Toolkit VA Palo Alto Health Care System

Toolkit VA Palo Alto Health Care System Developed by: Debra L. Hummel, MSN, ARNP-C Katie S. Holloway, MS, CTRS Sasha F. Smither, MSW, LCSW Jonathan G. Shaw, MD, MS Ian Tong, MD Lien Nguyen, MPH Danielle Cohen, MPH Cindie Slightam, MPH 1

Table of Contents Introduction 3 Overview of ImPACT Team Member Roles and Skills 4 Clinic Procedures Team Process Nurse Practitioner 10 Recreation Therapist 12 Social Worker 15 Program Coordinator 18 Medication Management Protocol 19 Graduation Procedures Process 20 Criteria 21 Letter to patient 22 ImPACT Clinic Documents and Materials PACT ImPACT Service Agreement 23 Patient Invitation Letter 25 ImPACT-Specialty Clinic Co-Attend Note Template 26 Patient Care Coordination Map 27 ImPACT Care Plan Template 28 Sample Language for Describing Impact Program 29 ImPACT Team Lessons Learned 31 Training and Resources for Clinical Team 32 Glossary 33 2

Introduction Mirroring patterns observed throughout the United States, approximately half of health care expenditures in the Veterans Affairs Health Care System are generated by 5% of patients. In 2013, in an attempt to provide excellent care and optimize health care utilization, VA Palo Alto launched an innovative clinical pilot project to provide intensive management for the facility s most complex and primary care patients (i.e., patients receiving care from VA Patient Aligned Care Teams (PACT)). The resulting program ImPACT (Intensive Management PACT) utilizes a multidisciplinary team (physician, nurse practitioner, social worker, recreational therapist, and program coordinator) to augment PACT care. The ImPACT project is designed to efficiently meet patient-defined goals, with the overarching objective of reducing preventable hospitalizations and emergency care and optimizing patient-centered outcomes. The ImPACT program was implemented in February 2013. While the program is still evolving and refining its processes, early input from patients and PACT providers suggests that the program is providing high-quality, patient-centered care that offloads intensive management from existing primary care teams. An evaluation is under way to determine how ImPACT influences health care utilization patterns and associated costs for enrolled patients compared to similar patients assigned to a delayed-enrollment group. Given growing interest in programs for high-utilizing patients within the VA and elsewhere, the ImPACT team developed this toolkit to share their materials, processes, and lessons-learned with other facilities that are interested in developing intensive management programs. We hope that this toolkit can provide framework and guidance for the development and implementation of multidisciplinary teams for high-utilizing patients with complex health and health care needs. While the contents of this toolkit may be of general interest, many of the materials and processes are specific to the VA Health Care System. Sincerely, The ImPACT Team VA Palo Alto Health Care Team 3

Overview of ImPACT Team Members Roles and Skills Recommended Skills/Experience for All Team Members Intensive management teams work with extremely complex patients many of whom even the most experienced clinical providers find challenging or overwhelming to manage within the traditional healthcare structure. Team members must be open to a holistic, multidisciplinary view of medical care that emphasizes the importance of addressing psychosocial needs on equal level with traditional medical treatment. Ideally all members should have adequate experience and mastery of their respective fields to be confident representing the perspective of their discipline in a multidisciplinary team. It should be noted that different intensive management teams may engage different types of staff. The specific roles are not as critical as ensuring that the team includes individuals with the range of skills, experience, and responsibilities described below. Team members should: Have experience working dealing with patients with complex medical AND mental health issues Be used to (and enjoy!) working collaboratively within a team Be comfortable practicing independently and relying on their own judgment within their discipline Be open to alternative approaches, and value the contribution of disciplines outside their own Be interested in continuously learning new skills and knowledge Possess: o the ability and desire to work creatively o flexibility, and good prioritization skills in face of multi-tasking o strong interpersonal and communication skills o strong patient teaching skills o an atypically high level of patience and tolerance (or better yet an affinity) for challenges o be healthy in their own right (active in pursuing self care and own physical and mental health) 4

