Implementing Care Management Functions
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Transcript Implementing Care Management Functions
Bea Herbeck Belnap, Dr Biol Hum
School of Medicine
University of Pittsburgh
Learning Objectives
1. To understand the different functions and tools required to
effectively implement the Chronic Care Model for
depression management in primary care
2. To identify the core roles and qualifications of care
managers, particularly as liaisons to providers and for
patient self-management support
3. To understand the role and function of care manager
registries and their utility in fostering provider and
patient communication
Wagner Chronic Care Model
Health System
Community
Resources &
Policies
Informed,
Activated
Patient
Health Care Organization
SelfManagement
Support
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Functional and Clinical
Outcomes
CCM: Core Clinical Elements
Leadership
Vision
Resources
Practice
Design
Care management
Clinical
Information
Systems
Clinical information tracking
Protocols- coordinated care
Registry
Feedback to clinicians
CCM: Core Clinical Elements
Decision
Support
Guidelines
Expert/specialist consultation
Self-management
Support
Patient preferences
Information on treatment
Information on and for
Community
Resources
consumers, groups, etc.
Access to non-provider
sources of care
Care Manager Role
Encompasses CCM core elements
General
Medical
(Chronic care,
Prevention,
Follow-up)
Care Manager
Self-management
CM/Liaison: PCP, MH
Community linkages
Crisis intervention
Registry
Behavioral
Health (crisis
referral,
complexity,
etc.)
Care Manager: Core Functions
Patient education
Registry tracking
Provider communication
Community linkages
Care Manager: Patients
Patient education about depression, treatment
options
Familiar with commonly used antidepressant
medications, doses
Support medication adherence and recovery
Brief interventions
Theory-based approaches (MI, PST, etc.)
Monitor treatment progress
Know when treatment is ‘not working’
Structured symptom assessment (PHQ-9)
8-12 week trial
Provider recommendations MHS, PCP
CM: Goals of a Registry
Identify, manage, and track patients
Facilitate patient contacts
Provide patient visit summaries
Provide real-time data on tx response, etc.
Reminders
Performance feedback
CM: Provider Liaison
Relay concerns/progress
Symptom monitoring
Refills
Symptoms and side effects
Urgent, emergent protocols
Medical record documentation
Cue providers if no improvement
Supplement, not replace providers
CM: Community Linkage
Cooperation with MHS
Supervision
Referral
Self-help groups
Support for comorbidities, psychosocial problems
Financial resources
Care Management:
Patient Support
CM: Customization
Cultural competence
Role of families
Role of religion/spirituality
Competing needs
CM: Self-management
Eliciting concerns/barriers
Problem-solving
Providing information
Clarifying preferences
Encouraging informed decision-making
Teaching skills
Monitoring progress
Reinforcing self-management
Community resources
CM: Self-management Tools
Workbooks
Medication lists
Appointment reminders
Healthy behaviors
Pleasure activities list
Pillboxes
Medication information
Websites
Care Management:
Provider Communication
CM: Provider Liaison
Help patients and providers identify
Potentially inadequate doses
Ineffective treatment (e.g., persistent depression after
Adequate duration of antidepressant trial)
Side effects
Facilitate patient-provider (e.g., PCP)
communication about antidepressant medications
Consult about medication questions
Care Manager: Providers
Tracks depressive sx and treatment response (PHQ-9)
Screens for co-occurring MH conditions
Alcohol use (e.g., AUDIT-C)
PTSD (e.g., PC-PTSD)
Consults with team psychiatrist
Provides follow-up and recommendations to PCP who
prescribes antidepressants
Collaborates closely with patient’s (PCP)
Facilitates referrals to specialty, community
Formal and informal connections
Prepares for relapse prevention
Examples of CM-Provider Contact
Medication toxicity, cross-reactivity
Notifying provider of patient concerns, follow-up
Fatigue, physical symptoms
CM prompted provider to call pt. after missed appt
Managing multiple medications, depression,
diabetes, and HT (medication lists, pillboxes)
Alcohol use and grief management
Kilbourne AM, et al. Bipolar Disorders, 2008
Kilbourne AM, et al. Psychiatric Services, 2008
CM: Provider Resource
CMs as a resource for clinic, providers
Dissemination of specific guidelines
Ask providers for suggestions on specific topics
Hold CME, lunches, or disseminate information
Examples
Bipolar disorder in pregnancy
Depression treatment in late life
Provider Communication Tips
Obtain preferred mode of communication
Emphasize as a supplemental service
Focus on providing information on changes in
treatment response, side effects, etc. to inform
decisions
Baseline, Current PHQ
Length of time on medications
Problematic symptoms/side effects
Adequate contact, but don’t overdo it
Care Management:
Registries
Care Manager: Registry
Registries are . . .
