Transcript slides for this presentation

BEST PRACTICES IN
DISEASE MANAGEMENT
Deanna Bell, M.D., F.A.A.P.
Medical Director, MHIP
Tennessee Chapter of the American Academy of
Pediatrics
GOALS OF D70 GRANT
“ . . . to improve medical home provision for
children and youth with special healthcare
needs by promoting systems and service
integration for children through education of
parents and providers on medial home
concepts of team-based care, care
coordination, and disease management.”
Who are Your
CYSHCN?
MOC QI AIM #3
----------------------------------------HIGH RISK REGISTRY
FORMATION
WAYS TO ID CYSHCN
• Screeners (CSHCN Screener, QuICCC, QuICCC-R)
• ICD-9 lists (NHIS, CAHMI, NDP)
• Administrative with risk stratification (3M-CRG)
• Physician Referral
• Payer referral
• Pharmacy utilization
ADMINISTRATIVE: 3M CRG
• Combines Dx and consequences based approaches
• Uses ICD-9 and procedural codes to classify cases
• Requires:6 months of claims data
2 or more encounters with same Dx code
• Takes into account: type and number of Dx, recurrences,
number of acute exacerbations,
cost/type/combination/frequency of services
• Strengths: identifies population and individuals; assigns
severity rating; assigns groupings:
SURVEY-BASED METHODS
• QuICCC: 41 question survey sequence
• QuICCC-R: 16 question survey sequence
• CSHCN Screener: 5 questions survey sequence
• All do not require formal Dx
• All 3 part sequence: consequences/presence of
condition/duration
• Qualify if positive answers to one or more sequences
• All identify population cohorts and can identify
individuals
• QuICCC and QuICCC-R: interviewer administered only
COMPARISON OF ADMINISTRATIVE
AND SURVEY-BASED METHODS
Of CSHCN identified by ICD-9 lists
• Only 52-53% met CSHCN criteria by survey methods
Of CSHCN identified by Survey Methods
• 20-24% were not identified by ICD-9 lists
Concordance between CRG/CSHCN Screener/QuICCC-R= 8590%
CSHCN IDENTIFIED BY SURVEY AND NOT BY
ADMINISTRATIVE DATA ARE LIKELY TO:
• Have developmental or emotional disorders not
coded in encounter records
• Use services not reimbursed under benefit
structure
• Have multiple health issues that include a range of
educational, developmental, and mental health
service needs and consequences
• Be in transition between health plans or PCPs
MCHB/AAP DEFINITION CYSHCN
“ . . . those who have or are at increased risk for a
chronic physical, developmental, behavioral, or
emotional condition and who also require health and
related services of a type or amount beyond that
required by children generally.”
McPherson M, Arrange P, Fox H, et al. “A new definition of children with spe
cial health care needs”, Pediatrics, 1998; 102: 137‐140.
CHILDREN WITH SPECIAL HEALTH
CARE NEEDS (CSHCN) SCREENER©
•non-condition specific, consequences- based
•identifies children across the range and
diversity of childhood chronic conditions and
special needs
•identified on the basis of one or more current
functional limitations or service use needs
•Scoring in based on positive cluster (e.g. 5
and 5a= positive; or 1 , 1a, and 1b=positive)
CHILDREN WITH SPECIAL HEALTH CARE NEEDS
(CSHCN) SCREENER©
1. Does your child currently need or use medicine prescribed by a doctor (other than vitamins)? ‫ٱ‬Yes Go to
Question 1a ‫ٱ‬No Go
to Question 2
1a. Is this because of ANY medical, behavioral or other health condition?
Go to
Question 2
‫ٱ‬No
‫ٱ‬Yes
Go to Question 1b
1b. Is this a condition that has lasted or is expected to last for at least 12 months? ‫ٱ‬Yes ‫ٱ‬No
2. Does your child need or use more medical care, mental health or educational services than is usual for most
children of the same age? ‫ٱ‬Yes Go to Question 2a ‫ٱ‬No
Go to Question 3
2b
‫ٱ‬No
2a. Is this because of ANY medical, behavioral or other health condition?
Go to Question 3
‫ٱ‬Yes
Go to Question
2b. Is this a condition that has lasted or is expected to last for at least 12 months? ‫ٱ‬Yes
‫ٱ‬No
3. Is your child limited or prevented in any way in his or her ability to do the things most children of the same age
can do? ‫ٱ‬Yes
Go to Question 3a ‫ٱ‬No
Go to Question 4
3b
‫ٱ‬No
3a. Is this because of ANY medical, behavioral or other health condition?
