Transcript Care Management and Clinical Decision Support: The

Care Management and Clinical
Decision Support:
The Foundation for a Strong Office Practice
March 1, 2007
Objectives for Today
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Define Care Management and Clinical Decision
Support and their interrelationship
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Review three activities that support care management
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Suggest strategies to implement Care Management in
a small physician office practice
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Care Management – Not a destination!
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A key component in caring for patients –it is an
ongoing process
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Assists in improving the patient’s health status and
functional capacity
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Benefits many –
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Individual patient
Family and caregivers
The office practice
The larger health care system
Eliminates waste and enhances efficiency
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The Care Model
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Care Management
incorporates the
components of The Care
Model
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Organizes delivery of care to
meet the six Institute of
Medicine quality goals:
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ICIC is a national program supported by The Robert Wood Johnson
Foundation with direction and technical assistance provided by
Group Health Cooperative's MacColl Institute for Healthcare
Innovation
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efficient
equitable
safe
effective
patient centered
timely
Care Management—Improving Care
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Improved
Practice
Culture Change
Plan
Clinical
Decision
Support
Act
Caregivers
Patient
Care Team
Study
Improved
Patient
Outcomes
SelfManagement
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Do
Office
Workflow
Redesign
Care Management
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Evidence-based, integrated clinical care
activities that are patient-specific and ensure
that every patient has a coordinated plan of
care and services.
The care plan, developed collaboratively by the
patient and care providers, is designed and
executed to optimize the patient’s health status
and quality of life.
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Key Activities—Enablers
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A well-executed care management program
must be designed and implemented in a
manner that is consistent with the long-term
sustainability of the practice.
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2 Types of Activities / Enablers
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Patient Specific
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Patient Engagement
Assessment
Planning
Implementation
Evaluation and
Measurement
Coordination
Practice Specific
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Office Redesign
Population Identification
Adoption of Health
Information Technology
Adoption of Clinical
Decision Support
Adoption of Coordination
Tools
Population Data
Measurement
Patient Engagement (Patient Specific)
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Use tools, services and approaches to maximally engage
patients and their families in their own care and to support selfmanagement. Elements include:
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Relationship building
Exploring patient’s needs and values
Education
Collaborative goal setting
Action planning
Problem-solving
Socioeconomic sensitivity
Assessing competency
Addressing language barriers
Linkage to community supports
Use of new ways of delivering care (e.g. planned visits/group
visits)
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Assessment (Patient Specific)
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Assess each patient initially, periodically, and
at critical junctures.
Elements include:
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The patient’s clinical condition
Feasibility of completing various interventions
Patient’s values, preferences and readiness to
engage in self-management and treatment
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Planning (Patient Specific)
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Create an individualized care plan
Balances best practices for managing the
targeted condition(s) with feasibility and patient
preference
Optimizes outcomes
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Implementation (Patient Specific)
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Provide services required to implement the
care plan
Arranging follow-up and referral
Continually fine-tuning the plan as needed
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Evaluation and Measurement
(Patient Specific)
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Measure services and interventions offered
Reason for implementation or nonimplementation
Modification and outcomes
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Coordination (Patient Specific)
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Utilize care strategies including health
information technology and other tools to
communicate and coordinate
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with the patient
with other caregivers
Ensure that the care plan is executed safely
and efficiently
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Office Redesign (Practice Specific)
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Design and implement new activities and
workflows
Increase patient engagement
Improve staff productivity
Optimize financial and clinical efficiency
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Population Identification
(Practice Specific)
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Select common clinical conditions
Target cohorts on which to focus in your patient
population
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Adoption of Health Information
Technologies (Practice Specific)
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Obtain and implement technologies such as
EHRs, registries and reporting systems to
facilitate data capture, patient tracking and
outcomes review
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Adoption of Clinical
Decision Support (Practice Specific)
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Deploy electronic and non-electronic tools to
effectively make use of best practices and
evidence to help guide care efficiently and
correctly
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Adoption of
Coordination Tools (Practice Specific)
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Design and implement communication and
care coordination tools
Ensure that care is consistent among a
patient’s many clinicians
Ensure care is consistent for patients between
the office and home
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Population Data
Measurement (Practice Specific)
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Report on health status, quality metrics, and
outcomes for the target population across the
practice
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What is Clinical Decision
Support (CDS)?
