Care Management Protocols, Disease Registries, and Other
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Transcript Care Management Protocols, Disease Registries, and Other
Systems Support:
Care Management Protocols, Disease
Registries, and Other Tools
Amy M. Kilbourne, PhD, MPH
VA Ann Arbor Serious Mental Illness Treatment
Research and Evaluation Center
Department of Psychiatry, University of Michigan
SMITREC
Mental Health Services Research Group
Chronic Care Model- chronic mental illness
Quality improvement interventions to improve
medication adherence
Mental health performance measures
Primary Care – Mental Health Integration
Program
Substance abuse in primary care
Predictors of suicide
Aging and preventable mortality
National VA Psychosis Registry
National VA Registry for Depression
Implementation
Care Management Guidelines
Patient Registries
Other Tools
Wagner Chronic Care Model
Community
Resources and
Policies
Health System
Health Care Organization
SelfManagement
Support
Informed,
Activated
Patient
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
Protocols- coordinated care
Clinical
Information
Systems
Clinical information tracking
Feedback to clinicians
CCM: Core Clinical Elements
Decision
Support
Guidelines
Expert/specialist
consultation
Self-management Patient preferences
Information on treatment
Support
Community
Resources
Information on and for
consumers, groups, etc.
Access to non-provider
sources of care
Care Manager Role
General
Medical
(Chronic care,
Prevention,
Follow-up)
Care Manager
Self-management
Liaison: PCP, MH
Crisis intervention
Behavioral
Health (crisis
referral for
ICM, etc.)
Care Manager: Skills
Tracks depressive symptoms and treatment
response (PHQ-9)
Consults with team psychiatrist
Collaborates closely with patient’s primary care
provider (PCP)
Provides follow-up and recommendations to PCP
who prescribes antidepressants
Facilitates referrals to specialty, community
Prepares for relapse prevention
Care Manager: Skills
Familiar with commonly used
antidepressant medications, doses
Patient education about antidepressants
Support antidepressant medication
adherence
Know when treatment is ‘not working’
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
Medication lists
Pillboxes
Appointment reminders
Healthy behaviors
Pleasure activities list
CM: Therapeutic Alliance
Cultural competence
Role of families
Role of religion/spirituality
Competing needs
CM: Liaison
Relay concerns/progress
Refills
Symptoms and side effects
Urgent, emergent protocols
Medical record documentation
Cue providers if no improvement
Supplement, not replace providers
CM: Liaison
Help patients and providers ID
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
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. Bipolar disorders, in press 2008
Kilbourne AM. Psychiatric services, under review, 2008
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
CM: Crisis Intervention
Suicidal ideation- coordinate with clinic
Protocols
On-call numbers
Missed appointments
Immediate follow-up
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?
Care Manager Registry
Registries are . . .
Simple tools to track patient progress (K.I.S.S.)
NOT EMRs
Best if “home-grown”
Facilitate structured patient contacts
Types of registries, pros and cons
Excel file
Web-based
Developing Registries
Things to Know
Know your stakeholders and get their input
(purchasers, payers)
Know your population- case mix, location
Know your key data sources
What is in the administrative datasets?
Do they capture utilization?
Know what information technologies are available
and whether they can be tailored
Web-based patient health risk assessments
Developing Registries
Things to Know (cont.)
Know your end users (e.g., care managers, clinic
staff, providers), including their work flow, and
ensure they can work with the registry on a day-today basis
Know what stakeholders want in terms of
outcomes: What quality and cost measures are
they interested in, and use registry to enhance
performance measures
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
Registry Examples
SMAHRT
IMPACT
Care Manager Toolbox
Self-management materials
Antidepressant medication list
Registry file
Provider contact sheet
Preferences
Crisis intervention
Operations manual
Care Manager 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 Subsequent Visit
Upcoming appointments
Registry- ongoing tracking