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Implementing Effective Clinical Care Management MODERATOR: Nicole Van Borkulo, MEd, Practice Improvement Specialist, SNMHI, Qualis Health SPEAKERS: Ed Wagner, MD, MPH, Director and Senior Investigator,
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Implementing Effective Clinical Care Management MODERATOR: Nicole Van Borkulo, MEd, Practice Improvement Specialist, SNMHI, Qualis Health SPEAKERS: Ed Wagner, MD, MPH, Director and Senior Investigator, MacColl Institute for Healthcare Innovation, Group Health Research Institute Kathryn Horner, MS, MacColl Institute for Healthcare Innovation, Group Health Research Institute Rebecca Ramsay, BSN, MPH, Senior Manager of CareSupport and Clinical Programs, CareOregon Casey Boland, RN, MSN, Disease Management Program Coordinator, Multnomah County Health Department Jody Reifenberger, MMS, PA-C, Chronic Disease, Education and Management Department, East Boston Neighborhood Health Center Implementing Effective Clinical Care Management July 11, 2011 Presented by: MacColl Institute for Healthcare Innovation, Group Health Research Institute CareOregon Multnomah County Health Department East Boston Neighborhood Clinic Agenda History and evidence for care management Ed Wagner and Kathryn Horner from MacColl Institute for Health Care Innovation, GHRI Health plan partnership with safety net clinics to build care management capacity Rebecca Ramsay from CareOregon Clinical care management in practice Casey Boland from Multnomah County Health Department Program to target diabetic patients at ED Jody Reifenberger from East Boston Neighborhood Clinic The Patient-centered Medical Home Key Change Concepts: 1. Engaged leadership 2. Quality improvement strategy 3. Empanelment 4. Patient-centered interactions 5. Organized, evidence-based care 6. Care coordination 7. Enhanced access 8. Continuous, team-based healing relationships Step Ladder of Care Case Load High-risk, multimorbid patients Patients with common chronic illnesses All patients in panel who are involved in referral or transition process Care Coordination Logistical Clinical Care Management Logistical Clinical Monitoring Self Mgmt Support Medication Mgmt Clinical Follow-up Care Logistical Clinical Monitoring Self Mgmt Support MacColl Institute for Healthcare Innovation, Group Health Research Institute 2011 Who are patients with complex health care needs? Multiple chronic conditions Frequent hospitalizations Many prescription medications Many care providers Limitation of daily functions High costs Bodenheimer and Berry-Millett, RWJF Synthesis Report No. 19 Medicare spending for beneficiaries with 5 or more chronic conditions % % % 0% 20% 40% 60% 80% Percent of total Medicare spending Thorpe and Howard, Health Affairs, Aug 22, 2006 Average per capita spending by number of chronic conditions (2004) $20,000 $15,000 $10,000 $5,000 $0 $16,819 $10,091 $7,381 $5,062 $2,753 $ Number of chronic conditions Anderson, Chronic conditions Johns Hopkins, 2007 Depression More Common among Chronic Medical Illnesses E Lin, Group Health Cooperative, presentation on TeamCare Study Liz article JAMA, April 7, 2010 The Multi-Condition Patient One-quarter US population Half of Medicare patients Two-thirds of Medicare Costs Chronic Illness Care Single disease care management o Diabetes, asthma, CHF, depression Multi-condition care o Natural clusters of illness o Diabetes/CAD/depression o Depression/chronic pain/substance abuse What is care management? Activities that assist patients and their support systems to manage medical and psychosocial problems with the aim of improving health and reducing the need for expensive medical services The goals are to: Improve patients functional health status Enhance coordination of care Eliminate duplication of services Reduce the need for expensive medical services Care Management Definition and Framework Center for Health Care Strategies, 2007 Care Management Settings Primary care Health plan Vendor supported Integrated multispecialty group Hospital-to-home Home-based Bodenheimer and Berry-Millett, RWJF Synthesis Report No. 19 How are patients identified? Care management is an intensive, costly process requiring highly skilled personnel Care management shouldn t be offered to people who are too healthy or too sick to benefit Some predictive models Charlson Comorbidity Index Chronic disease score Hierarchical Condition Categories (HCC) Adjusted Clinical Groups (ACG) Models work best if there is discussion with physician Bodenheimer and Berry-Millett, RWJF Synthesis Report No. 19 Key Components of Care Management 1. Identify patients most likely to benefit from care management 2. Assess the risks and needs of each patient 3. Develop a care plan together with the patient/family 4. Teach the patient/family about the disease and their management, including medication management 5. Coach the patient/family how to respond to worsening symptoms in order to avoid the need for hospital admissions 6. Track how the patient is doing over time 7. Revise the care plan as needed Bodenheimer and Berry-Millett, RWJF Synthesis Report No. 19 Do research-based care management programs improve quality and reduce costs? Site of study Quality of care Cost reduction Primary care Vendor supported Integrated multispecialty group Hospital-to-home Home-based 7 out of 9 studies found improved quality Some evidence of improved quality 2 out of 3 