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Providing clinicians or patients with clinical
knowledge and patient-related information
Intelligently filtered, or presented at appropriate
times
To enhance patient care
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What is Clinical Decision Support?
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Clinical knowledge of interest could include:
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Simple facts and relationships
Established best practices for managing patients
with specific disease states
New medical knowledge from clinical research, and
many other types of information
Improving Outcomes with Clinical Decision Support: An Implementers’ Guide.
Osheroff JA, Teich JM, Pifer EA, Sittig DF, Jenders RA. 2005. Healthcare
Information Management and Systems Society
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5 Rights of Clinical Decision Support
1. The right information
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evidence-based where evidence is available,
responsive to the need at hand,
practical to implement,
ideally context and patient-specific, current, etc.
2. To the right person
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including all those involved in providing care to the patient
as well as the patient and their caregivers as appropriate
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5 Rights of Clinical Decision Support
3. In the right intervention format
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alerts, guidelines, data presentations, reference
information, order sets, documentation template or
flowsheets, whichever is most appropriate to the situation
at hand
4. Through the right channel
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via clinical information systems, mobile devices, desktop
workstations, the internet, etc.
5. At the right point in workflow
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at an opportune time to influence a key decision or action
without negatively impacting flow
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CDS Facilitators
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Multidisciplinary forms
Condition specific forms/templates
Patient specific tools – data and graphs, care plan
Real time alerts – based on guidelines
Order entry
Order sets – disease specific
Links to resources on the web
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Getting Started
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Assess what you’re currently doing
Identify the target population and area of focus
Evaluate the flow and decide where you can
make a change
Self Management strategies to engage the
patient
Include the whole team in your redesign!!
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What are you currently doing?
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Use a simple tool
Is the functionality present?
Are they using the functionality?
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Assessment of Care Management
Activities
1. Do you generate lists of eligible patients for
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each disease?
Do you generate a list of patients requiring
intervention?
Do you prompt clinicians to order lab tests?
Do you prompt clinicians to order
immunizations and other services?
Do you produce reminders for patients about
needed lab tests?
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Assessment of Care Management
Activities
6. Do you produce reminders for patients about
immunizations and other services?
7. Do you prompt clinicians and patients to
review self-management plans during office
visits?
8. Do you generate specific care plans for your
patient’s ongoing care?
9. Do you create written action plans that are
personalized to the patient’s condition?
10. Do you modify self-management plans as
needed as follow-up to the patient’s visit?
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Identify the target population and
area of focus
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Initial stratification based on diagnosis or
problem list
Pick the population and dig deeper
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Specific medication use
Lab values
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Evaluate the flow
Pre-visit
questionnaires;
Patient
reminders
Order sets,
parameter
checking
Structured
documentation
A.
