Transcript Care Management - Collaborative Family Healthcare Association

Session # B4
October 29, 2011
10:30 AM
The Expanding Role of Care Managers in
Integrated Primary Care and the Patient
Centered Medical Home
Alexander Blount, EdD
Director, Center for Integrated Primary Care
Professor of Family Medicine and Psychiatry
Alexa Connell, PhD
Assistant Director, Center for Integrated Primary Care
University of Massachusetts Medical School
Collaborative Family Healthcare Association 13th Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Faculty Disclosure
• I (Alexander Blount) currently have or have had the following
relevant financial relationships (in any amount) during the
past 12 months:
• Integrated Primary Care, Inc (consulting practice)
• I (Alexa Connell) currently have or have had the no financial
relationships (in any amount) during the past 12 months to
disclose.
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Behavioral Health
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Need/Practice Gap & Supporting Resources
The evidence for the need for behavioral health services in
primary has been well established. (Blount, A. (1998). Integrated Primary
Care, The Future of Medical and Mental Health Collaboration, W.W. Norton.)
The best referral systems don’t approach co-locating
behavioral health clinicians in primary care in providing
access. (Bartels, S., et.al., Am J Psychiatry 161:1455-1462, August 2004 )
The 2011 Certification Standards require practices to insure
delivery of mental health and substance abuse services to
patients and to have one population based program for
behavioral needs to become a Patient Centered Medical
Home. (http://NCQA.org)
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Objectives
• 1. Participants will be able to identify duties and limits of
historic roles of case manager, care coordinator and
care manager.
• 2. Participants will be able to list the role of care manager in
relation to the other team members in a primary care setting.
• 3. Participants will be able to list the different heritages of the
intermediate role between the patient and the provider.
• 4. Participants will be able to use complexity tools to assess
the needs of a client.
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Care Management/Case Management/
Care Coordination
• Different heritages, different current
constituencies
• In the space between the patient and the
physician(s)
• Now lots of new names: Navigator, health coach,
what others?
• We use the term “Care Advisor”
• Many disciplines and training levels
• Will be the biggest growth role in the foreseeable
future.
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“Care Management” – What are we
talking about?
• Three distinct histories of the term that I can find.
• Care Management (1) – Manage a system of care.
• Care Management (2) – Manage the care (broadly
defined) of one patient, usually who is living at
home.
• Care Management (3) – Protocol for treating
depression in primary care.
– When “disease management” was applied to depression,
the ensuing process was called care management.
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Mental Health Case Management
Generally the functions of case management have included:
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Obtaining basic supports
Crisis prevention and intervention
Assessment to determine need for services
Outcome/function focused treatment planning
Referral and linkage with chosen services
Engagement and developing a helpful, trusting relationship
Coordinating and adjusting service delivery
Advocacy
Tx to Barbara Mauer
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Care Coordinator
• “Coordinates patient care including patient/family education
and discharge planning to insure quality, cost-effective utilization
of resources consistent with the hospital mission and
Collaborative Patient Care Management goals and priorities.
• Directs the daily and short-range goal setting and planning for
the assigned case type and Group Practice.
• Participates in the annual goal setting and planning for Group
Practice.
• Guides health care team members in designing collaborative
teaching plans/programs and in planning/providing
patient/family education and discharge planning within
designated specialty.
• Accountable for clinical and financial outcomes of assigned case
types and the activities and accomplishments of the Group
Practice.” www.innovativecaremodels.com
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Behavioral Health
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History of Care Management (3) for
Depression
• Wayne Katon and the U of Washington/Group
Health Co-op hoards.
• Ed Wagner, the Institute for Healthcare
Improvement, and the Chronic Care Model
• Foundations get it going, Robert Wood Johnson,
JD&KT MacArthur
• It is the best “evidenced” and best worked out
primary care BH intervention ever.
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Depression Care Management Protocol
• Depression in primary care, RWJ and MacArthur programs.