studies found improved quality Many studies found improved quality No clear evidence of improved quality 3 out of 8 studies found reduced hospital use for subpopulations Inconclusive evidence 1 out of 3 studies found reduced costs Many studies found reduced hospital use and costs No evidence of reduced costs Bodenheimer and Berry-Millett, RWJF Synthesis Report No. 19 Care Management in Primary Care 3 key studies Geriatric Resources for Assessment and Care of Elders (GRACE) (Counsel) Care Management Plus (Dorr) Guided Care (Bolt) Common characteristics among studies: Clinic visits, home visits, phone calls Care management teams with extensive training led by RNs Small case loads Reduced hospitalization for higher-risk subgroups participating in care management compared to control groups Bodenheimer and Berry-Millett, RWJF Synthesis Report No. 19 Hospital-to-Home Care Management 2 key studies Transitional Care Model (Naylor) Care Transitions Intervention (Coleman) Key similarities: Nurse care managers with extensive training Patients visiting during hospitalization and at home postdischarge Key differences: Intensity of the intervention Use of coaching Reduced hospital use compared to control groups Bodenheimer and Berry-Millett, RWJF Synthesis Report No. 19 Characteristics of Successful Care Patient selection Management Programs In-person encounters including home visits Specially trained care managers with low case loads Multidisciplinary teams including physicians Informal caregivers/family assisting the patient Use of coaching Bodenheimer and Berry-Millett, RWJF Synthesis Report No. 19 How have care management programs been adapted to real-world settings? Medicare demonstrations: few show cost savings Program of All-Inclusive Care for the Elderly (PACE): hospital and nursing home utilization greatly reduced but it has been difficult to prove overall cost savings Hospital-to-home programs have been successful in real-world settings, but have required significant modifications High risk clinics have potential Bodenheimer and Berry-Millett, RWJF Synthesis Report No. 19 Next: Rebecca Ramsay from CareOregon Building care management capacity within a transforming primary care system July 11, 2011 Rebecca Ramsay BSN, MPH Senior Manager of Care Support and Clinical Programs -- CareOregon The Chronic Care Model Comprehensive Medical Home Model Advanced Medical Services Model This is a primary focus of our care management work. This may be This is where foundational most of the to successful medical disease and home work care started. management 2 Primary Care Population Health Strategies Registries Gaps in Care Outreach Planned Visits Self Management Support Medication Management Care Coordination Patient Education Patient Activation Complex Care Coordination Problem Solving Linking with Community Resources Empowerment and Education Transitional Care (post hosp/ed) 1.Panel Management 2. Care Management for 3. Complex Case Management Chronic Dz for high risk/cost patients Usual Care in Medical Home New Potential for Medical Home to Transform Patient Health Outcomes PCR Care Management Learning Collaborative TAKE ONE 2009 Five learning sessions once per month for 3 hours 50 + participants; primarily RNs with a few BH specialists and MAs Focused on defining and validating the practice, and creating common language and goals Spent three sessions building self-management support knowledge and skills 4 Lessons Learned from PCR Care Management Learning Collaborative (TAKE ONE) Care managers were engaged and enjoyed learning new skills; satisfaction with the sessions was very high, but the clinic infrastructure was in transition and had not changed enough YET to support this new practice Care managers wanted to step into this new world, but they needed more help 5 Primary Care the phone for the team? Population Health Strategies How do calls come in to the team? Who answers How do we free up time for care management? Who can do some of the work the team RN is doing now? Self Management Creating care management Support schedule templates How do we train Medication for self management support? For disease-specific Management interventions? What EMR tools Care do the Coordination care managers need? What new reports do Patient they need Education to keep track of their caseloads? Patient Activation Building a business/quality case for this work 1.Panel Management 2. Care Management for 3. Complex Case Management Chronic Dz for high risk/cost patients Usual Care in Medical Home New Potential for Medical Home to Transform Patient Health Outcomes Care Management Learning Collaborative TAKE TWO 2010 Narrowed the focus: building the care management skills using depression and diabetes as the conditions of focus recognizing skills will be transferable to multi-condition Required operational/infrastructure development first: structured process of workflow development and role clarification Expanded the audience: encouraged the primary care team to participate in the learning sessions Enhanced the incentives/drivers: Clinics as delegated DM entities for NCQA accreditation; new payment incentives for care management process and outcome measures Developed EMR tools to support the work: leveraged OCHIN to work 7 with CareOregon and the clinics IMPACT Integrated Depression Care CareOregon Training Portland, OR May 13-14, 2010 Rita Havercamp, MSN, PMHCNS-BC, CNS Rebecca Ramsay, BSN, MPH A rational