Transcript Shared Care Plansx - PCMH e

Shared Care Plans
Aimee English (AF Williams)
Jaclyn King (HealthTeamWorks)
Kerry Salter (SFMR)
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Learning Objectives
By the end of this session participants will be able to:
• Explain the value of the shared care planning
process and shared care plans as documents.
• Summarize the implementation of shared care
plans from two residency practice examples.
• Improve or apply concepts of shared care plans to
your practice.
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Shared Care Planning
• A collaborative process that engages
patients, families, providers, the care team
and community partners to focus together on:
• patient centered shared decision making
• active patient engagement
• self-management support
• communication among and across
multidisciplinary care teams
• A collaborative document used to structure
the clinical information, goals and activities of
the patient.
Shared care plan in context:
Care Compact: a framework for standardized
communication between primary care and
medical neighbors to improve care transitions for
patients.
Care Plan: a document of how a patient can
manage their day to day health, often located in
the clinical notes.
Shared Care Plan: A co-created document to
keep track of important information and a health
improvement plan for the patient that can be
shared with family and other health care
providers.
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Value of Shared Care Plans
•
•
•
•
Focuses on the whole health of the patient
Is a tool for patient engagement
Creates a team-based approach to providing care
Provides the opportunity to integrate care, clinical
information and goals across health care settings
• Builds relationships & improves communication
between medical neighbors (smoother care
transitions)
• Provides more efficient and high quality clinical
care
• Other?
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Shared Care Plan: A Philosophy
Instead of speaking for the patient
and saying….
• Patient problem list
• Clinical recommendations or
clinical care plan
• Patient to dos
• Next appointment with PCP
• Diagnoses such as
•
Diabetic patient, obese
patient or depressed patient
Try having the patient speak for
themselves by asking…
• What are your concerns?
• What are your life goals? How I
will achieve your goals.
• Actions items for:
Patient/Family, Care Team
(Providers, medical assistants,
health educators) & other
resources.
• Next steps including use of
patient portal for
communication, patient update
the care team & next
appointment(s).
• Patient experiencing
depression, person with goals
of weight management or
diabetes management
Swedish Family Medicine
Residency
Swedish Family Medicine Residency
Care and Medication Management Documentation (Macro(s))
-For patients with our designated clinically important conditions (Diabetes, Ischemic Vascular Disease,
Depression) and complex patients (those recently hospitalized) care management documentation
must be entered into the visit if the care plan changes (i.e. – if it is addressed at the visit).
-This is achieved by using the Care Coordination macros. This is accessed by clicking the browse
button
in the assessment notes screen.
-The macros will no longer be attached to the specific disease related ICD codes as was done in the
past.
-Instead, attach the Care Coordination macros to the diagnosis code – “Counseling and Coordination
of Care.” This exact phrasing must be entered to search for the code. DO NOT search under the
IDC
9 code V65.49 because there are many different titles under this number.
Swedish Family Medicine Residency
-Enter information for diabetes/IVD/Depression and hospital follow up care
management in the single
Care Coordination macros.
-Save this ICD9 code to the problem list in the assessment screen to ensure
that the information carries
forward.
-This should be updated whenever addressing one of these specified conditions
(i.e. – whenever you
enter the ICD 9 code into a visit note).
Swedish Family Medicine Residency
Macros defined
Medications:
• Medication understanding (3D:3) (pt’s level of understanding) Answer: Y/N
• Need for medication education (3D:4) (does pt need med education? Answer: Y/N
• Date provided (3D:4) (if so, date) Answer: not needed if no medication education provided, date
if medication education provided
• Barriers to medication adherence (3D:5) (does pt not understand how to take medications, etc)
Answer: Y/N
Care Management:
• Motivational interviewing (4A:5) (motivational interviewing needed?) Answer: Y/N
• Need for coaching/care management (4A:1) (Need for coaching/need for care management)
Answer: Y/N
• Readiness to change (4A:4) (pt’s level of activation) Answer: precontemplative, contemplative,
preparation, action, maintenance
• Education resources given (3C:6) (Healthwise or other education material) Answer: Y/N
• Self management tools (4A:5) (blood pressure diary, blood sugar diary, diet diary provided to pt)
Answer: Y/N
• Barriers to care (3C:4) (social determinants of health, etc) Answer: list barrier(s)
• Goals of care (3C:3) – (weight loss, improve labs, etc) Answer: list goal(s) After defining goals of
care, paste goals into the treatment section so that goals populate the after visit summary
Resources
• HealthTeamWorks Guides:
• Treatment Tracking Log for Depression
• Patient Handout: What is Type 2
Diabetes?