– http://www.depression-primarycare.org/
• Toolkit
• Help in re-engineering practices
• Develop screening for depression in collaboration with providers
– Who
– When
– What triggers
• Assure that assessment/diagnosis protocol is in place for positive
screens and that all assessed positive are on a registry.
• Protocol
– Assures that patients know types of care offered
– Makes phone calls to assess medication effect and side effects
– Tracks visits
– Re-screening/outcome
• Brief face to face or telephone problem solving and behavior activation
interventions.
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Four Quadrant Model
(Mauer)
Quadrant II
high BH low PH
Quadrant IV
high BH high PH
Quadrant I
low BH low PH
Quadrant III
low BH high PH
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The complex “medical-only” patient is
rare among complex patients.
• The more somatic illnesses a person has, the more
they are likely to have one or more psychiatric
diagnoses.
• Low income and “neuroticism” correlate with more
somatic diagnoses as well as more psychiatric
diagnoses.
Neeleman, J., Ormel, J. AND Bijl, R. V (2001). The distribution of psychiatric and somatic ill
health: associations with personality and socioeconomic status, Psychosomatic Medicine
63:239–247
• Similar findings in large PCMH pilot done by Boeing
Corp. www.integratedprimarycare.com
• The sicker you are, the sicker you are.
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Behavioral Health
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When depression is an important factor in a
complex presentation, case managers without
behavioral health training can be a poor fit.
“Nurses, practice assistants, and HCAs complain
of the psychological burden of providing
mental health services in depression care. To
avoid exhaustion, they prefer to work parttime. Reports of HCAs working in innovative
depression care programs are still rare."
Genschen, J, et al, Health Care Assistants in Primary Care Depression Management: Role Perception,
Burdening Factors, and Disease Conception. Annals of Family Medicine, Vol 7, no.6. 2009.
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Merging Heritages: Mental Health Side
Medical Care Management
for SMI patients
Intervention Group
• Care managers/coordinators
– communication and advocacy
with medical providers
– health education
– support in overcoming systemlevel fragmentation and barriers
to primary medical care.
Control Group
• Usual care
• 21.8% of recommended
preventive services
• No improvement.
• 58.7% of recommended preventive
services
• Significant improvement in SF-36
mental component and Framingham
Cardiovascular Risk Index.
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Behavioral Health
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Care Coordination-2011
PCMH 2011 Standards attempt to rectify the oversight related
to behavioral health
• Develops written care plans for 75% of patients in 3
population protocol programs (one behavioral) and for
high risk complex patients.
• Arranges or provides treatment for MH and SA disorders.
• Monitors and assures that patients and families receive
offered (referred) resources.
• Supports patients and families in self-management, selfefficacy and behavior change with education, counseling
for healthy behavior and goal setting.
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Why should behavioral health be a
core service of PCMH?
• Access – At least 50% better access to MH care if offered in
primary care. (different from managing care across medical
specialties) (Bartels, Coakley, Zubritsky, et al. Am J Psych, 2004)
• Complex patients with chronic illnesses needing behavioral
health care are more likely to be designated for Medical
Home level of care.
• Care in medical setting is a better cultural fit for many
patients.
• Behavioral Health Clinicians free up time for PCPs to spend
with other patients, while enhancing patient satisfaction and
self-efficacy.
• Care management is more effective when done by
professionals with behavioral health skills. (Pincus, Pechura, Keyser, et
al. Administration & Policy in Mental Health. 33(1):2-15, 2006
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Behavioral role in CVD risk factors
H
E
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T
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high blood pressure
existing CAD
age, gender
relatives (family hist)
tension/stress
smoking
alcohol, exercise
health literacy
L
O
A
D
lipids, HDL, LDL
obesity
aerobic physical act.
diabetes -
nutrition, exercise
nutrition, exercise
exercise
monitor, nutrition,
exercise, adherence
family support
relaxation
cessation
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Behavioral Health
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What does all this mean?
• The PCMH model is going to be everywhere,
even in mental health centers.
