Transcript Helping our Patients Know What to Expect: Tools from the

Michael A. LaMantia, MD, MPH
Medical Director, Aging Brain Care Medical Home
Assistant Professor of Medicine
Center Scientist, IU Center for Aging Research
Research Scientist, Regenstrief Institute
Malaz Boustani
 Mickey Vogel
 Ebony Rich
 Jane Brooks
 Samantha Seright
 Cathy Alder
 Michael LaMantia

ABC Medical Home: Brief Overview
 Our Problem
 Questions for our Consultants
 Proposed Solution to the Problem (in 3
parts)
 Feedback/Comments

 Grew
out of Healthy Aging Brain Center
 Started October 2009
 Incredible Growth:
• July-December 2011: Add new medical director and SW
• January-June 2012: Add 2nd NP
• July 2012: Begin CMS Innovation Grant to expand our
services to 2000 patients with dementia or depression across
Marion County served by the Wishard Health System
 Will employ 20 care coordinator assistants, 4 care
coordinators (NPs), and 2 SWs in 4 teams

Focus:
◦ Dementia/Cognitive Impairment
◦ Depression
◦ Acute Care Utilization

Tools:
◦ eMR ABC
 Allows case management and population health management
◦ HABC Monitor
 Assesses caregiver stress and patient behavior
◦ PHQ-9
 Gauges patient depression
◦ Mobile Office
 Meet patients and caregivers in their homes
Caregiver Counseling &
Self-Management
Consultants: HABC & Midtown
The ABC
Medical
Home
Team
Community Resources
Primary Care Physicians
 Feedback
from patients:
 Confusion about how our program is related to other
Wishard programs
 Confusion about who to call in the office for specific
needs
 Sense that they (patients) may not know where to turn
when facing urgent medical issues
 Patients medications become incredibly “mixed-up”
around ER visits and hospitalizations
 We
need help with the following questions:
•Are the tools we developed likely to be useful?
Are there other tools that we should develop instead
or in addition?
Should these tools be presented in a different
format?

3 products:
◦ 2 brochures
and
◦ Vial of Life

Brochure 1:
◦ Who to Call in the Program
 Provides Key Names and Numbers
 Provides Overview of How to Make Appointments
 Provides Outline of Program’s Role and How We
Interact with Patient’s Doctors

Brochure 2:
◦ What to Do in a Crisis
 Where you can get help
 Who you can speak with
 When you should definitely go to the ED
◦ How to Navigate the ER/Hospital & What to Expect
 Provides tips on what to bring
 Outlines role of most commonly encountered providers
 Points out ways patients/caregivers can advocate for
themselves

Vial of Life:
◦ Critical Information for Emergencies






Med List
Allergies
Major Diagnoses
Family Names/Contacts
Doctor’s Names/Contact
Advance Directives
 Are
the tools we developed likely to be useful?
 Are there other tools that we should develop
instead or in addition to these?
 Should these tools be presented in a different
format?
Contact info:
Michael LaMantia, MD, MPH
[email protected]