Transcript Care Management and the role of the Health Coach

Care Management and the
role of the Health Coach
Gettysburg Adult Medicine/Brockie Internal Medicine
Pamela Brant, RN Nurse Care Manager
Julie Assi, LPN Health Coach
Amy Mummert, LPN Health Coach
Care Manager
 RN
 Provides service to 3 medical group practices
 On site for 12 hours a week at Gettysburg Adult Med
 Provides follow up services to the high risk population
 Monitors population management
 Provides education/goal setting/action plan development
to diabetic patients with A1c > 9 %
 Provides psychosocial/economic interventions in
collaboration of community services/Hospital care
managers/social workers
High Risk Criteria
 ED/Hospital visits related to a fall if over the age of 65
 Any patient visiting the ED/Hospital for the same
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diagnosis > 1 time in 3 months
Diabetic patients with A1c > 9%
Frail elderly (FTT)
Referrals from Transition Care Manager (CRNP)
Referrals from Health Coach
Provider referrals: where a home visit may be
indicated
Health Coach Guiding Principles
 STEEEP: Safe, timely, efficient, effective,
equitable, patient centered
 Triple AIM:
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Better health
Better care
Reduce the cost curve
 Chronic care model—prepared, proactive
care teams, engaged, activated patient
Why do we need this?
 Primary care clinicians are “struggling to fit multiple agenda
items into the 15 minute visit – cannot meet every need of their
patients with chronic conditions.” ( Bennett, Coleman,
aafp.org/2010)
 “Half of patients leave primary care visits not understanding
what their doctor told them.” ( Bennett, Coleman, aafp.org/2010)
 Average adherence rates for prescribed medications are about
50 percent, and for lifestyle changes they are below 10 percent.”
( Bennett, Coleman, aafp.org/2010)
 “Although clinical research is still being amassed,…..Health
coaching has been proven in randomized trials to make a
difference…People can be helped using motivational
techniques.” (Buckley, 2010)
Health Coach Model:
Role Expectations
 Call ED/Hosp discharge patients within 48 hours
 Referral to CM
 Follow up on self-management action plans
 New med follow up
 Address barriers to treatment plan/goals
 F/u of referrals from CM
 Population management
Health Coach Program
 Mid July 2011--Selection process completed.
 July 25, 2011– training day
 August 1, 2011--HC began on a part-time
status
 September 1, 2011-- HC began full-time
 1 HC to 3 providers
 Transition phone calls– population
management– patient goals
 Phone conferences
Health Coach Program
 HC patient census= 104 patients (mostly
transition of care)
 3 HF
 6 DM
 20 Physician referrals
 4 Self management
 Majority of time is spent on transition of care
 First program audit is underway
Cerner Message ED/Hospital D/C
HC Tracking Form
Discharge Transition F/U Questions
Patient Name:
Date: ___________
DOB/MRN:_____________________
Provider:
ED or Hospital D/C date: _________
F/U appointment Date:
Admitting diagnosis: __________________________
1. Are there any barriers to communication? (Language, hearing,
comprehension, literacy)
2. Name of support/contact person: ______________________
Phone Number: _______________________
Relationship to patient: ________________
3. How is the patient feeling today?
4. Did the patient receive written discharge Instructions when they left the
hospital/ED?  No
 Yes
Review the instructions on the form with the patient (teachback).
5. Is the patient able to identify any warning signs or symptoms for their
condition. (Hypo/hyperglycemia, CHF, A- fib, pneumonia, chest pain,
etc.)
 No  Yes
 N/A
6. Does the patient have any restrictions in activity?
 No
 Yes
 N/A
Details:
7. Does the patient require assistance with ambulation?  No
 Yes
 N/A
Details:
8. Does the patient have diet instructions or fluid restrictions? Details. 
No
 Yes
 N/A
Details:
9. Complete medication reconciliation: ask patient to get pill bottles for
review, retrieve discharge summary from chart and discharge
instructions from PowerChart, if available. Be specific and review with
the patient how they take them, how often and what they are taking
each medication for.
____Medication reconciliation completed—no changes needed
____Medication reconciliation completed—changes made to eCare medication
record.
____Discrepancy from discharge summary regarding “resume home meds”.
Medication changes since hospital admission:
Medication
Dose
Frequency
10. If the patient is not following medication regime determine the eason and
provide intervention.
Intervention:
11. If any gaps are identified provide education or instruct them to follow up
with their PCP or make an office appointment with Health Coach or Care
Manager
____Additional interventions:
_____No additional interventions needed.
12. Are there any other services ordered? (Home Health, Outpatient therapy,
etc)
List name of service;
_______________________________________________
HC Signature: ______________________________________
Date: ________________________
Upcoming Care Management Projects
 Transition Care Manager (TCM)– CRNP
Pilot completed
 Currently recruiting for position
 See patient in hospital
 F/U at home
 Refer to additional services as necessary
 Refer to Nurse Care Manager
 Hospital Social Workers to begin joint service to hospital and
medical group practices
 Pilot running in 2 medical group practices
 SW will spend specific amount of hours in practice weekly
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Care Management Swim Lane Diagram
Hospital
Case
Manager/ RN
Transition
Care Manager
(CRNP)
and/or VNA
Transition
(Patient’s Home/
Rehab)
Inpatient
(Hospital/ECF/
Observation)
WellSpan Case Management Continuum
So
c
ial
Wo
rk
er /
He
alt
hP
lan
Outpatient
(PCMH/ Retail Clinic/
ReadyCare/ Specialty
Care/ ED)
Ca
se
Ma
WMG
na
ge
Case Manager/ RN
r
Practice
Health Coach
(Embedded in
Practice or Virtual)
Illness/ Injury
Goals:
Better Care
Better Health
Better Value
Priority Chronic Diseases
(Diabetes/Heart Failure/COPD/Adult
Asthma/CAD)
Community Case
Manager (Bell
Social Services,
BHS, etc.)
Wellness