Go to Question 4
‫ٱ‬Yes
Go to Question
3b. Is this a condition that has lasted or is expected to last for at least 12 months? ‫ٱ‬Yes ‫ٱ‬No
4. Does your child need or get special therapy, such as physical, occupational or speech therapy?
to Question 4a ‫ٱ‬No
Go to Question 5
‫ٱ‬No
4a. Is this because of ANY medical, behavioral or other health condition?
Go to
Question 5
‫ٱ‬Yes
‫ٱ‬Yes
Go to Question 4b
4b. Is this a condition that has lasted or is expected to last for at least 12 months? ‫ٱ‬Yes ‫ٱ‬No
5. Does your child have any kind of emotional, developmental or behavioral problem for which he or she
needs or gets
treatment or counseling? ‫ ٱ‬Yes
Go to Question 5a ‫ٱ‬No
5a. Has this problem lasted or is it expected to last for at least 12 months?
‫ٱ‬Yes
Go
‫ٱ‬No
CSHCN SCREENER© GRADING
• All three parts of at least one screener question (or in the
case of question 5, the two parts) must be answered
“yes” in order for a child to meet CSHCN Screener©
criteria for having a chronic condition or special health
care need.
• The CSHCN Screener© has three “definitional domains:”
1) Dependency on prescription medications. 2) Service
use above that considered usual or routine. 3) Functional
limitations. The definitional domains are not mutually
exclusive categories.
ENTRY CRITERIA FOR REGISTRY
• Positive screen for barriers to compliance
• Positive CYSHCN screen
• Physician referral
• Health plan referral
• Diagnosis list
TRACKING REGISTRY
• Once your chronic or complex illness cohort is
identified, you must decide on a tracking system.
• Most EMRS have flag systems, so a flag or icon can be
added to these patients
• Many practices on paper charts use stickers of a specific
color on the patient’s chart.
• There needs to be communication of Registry status to
patients and staff
TNAAP
High Risk Registry Tracking Tool
Emergency Plan Updated Last
Plan of Care Last updated:
Disease States
Follow up Interval
Last appointment
Last WCC
Influenza Immunization Given? (Y/N)
Barrier to Compliance Screen Last Given
Disease Specific Plan of Care Up-to-Date? (Y/N)
Needs:
Patient
Name/DOB
Patient
Name/DOB
Patient
Name/DOB
Patient
Name/DOB
Patient
Name/DOB
Patient
Name/DOB
Patient
Name/DOB
Patient
Name/DOB
Patient
Name/DOB
Patient
Name/DOB
Patient
Name/DOB
Patient
Name/DOB
Patient
Name/DOB
Patient
Name/DOB
Patient
Name/DOB
MOC QI AIM #3 MEASUREMENTS
• Report baseline registry formation based on
objective screening (20 charts, alright if 0).
• Institute CSHCN screener and/or other
• Enter children with positive screens into registry.
• Tag record with identifier positive or negative
• Monthly, select 10 charts from general population
that month to audit for use of CSHCN Screener or
other evidence of screening for registry entry.
Care Coordination Framework
Team-based
Communication
Case
Management
Patient
Disease
management
What is Disease
Management?
Disease Management
“Disease
management supports the
physician or practitioner/patient
relationship and plan of care,
emphasizes prevention of exacerbations
and complications using evidence –based
practice guidelines and patient
empowerment strategies, and evaluates
clinical, humanistic, and economic
outcomes on an ongoing basis with the
goal of improving overall health”
Disease Management Association of America. DMAA Definition of Disease Management. {Accessed: January 26,2007};available from :http://www.dmaa.org/dm_definition.asp
What are the
characteristics of
successful disease
management programs?
Successful Disease Management Programs
Individualized
Case
Management
In-person contacts
Focus on hospital
discharges
Encourage use of
cost effective
therapies
Simple
Patient
Centered
Large/overarching
Identified
measurement
parameters
Incentives
Context of Studies
Adult cohorts
 Large
Pediatric Cohorts
volumes of same  Few large volume
diagnosis
cohorts
 Good evidence base for  Many severe illnesses
therapies
without standardized
evidence base for
 Costs/Morbidity center
therapy
around large volume
cohorts
 Cost/Morbidity located
in 10% of children,
small cohorts
Considerations in pediatrics
 Disease
management strategies in pediatrics must
be applicable across a variety of disease states.