Pre-Visit
B
C
D
Start of
Visit /
Intake
Clinician's
H&P and
plan
Documentation
Timebased
checks,
reports
Follow-up
care
prompts
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G
Orders /
Rx
Therapies/
Procedures
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End of
Visit /
Check-out
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Rx
Dispense
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Results
Arrive
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Consult
requests
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Post-Visit
/ Home
Care
Alerts & Evidence Based Guidelines
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Flow Sheets and Alerts
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Key criteria for a
specific condition
Triggers based on
diagnosis or from
a core use
template
Color coded to
assist in
identification of
overdue labs or
procedures
Diabetes Specific Treatment Plan
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Care Plan - Templates
Self-Management
Action Plan
Clinical Care Plan
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Care Plan Example
John Doe
10-12-1964
MRN
Healthy Living Goals (Includes all parts of plan that are specific
patient behaviors)
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Healthy Eating—I will focus on carb counting each day at dinner
Healthy Eating—I will keep a food record for 3 days in a row and
bring to next visit
Follow monitoring schedule
Follow meal plan
Make better food choices
Reduce fat intake
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Care Plan Example (continued)
Clinical Plan:
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Diabetes
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Blood Pressure
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Refer to Medical Nutrition Therapy
Refer to DSMT
Begin home BP monitoring once daily or “x” times weekly at
home
Labs Today – Lipid profile, CBC, Urine, Microalbumin
Future Labs – A1c
Medication changes/update -Changes to medications –
stop/start/increase/decrease; include insulin
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Care Plan Example (continued)
Follow Up Appointments:
Provider:
Comments
Time
Frame:
Date
Scheduled:
Nurse Practitioner
Smith, Jane
—
4 months
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Renal Consult
White, Annie
Decreasing
GFR
2 month
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Nurse Educator
any available
Meter Switch
Today
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BIDMC – 617-667xxxx
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Within 2
weeks
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Orders for Today
Today
—
EKG
Today
Appt. Type:
Stress Test
Flu Vaccine
Hospital
Today
This plan has been mutually determined and agreed upon with myself, Lauren, Jones, Hospital Care
Partner and the Dr. Winter. I commit to doing my best to follow my care plan. I know who to contact in
the event I have any questions.
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Care Plan Example (continued)
KEY CLINICAL INFORMATION
Most Recent Value
Your Target/Goal
Previous Value
8.6 %
7.0%
6.8 %
156/81
130/80
140/70
180 mg/dL
Less than 200
205 mg/dL
Triglycerides
130 mg/dL
Less than 150
140 mg/dL
HDL – good cholesterol
39 mg/dL
Greater than 45
35 mg/dL
LDL (direct) – bad cholesterol
80 mg/dL
Less than 100
100
173.4 lbs
150 lbs
178 lbs
Basal Mass Index (BMI)
28.85
20-24 calculated
29.62
Waist Measurement
include
September 06
Yearly
9-14-05
Due now
Oct-Jan each year
12-1-04
Hemoglobin A1c
Fasting Glucose
Post –Prandial (after eating)
Post – Exercise (after exercise)
Blood Pressure
Cholesterol – total
Weight
Ability to add urine micro and other tests?
Yearly Dilated Eye Exam
Flu Vaccination
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Care Plan Example (continued)
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Insulin Prescription
Before Breakfast:
Time
Glucose level
< 150
151 250
200 300
300 400
400
>
Before Lunch:
Before Supper:
9:00
Lantus
Humulin R
12
0
12
1
12
2
12
3
12
4
All insulin doses in units
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At Bedtime:
A Care Plan Example (continued)
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Current Medications
Dose
Units
Sig
Lasix
20mg
½
½ tab po qd
Lipitor
20mg
Once a day
Tessalon Perle
100mg
1-2 perles po q
8hrs, prn cough. do
Micronase
5mg
As directed 1 ½
tablets qd
One Touch Ultra –
Meter
Meter
For glucose
monitoring
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A Care Plan Example (continued)
Resources/How to Reach us
Clinical Support - 617-222-3333
Jane Richards, MA
 Lisa Rogers, MOC
 Tabitha Stevens, MOC
 Jessica Littlehale, MA
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Patient Care Coordinator
Lauren Jones RN, CDE 617-222-3333
Physician – Dr. Bob Nickles
Nurse Practitioner – Hope Miller, ANP
Appointments - 617-222-4444 to schedule or cancel appointments
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Strategies for Success
1. Don’t just collect data – measure something
meaningful and know how you got it
2. Share your data often and in a user friendly format
3. Make it easy for providers to do the right thing –
forms, prompts, reports
4. Involve providers, staff and patients through out the
process. Don’t rely on just one person or group to
achieve the goal, share responsibilities
5. Change your model – engage the patient – share
the standards and their own information. Help them
to be prepared and proactive
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Questions?