Simple tools to track patient progress
Integrated into routine clinical care
Easily updated
NOT EMRs
NOT research-focused
Best if “home-grown”
Registry Functions
Patient risk stratification
Tracking and management
Patient characteristics facilitating treatment
Acute phase
Continuation, maintenance
Performance feedback
Patient process and outcomes
Registries
Other data sources (e.g., pharmacy, EMR)
should NOT replace a registry
BUT can be used to:
Improved patient identification (top conditions)
Enhance performance measurement
Challenges to using electronic data
Cumbersome to update and merge
Time lag
Data not available on all patients
Privacy and security issues
Key Registry Variables
Dates
Patient contact information
Best number, time to call, and leave message
Status
No shows
Treatment stage
Current medications (dose, duration)
Self-management materials
Depression severity score, MD assessment
Referral status (MHS, community resources)
Next contact, date
Registry: Sample Fields
General information (update at each contact):
Patient contact info, including emergency contact
Providers
Best time to call/OK to leave message?
Plan to keep then safe/calm
Contact (Encounter)-specific information:
Contact or visit date
Current Mood, Speech, Comorbidities
Current medications/OTCs, refills needed?
Medications not taking and reason
Symptoms and side effects
Health behaviors (sleeping, drug use, smoking ,exercise)
Job/personal problems
Education provided
Access/barriers, provider engagement
Next appt
Care Management:
Crisis Intervention
CM: Suicidal Ideation
If the patient articulates thoughts death/suicide:
Where are you now?
What is your phone number at the location?
Are you alone or with someone?
Do you have a plan of how you would do this?
Do you have these things available (guns, pills)?
Have you actually rehearsed or practiced how you would do
this?
Have you attempted suicide in the past?
Do you have voices telling you to harm or kill yourself?
CM: Crisis Intervention
Suicidal ideation- coordinate with clinic
Protocols
On-call numbers
Missed appointments
Immediate follow-up
Care Management:
Implementation Tips
Care Manager Timeline
Initial Visit
Rapport- providers
Patient initial intake
Contact preferences
Crisis and urgent care protocols
Assessment
Discuss treatment options / plans
Coordinate care with PCP
Start initial treatment plan
Arrange follow-up contact
Document initial visit
Care Manager Timeline
Subsequent Visits
Registry- ongoing tracking
Reminders for upcoming appointments
Regular contact with providers
Implementing Registries
Adequate staffing, who should update?
Research vs. clinical use
Integrating into routine care
How identified patients are entered
Involving PCP
IRB issues
Types of Registries
Formats (pros and cons for each)
Excel file
Web-based
Examples
SMAHRT
IMPACT
REACH-NOLA
Care Manager Toolbox
1.
Manual: provider interactions
Contacts, location, communication preferences
Medication info
Protocols to ID treatment response, side effects
2. Manual: patient interactions
Brief interventions (e.g., PST, MI, others)
Crisis intervention
3. Self-management materials
Medication information
Behavioral change information (e.g., pleasure activities)
4. Registry file
Bottom Lines
The CCM for depression includes key elements
Self-management
Care management
Community linkages
Registries
Guidelines
BUT the CCM is most effective if customized to local
settings . . . . .