• Bits from all the heritages, case manager, care
manager for depression, behavioral health
consultant and care coordinator will probably be
recognizable in the future version of the job.
• It is likely to be a role for which we will need
thousands of properly trained people.
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Behavioral Health
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The Story of “Joan”
MEDICAL DIAGNOSES:
1. Chronic thrombocytopenia probably secondary to
chronic ITP.
2. Coronary artery disease. Status post CABG in 1993.
3. Chronic obstructive pulmonary disease. The patient
is intermittently oxygen dependent (and a smoker).
4. Insulin requiring diabetes associated with
neuropathy.
5. Osteoarthritis.
6. Bipolar disorder.
7. Recurrent urinary tract infections.
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Behavioral Health
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The Story of “Joan”
Medications:
• Norvasc, famotidine, furosemide, metformin,
Neurontin, diazepam, fluconazole, insulin, and
Mellaril.
Other Statistics:
• Rank in calls to on call line: #1 (>1x night)
• Rank in ER utilization (out of 22,000 pts): #1
(>2x wk)
• Rank in eliciting frustrated comments from
nurses and residents: #1.
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Joan Gets a “Plan Based”
Case Manager
• Blue Cross, trying desperately to contain costs,
assigns her a telephone case manager for her
diabetes.
• She tells the case manager how verbally
abusive her husband is to her, initiating a
referral for elder abuse. It is not substantiated.
• The case manager stops calling.
• ER use unchanged
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Behavioral Health
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A Change of Pattern for Joan
• Family systems thinking teaches us that recurrent patterns
can be understood as circular.
• If they seem unidirectional, look for the hidden influence
going the other direction.
• Arthur was always taking care of Joan, with more or less
success.
• How could it be seen as the other way around?
• Joan and Arthur engage in occasional couples visits. ER
visits down significantly after meetings. Strategies for
night call devised, though not consistent across residents.
• Program was missing the outreach and connection (Care
Advisor) needed to sustain gains and maintain
improvement.
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Behavioral Health
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Options arise when we develop new
descriptions or stories of familiar events.
• When the health system is stuck in recurrent
unhelpful patterns with a “complex” patient, we
need to look for another story.
• The details that support a new story could be
anywhere in the interactions of the person in their
social network, but their family is usually the richest
source.
• PCMH care managers need access to skills in family
interviewing and systems thinking in addition to skills
in CBT, relaxation therapies and Motivational
Interviewing.
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Behavioral Health
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How can the necessary skills be broadly
available?
• Behavioral Health Clinician in Primary Care practices
willing to do more active outreach, i.e. care
management, than has traditionally been asked.
• Properly trained clinician (usually psychiatrist or
health psychologist) with PCP provides supervision for
care manager who has some behavioral health
training (IMPACT model)
• Special training programs for the emerging roles, e.g.,
Care Managers and Navigators Course of the Center
for Integrated Primary Care at UMass Medical School.
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We need to develop “integrated
care management”.
• Need to be able to address mental health,
substance abuse and behavior change/activation
needs
• Need an “undifferentiated” assessment measure
for identification and tracking outcomes for most
complex people.
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Behavioral Health
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Complexity measures are proving
very useful.
Peek, Baird & Coleman, Families, Systems, & Health, 2009,
Vol. 27, No. 4, 287–302.
Roger Kathol, The Integrated Case Management Manual,
Springer, 2009.
Let’s look over the Peek et. al. form.
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Routines We Can Build In for
Transparency
• Patient owns the health record (Shared Care,
WA)
• Reading the note at the next visit
• Sharing the screen of the EMR
• Patient signs all MH treatment plans
• Family involvement when possible
• Patient at their team meetings in primary
care whenever possible
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Care Manager’s Toolkit
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Patient Registries
EHR
Lists of community resources
Lists of referral sources
Relationships with PCPs and nursing staff
Relationship with patients and their family
The internet (aka Google is your friend)
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What is a Registry?
