Through national health care quality standards
Advancing Health Equity Through national health care quality standards TABLE OF CONTENTS Stage 1 Requirements for Certified Electronic Health Records... 3 Proposed Stage 2 Requirements for Certified Electronic
Columbus Regional Health. Diabetes Educators designing programs using Health Coach extenders in the PCMH.
Columbus Regional Health Diabetes Educators designing programs using Health Coach extenders in the PCMH. Objectives: Define what generated the need for the project. Discuss the delivery design model in
Change Idea: Shared Care Plans My Total Health Plan
Change Idea: Shared Care Plans My Total Health Plan Marc Avery, MD University of Washington, AIMS Center & Gale Bataille, MSW California Institute for Mental Health & Darren Urada, PhD UCLA Integrated
Behavioral Health Centers of Excellence & the Future of Health
Behavioral Health Centers of Excellence & the Future of Health -draft concept paper- Healthcare reform is creating tremendous disruption in nearly all aspects of healthcare. As many industries have already
Behavioral Health Services 14.0
Behavioral Health Services 14.0 Kaiser Permanente s Behavioral Health Services operates within the multi-specialty Mid- Atlantic Permanente Medical Group (MAPMG). It is a regional service committed to
Game Changer at the Primary Care Practice Embedded Care Management. Ruth Clark, RN, BSN, MPA Integrated Health Partners October 30, 2012
Game Changer at the Primary Care Practice Embedded Care Management Ruth Clark, RN, BSN, MPA Integrated Health Partners October 30, 2012 Objectives To describe the recent evolution of care management at
Integrated Health Care Models and Practices
Integrated Health Care Models and Practices The Greater Houston Behav io r al Health Affordable Care Act Initiative S e c o n d C o m m u n i t y E d u c a t i o n E v e n t I n t e g r a t e d H e a l
Healthcare Associates Caring for You
Healthcare Associates Caring for You Welcome to Healthcare Associates Dedicated to You At Healthcare Associates (HCA), patients come first, and caring for you is what we do best. We are pleased to offer
Costing statement: Depression: the treatment and management of depression in adults. (update) and
Costing statement: Depression: the treatment and management of depression in adults (update) and Depression in adults with a chronic physical health problem: treatment and management Summary It has not
Integrating Primary Care and Behavioral Health Services: A Compass and A Horizon
Integrating Primary Care and Behavioral Health Services: A Compass and A Horizon A curriculum for community health centers Developed for the Bureau of Primary Health Care Managed Care Technical Assistance
Developmental. SBIRT Substance Abuse (AUDIT & DAST Scales)
s Tools Developmental 96110 Developmental testing; limited (e.g., Pediatric Symptom Checklist, Vanderbilt AD/HD, Developmental Screening Test II, Early Language Milestone Screen), with interpretation and
Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Summit Health Plan of Florida
Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Summit Health Plan of Florida Medicare Quality Management Program Overview Quality Improvement (QI) Overview At Coventry, we
caresy caresync Chronic Care Management
caresy Chronic Care Management THE PROBLEM Chronic diseases and conditions, including heart disease, diabetes, COPD and obesity, are among the most common, expensive, and preventable health problems in
Establishing an Integrated Behavioral Health Program and Practicum Site in a Community-Based Primary Care Center
Establishing an Integrated Behavioral Health Program and Practicum Site in a Community-Based Primary Care Center Christina S. Lee, Ph.D. Dept. of Applied Psychology Northeastern University, Boston, MA
Improving Service Delivery for High Need Medicaid Clients in Washington State Through Data Integration and Predictive Modeling
Improving Service Delivery for High Need Medicaid Clients in Washington State Through Data Integration and Predictive Modeling Getty Images, istock David Mancuso, PhD Analytics in the Social and Health
Innovations@Home. Home Health Initiatives Reduce Avoidable Readmissions by Leveraging Innovation
How Does CMS Measure the Rate of Acute Care Hospitalization (ACH)? Until January 2013, CMS measured Acute Care Hospitalization (ACH) through the Outcomes Assessment and Information Set (OASIS) reporting
Health Home Program (Section 2703) Iowa Medicaid Enterprise. Marni Bussell Project Manager December 13, 2013
Health Home Program (Section 2703) Iowa Medicaid Enterprise Marni Bussell Project Manager December 13, 2013 1 Two Health Home Programs: Same Triple Aim Goals Chronic Condition Health Home: Primary Care
Behavioral Health Quality Standards for Providers
Behavioral Health Quality Standards for Providers TABLE OF CONTENTS I. Behavioral Health Quality Standards Access Standards A. Access Standards B. After-Hours C. Continuity and Coordination of Care 1.