• Shared Care Plans: A Reference
Guide
Shared Care Planning at
UCH Family Medicine Residency
• Aimee Falardeau
Practice Transformation Fellow
Outline
• Overview of 3 ways Shared Care Plans have
been/are being
• Review template
• Successes/failures/lessons learned
3 Areas of Shared Care Plan
Use over the Years
• Care Team
• Inpatient Discharge Planning
• Shared Care Plan Visits
3 Areas of Shared Care Plan
Use over the Years
Care Team Meeting
• 1 hour long twice monthly multidisciplinary meeting attended by
3rd year residents on outpatient months, pharmacy residents
and/or faculty, psychology interns, fellows, and/or faculty, care
manager
• Meeting process:
-- resident reviews a complex patient’s case
-- team solicits unanswered information regarding case
-- team offers advice within their given field
-- resident decides on next steps of action to be taken in this
patient’s care
• Shared Care Plan document is generated for this patient
-shows up in top of snapshot
-dates when it was created and updated
-linked with an FYI, so that a BPA pops up
-uses an epic dot phrase as template
-seen by anyone who opens the chart
SCP Template Components
•
•
•
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One-liner on patient
Approach to patient care by triage nurse
Approach to patient care by ED
Care Team members (with contact info if outside system)
including:
• PCP, care manager, living facility, social worker, specialists,
MD-POA, etc.
• Active Issues/Problem List (for chronic issues) with long-term
plan
• “Essential Care Issues” (i.e. advance directives, social/family
support, spiritual beliefs, transportation needs, housing,
language, cognitive limitations)
• Self Management Goals
3 Areas of Shared Care Plan
Use over the Years
• Inpatient Discharge Planning
• Same template used, except top part changed to include:
- Date of recent admission/discharge
- contact info for discharging resident and attending
- reason for hospitalization
- immediate action items for follow up visit
• Shared Care Plan document is generated for this patient
• Target population – complex patients being discharged from
our inpatient service with follow up in our clinic; occasionally
high utilizers following up in other clinics
3 Areas of Shared Care Plan
Use over the Years
• Shared Care Plan Visits
• Same concept as Care Team except in the form of a 1 hour
multidisciplinary office visit
- Occurs in the exam room
- Coded as a 99215
- uses a collaborative agenda setting form to guide discussion
- scheduled by Care manager
• Shared Care Plan document (and clinic visit note) is generated
for this patient
• Target population – complex patients as determined by internal
complexity scoring system
Pros/Cons of the 3 SCP Uses
• Care Team:
• Pros:
•
Way to involve multi-disciplinary learners
•
Gets lots of input in a 1 hour session from multiple areas of expertise
•
SCP easily viewable in Epic by anyone in patient’s chart
•
FYI alerts ED providers who may not look at pt snapshot
•
Forces provider to do a deep dive into patient’s chart
• Cons:
•
Time consuming for resident to review chart, document entire SCP
•
Up to provider to make SCP a living document
•
Patient is not directly involved
•
Other unrepresented voices exist: family, outside social worker,
specialists, outside case managers, etc.
•
Difficult to upscale (only 2 done per month)
Pros/Cons of the 3 SCP Uses
• Discharge Planning:
• Pros:
•
Centralized a “to do” list for provider seeing pt in hospital follow up (if
they looked at both the snapshot and the d/c summary)
• Cons:
•
Extremely time consuming for residents to double document d/c
summary and SCP.
Pros/Cons of the 3 SCP Uses
• Shared Care Visits:
• Pros:
•
Patient was involved
•
Worked well for patients poised for immediate benefit from those
involved
•
Required advanced collaborative agenda setting and facilitation skills on
the part of the provider
•
Helped arrange consistent follow up before patient left
•
Benefited when it linked those without continuity of care to their care
team and when it served as a jumping off point with the most needed
care
• Cons:
•
Sometimes had unneeded cooks at the table (i.e. right care, wrong
time)
•
Scheduling NIGHTMARE
•
Potentially difficult format for anxious patients
What’s Being Done Now
• Care Team
• Rare Shared Care Visits (hoping to get back off the
ground with hiring of care manager)
• Immediate action items for hospital follow up visit as
part of discharge summary
What ideas can you share
for keeping Shared Care
Plans a living, updated
document?
Discussion & Questions
Resources
• https://www.sharedcareplan.org
Thank You
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