Nurse Practitioner (Full Time Position) Ideally should be an experienced practitioner who is trained in adult or family medicine, used to working both collaboratively with teams but also comfortable practicing independently, confident relying on their own clinical judgment. As with all members, he/she should have the ability and desire to work creatively and collaboratively with a team, and possesses patience, strong interpersonal skills, and teaching skills. Key Activities Patient clinical care: o Often first point of contact when clinical issues arise o Responds immediately to patient and caregivers needs, building trust and providing comprehensive follow-up. o Acts as surrogate for PCP when unavailable, as messenger and translator between PCP/patient as necessary always in close coordination and agreement with PCP. o Provides care primarily by phone, but in person as needed o Addresses majority of clinical care needs (in coordination with PCP/PACT) that arise between usual routine annual/bi-annual medical visits (which remain the domain of the PCP/PACT). Elicits patient goals and helps achieve them Conducts medication reconciliation and adjustment Directs phone line for patients. Assists patients in navigating the medical system. Educational role: explains providers treatment plan, provides health coaching, proactively directs patients regarding chronic disease management Provider interface o Point of contact for PACT providers and specialists o Advocates for patients during specialty visits via co-attendance or brief communications pre/post visits Social Worker (Full Time Position) Ideally should have an LCSW or similarly advanced level or training/experience, with prior experience in Medical Social Work, and either formal training in mental health social work or experience working with complex co-morbid mental and physical illness. As with all members, he/she should have the ability and desire to work creatively and collaboratively with a team, and possesses patience, strong interpersonal skills, and teaching skills. Key Activities Performs detailed chart review and psychosocial assessment to identify patient/caregiver needs 5

Strong emphasis on motivational interviewing and brief interventions/counseling for behavioral change (i.e. coping skills, relaxation techniques, anger management, mindfulness, grounding skills) Coordinates care with inpatient and outpatient medical, mental health and specialty providers Assesses patient/caregiver strengths, aspirations, psychosocial and system barriers to learning/adaptation Provides supportive counseling and education to support adjustment, coping with illness/disability Identifies appropriate VA and community resources while promoting self-determination and autonomy Provides brief counseling to help manage relationships, employment concerns and promote future health care planning (future incapacity) Serves as a patient advocate and liaison to increase access to needed care/services by addressing systems issues/barriers Coordinates care during transitions from hospital and other facilities Meets with stakeholders in the VA and community to develop shared partnerships/program Recreation Therapist (MS CTRS) (Full Time Position) Ideally should possess high energy and be a gregarious and confident individual as role involves representing and explaining the Recreation Therapy (RT) discipline to patients/providers who are naïve to RT. This individual must have the flexibility and willingness to be practicing on their own out in the field for much of their time, balancing time in the office with the team and acting as an invaluable extension of the team beyond the walls of the medical center. Must be adaptable, diligent, and creative in building treatment around complex patients with low-levels of engagement. As with all members, he/she should have the ability and desire to work creatively and collaboratively with a team, and possesses patience, strong interpersonal skills, and teaching skills. Key Activities Establishes rapport with patient to begin leveraging self-management of chronic condition or initiate manageable changes to lifestyle Mobile Arm meet patient in community setting and encourage a relationship in his or her community, with an emphasis on health & wellness activities (Community Reintegration) Facilitates access to community resources, including Aquatic Exercise, Acupuncture, Body Awareness Class, Healthy Cooking Classes, etc. Provides inclusive activities which garner social support and positive interactions Meets with stakeholders in the VA and community to develop shared partnerships/program 6

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Sample Language for Describing VA-ImPACT Program To Patients: We are a complimentary program to your PACT team. We work alongside your provider to help you, the patient, achieve your goals in health & wellness. We do not replace your provider; rather we work with them, your specialty providers, and you to form a team to meet your needs. Our team consists of a nurse practitioner, a physician, a social worker, and a recreational therapist. ImPACT is a holistic multidisciplinary team that assists individuals in their health and wellness goals, as well as helps with navigating the medical system in regards to multiple appointments and providers. To Other (VA) Providers: We are a new team that compliments the PACT providers to work with patients identified as high utilizers which have frequent ER/hospitalizations in order to reduce cost. We provide more individualized care and direct access/ after-hours line. We also use alternative modalities and interventions to increase patient engagement. ImPACT or Intensive medical management of P...A...C...T..., consists of a multidimensional team that assists medically complex patient's to achieve their optimal health, assist in care coordination, engage with their community, and provide "high touch" in order to reduce avoidable, uncoordinated, or inappropriate healthcare utilization, that can lead to both poorer outcomes and higher costs. Through a high-touch model, the ImPACT team aims to prevent exacerbations in illness, through early detection and engagement of patients in appropriate social and medical support. The team augments existing care with an added layer, coordinating primary and specialty care, providing intensive case management of chronic conditions, directing patients to additional resources to enhance medical and social support, responding rapidly to health status deterioration, and facilitating smooth transitions after high-acuity events. ImPACT provides care coordination and intensive management building on existing PACT infrastructure without replacing the patient s existing primary care. Our multidisciplinary ImPACT team includes an NP, MD, SW, and RT; we work with the highest risk patients to ensure care is efficiently aligned with meeting patient-defined goals, with the overarching objective of reducing preventable hospitalizations or emergency care, and optimizing patient centered outcomes. The ImPACT team is a multidisciplinary team that intensely co-manages a small group of the highest risk patients with the existing PCP/PACTs. This allows us the strength to be nimble in 29

nature, and respond to each patient s individual needs and goals and to navigate the VAPAHCS resources, with high-touch and timely interventions, and by coordinating and maximizing efficient use of the facility s pre-existing PACT infrastructure. At the end of each ImPACT note in CPRS: ***This patient is currently enrolled in the ImPACT program (Intensive Management PACT). We are an Interdisciplinary care management team assisting patients with multiple chronic conditions, to maximize patient engagement and coordination of care. ImPACT is an extension of the patient's primary care physician. Please feel free to contact us for questions or assistance in this patient's care coordination. Impact direct line 650-XXX-XXXX.*** 30