“A patient registry is an organized system that
uses observational study methods to collect
uniform data (clinical and other) to evaluate
specified outcomes for a population defined
by a particular disease, condition, or exposure,
and that serves one or more predetermined
scientific, clinical, or policy purposes.”
AHRQ. Registries for Evaluating Patient Outcomes: A
User’s Guide
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Registries For Care Management
• Important resource to make sure patients don’t “fall through
the cracks
• Practice Registries are different from EHRs because they
manage selected information related to patients with
particular conditions. They do not contain information such
as patient history or other health problems.
• Computerized practice registries are “tools that capture and
track key patient information to assist physicians and their
team members in proactively managing patients”
– California Health care Foundation. “Chronic Disease Registries: A
Product Review,” ihealth Reports, NAS Consulting Services, May 2004
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Considerations for Registry Use and Design
• What information is relevant for tracking?
– Necessary or just desirable?
• Where will your data come from?
– Personnel data entry? Querying an EHR?
– Initial data entry is time consuming.
• Will the registry interface with your EHR?
• Who will be able to access the registry?
– Generally everyone, but will some have restricted access?
– Who is responsible for maintaining registry accuracy?
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Considerations for Registry Use and
Design
• What resources (financial and personnel) can
we dedicate to registry creation and
maintenance?
• What do we need this registry to do?
• How will we use this information in the
future?
• Registries are only fully searchable and useful
if they are standardized.
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What is the Relevant Information?
• Demographics: Name, address, phone number, email
• Provider Information: PCP, BH consultant (if any), Care
manager
– Anyone involved in the patient’s care
• Health Data: Screening results, diagnoses, clinical outcomes
(lab results, BMI), preventative medicine
• Interaction Data:
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Who was present? Who needs to receive an update?
Which conditions/goals addressed? Which interventions?
What is the current plan?
When is the next contact/screening/appointment?
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An Example: Care Advising at UMass
• Who: Graduate students in psychology/
mental health counseling, LICSWs, Social
workers, Nurses, MAs, Psychologists
• Located at 3 Family Medicine practices:
– 1 Adult Internal Medicine practice
– 2 Pediatric practices
– 3 Family Medicine practices
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Care Advising Resources at UMass
• Between 10-50 hours Care Advising time per
practice, per week.
• Patient registry built in MSAccess, populated by
– querying our EHR for demographic, screening, diagnosis
and dates of preventative medicine interventions
– Manual data entry to record Care Advisor interactions
• Searchable lists of referral sources
– Mental Health, Support groups, Massage, Chiropractic,
Acupuncture, Yoga, Fitness centers, Shelters, Vocational
Rehab, Adult Ed, Volunteer organizations
• Relationships with community organizations
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What are Our Care Advisors Doing?
• Care advising team meets on a weekly basis to discuss cases, share
resources etc.
• Develop and implement protocols for the Care Advisor’s role in
disease management
• Facilitated more than 200 mental health referrals at a single health
center
• Attended home visits
• Completed patient transportation paperwork
• Contacted patients with reminders for colonoscopy screening
•
Accompanied patient to apply for disability
• Advocated for patients with health insurance coverage difficulties
• Delivered CBT and MI interventions over the phone
• Provided peace of mind to providers
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What Have We Learned So Far?
• Physicians do not refer the most complex cases.
• Without a “push” from some sort of population
based risk assessment, or disease based
protocol, care advisors get a lot of “low level”
referrals.
• The ongoing meeting among Care Advisors to
refine role definition, refine expertise and share
resources is crucial, folks in supervisory roles
are not expert at new integrated approaches.
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UMass Patient Registry in MSAccess
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UMass Patient Registry
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Behavioral Health
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UMass Preventative Medicine Tracking
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UMass Intervention Tracking
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Learning Assessment
Questions and Discussion
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Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!
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Center for Integrated Primary Care
Alexander Blount, EdD
[email protected]
Alexa Connell, PhD
[email protected]
Center for Integrated Primary Care
[email protected]
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Behavioral Health
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