and practical approach to diabetes management David K. McCulloch, MD Clinic Diabetes and Depression Care Management Timeline 10 Clinic Diabetes and Depression Care Management Timeline 11 Diabetes and Depression Care Management Metrics Program participation rates Engaged or opting out Disease coaching intensity Percent meeting minimum frequency targets Disease outcome metrics Percentage of depressed patients with symptom reduction of 50% or greater (PHQ9 score change) Percentage of diabetic patients with clinical indicators meeting or exceeding targets (HbA1c, LDL, BP) Patient satisfaction metrics Annual survey of patient satisfaction with disease management from PCR clinics 12 Disease Management Stratification: LEVEL 3: Depression- Complex LEVEL 3 / Excluded/ Complex Care Elsewhere Stratified into level 2 but either: Haven t yet attempted to engage Already participated in disease mgmt and discharged but didn t meet graduation goals Benefits of detailed categories: Care managers can keep track of what has happened or needs to happen with dz mgmt eligible patients Allows patients to be discharged from dz mgmt if adequate effort has not produced optimal outcomes LEVEL 2a: Depression- Care Mgmt- Eligible LEVEL 2b: Depression- Care Mgmt- Participating LEVEL 2c: Depression- Care Mgmt- Opt Out LEVEL 1: Depression - Usual Care Stratified into level 2 but either: Actively opted out Passively opted out d/t inability to engage FYI Flags developed in EPIC to support stratification tracking and reporting FYI Flag Depression (Diabetes) Usual Care Depression (Diabetes) Care Mgmt-Eligible Depression (Diabetes) Care Mgmt- Participating Depression (Diabetes) Care Mgmt- Opt Out Depression (Diabetes) Complex Care/Excluded/Care Elsewhere FYI Flag Description/Crosswalk Level 1: not receiving dz mgmt bc patient is stable; receiving usual primary care Level 2a: meets criteria for dz mgmt but is not currently engaged/participating bc the care manager hasn t reached out to the patient yet or the patient was discharged (but hasn t met clinical goals to move to Level 1) Level 2b: currently participating in dz management Level 2c: meets criteria for dz mgmt and the care manager attempted to engage but the patient either actively refused to participate or would not engage after the care manager tried Level 3: meets criteria for complex patient; usually means the patient is too complicated to enroll in a disease mgmt program but will receive a different intervention OR patient is receiving care outside of primary care setting for this condition Basic Disease Management Process: Typical Coaching Activities Preliminary Assessment Care Mgmt Intake Care Mgmt Follow-up (multiple) Psych Consult (multiple) PST for Depression (multiple) Maintenance Plan Introductory conversation Assessing for appropriateness of enrollment Not a formal intake Formal intake assessment once enrolled Self management coaching Medication check-in Teaching Developing a plan to sustain dz remission or stability Care Management Dashboard Example Care Management Roster 17 Access teams training Call management time workflows technology 18 Final Conclusion re Implementing Care Management Care management needs to be part of the value equation for the primary care system They want to do it, but the current incentives haven t fostered it as a need Health plans have a need because we have found that care management effects our bottom line 19 The Build and Spread of Disease Management 1.0 Multnomah County Health Department Casey Boland, RN, MSN Program Coordinator, Chronic Disease Management Aim Standard clinical guidelines for Diabetes and Depression disease management All primary care Nurses transitioned to Care Manager Role New standing orders to promote staff working at the top of their license Improved patient outcomes Measures Outcome Measures % of Diabetic pts with D3 Bundle in control % of Depressed pts achieving 50% decrease in PHQ-9 score: Process Measures 3 care management referrals per team, per week (1 nurse on each team) 2 Intakes per nurse, per week Process Accountability Visual Management of referrals & intakes Chart audits by clinic leadership team Referral and Caseload reports Weekly conference calls Risk stratification reports Elbow support for staff and clinic leaders Risk Stratification Referral Reports Early Results Caseload Build Lessons Learned Support for clinic leadership is key Many challenges are shared across clinics Pilot Teams set the stage Project Team Pilot teams and clinical champions Northeast and East County health centers-based teams Epic Optimization Jennifer McClure Internal Trainers Amy Henninger, Jessica Sosso-Vorpahl, Lisa Sprague, Joanne Serna, Teri Erickson, Kathy Thomes-Rhew, Florence Gerber, Kimmy Figueroa Visual Mgmt/Reporting Support Mindy Stadtlander, Monica Gration Patient Education Materials Andrea Deen, Sylvia Ness External Trainers Rebecca Ramsay, Ariel Singer, Legacy Mt. Hood Diabetes Center Next Steps Collate feedback into revised standard work and improved materials Adapt process and materials for sustainability (new staff orientation, easier shared drive access) Support clinics by supporting clinic leaders Implementing Effective Clinical Care Management Jody Reifenberger, MMS, PA-C Lieutenant Team Leader SNMHI Chronic Disease, Education and Management Department East Boston Neighborhood Health Center SNMHI Sponsors and Co-Funders
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