Lessons Learned START-UP A dedicated meeting space and /or clinic room is crucial to having privacy and establishing rapport with patients Early start on staff recruitment is key Patient tracker is vital Shared calendar of appointments Importance of meeting with specialty and subspecialty practices ImPACT visibility -explain and re-explain program to patients and VA services Hold meeting specifically for team members to discuss each individual s role, discipline, background and philosophy of care Trainings are critical (see attached) INTAKES At least two members of the ImPACT team should be present for intake. It is ideal if all three members can be present. Be realistic about how many intakes can be done each week. Surveys should be completed before intakes & administrator schedules intakes Ongoing education to patients and providers of ImPACT provider line Listen to patients story to establish relationship Takes 3-4 encounters to begin a rapport and develop a relationship Often takes several touches before goals are meaningfully discussed Set realistic, easily attainable, small goals Home visits provide unique insight, but carry significant regulatory implications Notifications in CPRS of ER/Hospital admits are helpful to capture patient while inpatient Skeptical that PAM score may not be accurate for our demographic of complex VA patients. The team should be wary of working harder than the patient towards his/her goals; primary role is one of coaching Patients appreciate birthday/condolence cards COORDINATION OF CARE Meet other VA service representatives early on and often to increase visibility Clarify role of team with primary care Coordinate with discharge planners in inpatient medicine and psychiatry Coordinate care with mental health providers, primary care physicians, and specialty services Call patient within 48 hours of discharge from inpatient psychiatry, inpatient medicine, or the emergency room. If applicable, call receiving SNF/Rehab facility prior to and upon discharge Medication reconciliation/med list for patients with a comments section of whom ordered medication and when changed Ensure that all labs, medication, equipment, and home services were ordered prior to discharge. Be proactive in asking patients if they have any concerns about aspects of their health and VA care Access CURES for patients who may be abusing opioids TEAM COMMUNICATION Importance of entire ImPACT clinical team starting at the same time Develop backup mechanism for team members Importance of team huddles and team building Shared Team Calendar Outlook or physical white board in shared office Flexibility, creative thinking and collaboration of team members Leadership assistance/meetings weekly is very important Ongoing team building and development 31

Training/Resources Listed below are key courses, trainings, and events the team felt was helpful. Each team member pursued content applicable to his/her discipline or areas of interest. VA-Based Training: Whole Health Coaching Course (details at healthforlife.vacloud.us) Motivational Interviewing & TEACH Working with Active Substance Abusers Substance Dependence: Assessment, Treatment, and Prevention VA Community Safety Course: Non-Abusive Psychological & Physical Intervention VA Scheduler TMS training My HealtheVet team training Legal & Ethical Updates: Protective Mandated Reporting, Conservatorship & Capacity Department of Veterans Affairs Geriatric Scholars Program, and The Foundations of Healthcare Quality Improvement: A Workshop for the Geriatric Scholars Program Non-VA Training: Team Training at Stanford Coordinated Care - Stanford, CA (February/March, August 2013) Chronic Disease Self-Management Facilitator Training, designed by Stanford University, provided by Health Trust Spousal/Partner Abuse: Detection, Intervention & Reporting, EMQ FamiliesFirst - Campbell, CA (January 2014) Aging and Long Term Care, EMQ Families First - Campbell, CA (October 2013) Stanford Compassion Cultivation Training Stanford, CA (January-March 2014) Non-VA Conferences: Innovative Primary Care for High-Utilizing Complex Patients - Palo Alto, CA (June 2013) California Readmission Summit: Driving Readmissions Down - San Francisco, CA (October 2013) Community Care Teams Summit (online attendance ; November 2013) http://www.mainequalitycounts.org/page/2-946/cct-summit-materials 32

Glossary/Acronym Lookup ACTION PLAN-Concrete actions that patient will take towards improved selfmanagement, made on a daily, weekly, or monthly basis CLC- Community Living Center CPRS-electronic medical record system for the VA Healthcare System GUI MAIL-Secure messaging between providers at the VA ImPACT- Intensive management Patient Aligned Care Team PACT- Patient Aligned Care Team PAM- Patient Activation Measure POLST- Physician Orders for Life Sustaining Treatment SNF-Skilled Nursing Facility 33