Approaches to Asthma Management:
Approaches to Asthma Management: BY CAROL MCPHILLIPS-TANGUM AND CAROLINE M. ERCEG ASTHMA IS A CHRONIC DISEASE that affects millions of people in the United States and disproportionately impacts children,
Member name, address, phone number, DOB, MC400 Member ID, MA Recipient Number
CONNECTED CARE DATA TEMPLATE Member Tier Display SMI Tier 1, 2, or 3 (plus historical activity to show changes in tier) Member Demographics Member name, address, phone number, DOB, MC400 Member ID, MA
Pediatricians Implement Office-based Care Management Guided by Meaningful and Actionable Population Health Management
Pediatricians Implement Office-based Care Management Guided by Meaningful and Actionable Population Health Management Changing needs of technology and data for successful coordinated care transformation
UW Medicine Integrated Mental Health Care. Laura Collins MSW, Darcy Jaffe ARNP Jürgen Unützer, MD, MPH, MA
UW Medicine Integrated Mental Health Care Laura Collins MSW, Darcy Jaffe ARNP Jürgen Unützer, MD, MPH, MA Why Behavioral Health Care in Primary Care? 1. Access to care: Serve patients where they are 2.
Community Health Worker Led Diabetes Coaching within the Medical Home
Community Health Worker Led Diabetes Coaching within the Medical Home Christine Snead, RN Erin Kane, MD Baylor Scott & White Health www.alliancefordiabetes.org Objectives Identify tools, resources and
1900 K St. NW Washington, DC 20006 c/o McKenna Long
1900 K St. NW Washington, DC 20006 c/o McKenna Long Centers for Medicare & Medicaid Services U. S. Department of Health and Human Services Attention CMS 1345 P P.O. Box 8013, Baltimore, MD 21244 8013 Re:
Kaiser Permanente: Health Education. Mei Ling Schwartz, MPH Director, Health & Physician Education Kaiser Permanente Panorama City Medical Center
Kaiser Permanente: Health Education Mei Ling Schwartz, MPH Director, Health & Physician Education Kaiser Permanente Panorama City Medical Center Who Is Kaiser Permanente? Founded in 1945, Kaiser Permanente
Disease Management Identifications and Stratification Health Risk Assessment Level 1: Level 2: Level 3: Stratification
Disease Management UnitedHealthcare Disease Management (DM) programs are part of our innovative Care Management Program. Our Disease Management (DM) program is guided by the principles of the UnitedHealthcare
NCQA PCMH 2011 Standards, Elements and Factors Documentation Guideline/Data Sources
NCQA PCMH 2011 Standards, Elements and Factors Documentation Guideline/Data Sources Key: DP = Documented Process N/D = Report numerator and denominator creating percent of use RPT = Report of data or information
Community Care of North Carolina
Community Care of North Carolina CCNC Transitional Care Management Jennifer Cockerham, RN, BSN, CDE Director, Chronic Care Programs & Quality Management 1 Chronic Care Population Within the NC Medicaid
Florida Medicaid: Mental Health and Substance Abuse Services
Florida Medicaid: Mental Health and Substance Abuse Services Beth Kidder Assistant Deputy Secretary for Medicaid Operations Agency for Health Care Administration House Children, Families, and Seniors Subcommittee
Objectives. Family Stress. Pediatric Diabetes Complications. Diabetes Self-Management Education (DSME)
Objectives Recognize the problem related to lack of access to pediatric diabetes subspecialist in Rural Maryland. Appreciate the impact of pediatric telehealth delivery of care to improve access to pediatric
Elderly males, especially white males, are the people at highest risk for suicide in America.
Statement of Ira R. Katz, MD, PhD Professor of Psychiatry Director, Section of Geriatric Psychiatry University of Pennsylvania Director, Mental Illness Research Education and Clinical Center Philadelphia
Managing Patients with Multiple Chronic Conditions
Best Practices Managing Patients with Multiple Chronic Conditions Advocate Medical Group Case Study Organization Profile Advocate Medical Group is part of Advocate Health Care, a large, integrated, not-for-profit
Mental Health Services for Children and Youth in Nova Scotia
Mental Health Services for Children and Youth in Nova Scotia Presentation to the Standing Committee on Community Services - June 1, 2010 Patricia Murray, Director of Children s Services Mental Health,
Profile: Incorporating Routine Behavioral Health Screenings Into the Patient-Centered Medical Home
104 A LOOK TO THE FUTURE Profile: Incorporating Routine Behavioral Health Screenings Into the Patient-Centered Medical Home Background Management of chronic diseases can be challenging in primary care,
To provide standardized Supervised Exercise Programs across the province.
TITLE ALBERTA HEALTHY LIVING PROGRAM SUPERVISED EXERCISE PROGRAM DOCUMENT # HCS-67-01 APPROVAL LEVEL Executive Director Primary Health Care SPONSOR Senior Consultant Central Zone, Primary Health Care CATEGORY
How To Treat A Mental Illness At Riveredge Hospital
ABOUT US n Riveredge Hospital maintains the treatment philosophy of Trauma Informed Care. n Our commitment to providing the highest quality of care includes offering Animal Assisted Therapy, and Expressive