 Disease management in pediatrics requires both
population approaches and individual case
management approaches
 Processes in pediatrics must be fluid enough to
respond to the situational needs of highly
specialized/varied patients.
 Formalized disease management in primary care
Disease Manager Functions
 Support
evidence based care and individual
plans of care
 Disease-specific knowledge a must
 Provides education for self-management
 Compliance tracking and reassessment a large
role
 Works with MD and case manager to optimize
access, compliance, and education
Disease Management Team Tasks
Patient
screening and registry formation
Evaluates patient/family comprehension of
plan of care
Performs disease education as appropriate
Refers patient to case manager as risks for
noncompliance identified
Disease Management Team Tasks
Tracks
and monitors patient compliance
with care plans by registry
Augments communication by keeping team
members aware of patient status
Assists with transitions to/from
hospital/adult care
Authority to schedule override
Disease Management Workflow
Assess
Monitor/Evaluate
/Adjust
Support self
Management
Link Community
Resources
Evidence-based
plan
Maintain
Registry
Communicate
Plan
Execute
Keep it Simple
 Form
your registry
 Support the evidence base with process
 Educate and involve the team
 Use Tools
 Continually reassess
 Set regular communication times
Assess
• Record which diseases in your practice are
leading to increased service utilization or
functional capacity limitation
• Review the evidence base for these diseases
• Form your registry (General or disease-specific)
Evidence-based plan
• Support evidence base with process
• Identify essential action steps that will support
evidence base
• Form office procedure around information exchange
that must take place to support evidence-based
intervention
• Describe the responsibilities in this work-flow by job
description
• Don’t forget case management plan
Communicate
Plan
• Physician
• Disease Management
• Case Management/Linkage with Resources
• Referral coordinator/other staff
• Patients
• PHYSICIAN MUST HAVE WRITTEN CARE PLAN FOR
PATIENTS
Execute
•Processes for a diagnosis cohort or individual
patient executed
•Patient expectations communicated to
patients
•Team aware of plan and monitoring
compliance
Link Community Resources
•Screen for barriers to compliance
•Create care plan for overcoming barriers
•Monitor patient compliance with this plan
•Follow-up and reassess
Support Self Management
• Written plan of care to patients
• Assessment of health literacy for self
management
• Disease or patient-specific patient education for
self management
• Referral to case management as needed.
Monitor/Evaluate/Adjust
• Follow-up interval specified in patient plan of care
or part of evidence-based care path
• Track no shows and compliance with referrals
• Maintain patient contact/Assure follow-up occurs
• Reassess response to interventions
• Adjust plan accordingly
• Continually reassess for barriers to care
A written plan of care is
essential to communicating
patient specific expectations to
all team members.
Three types of plans for CYSHCN
 Patient
Summary: Problem list, PMH, Meds,
Allergies, Specialists, Therapies, Typical
Laboratory Values and Exam, Cultural and
Social Considerations, Legal
 Action
Plan: today’s additions, changes
 Emergency
Plan
MOC QI Aim #4
----------------------------------
Written plans of
care for team
MOC QI Aim #4 Measurements
 Report
baseline proportion of chronic
disease registry patients with written
plans of care on chart (20 patients from
baseline chronic illness registry, alright if
0)
 Institute team management strategies
 Monthly, select 10 charts from patients
seen in the chronic/complex disease
registry to audit for presence of written
plan of care
Example Forms
Franklin, TN 37065-1346
Phone: (615) 790-0567
Fax: (615) 595-8030
(YOUR CLINIC NAME) Plan of Care
Plan de cuidados
Personal Information/Información Personal
Name/Nombre:
Nickname/Apodo:
DOB/Fecha de Nacimiento:
Primary Language/Lenguaje:
Phone Number/Número de Teléfono:
Insurance/Aseguranza:
Date Form Completed/Fecha:
Pediatrician/Pediatra:
Name:
D.O.B.:
Date:
Date for Next Visit:
Frequency of Visits:
The new changes to your care plan are listed below. Please read the
Emergency Care Plan for medication list, emergency management, and
routine care.
Allergies/Alérgias:
Diagnoses/Diagnósticos
Patient Care Plan
ICD-9
Care Concern/Dx (1)
Plan:
Care Concern/Dx (2)
Plan:
Resolved Diagnoses/Diagnósticos Resueltos
ICD-9
Care Concern/Dx (3)
Plan:
Care Concern/Dx (4)
Plan:
Upcoming Needs/Necesidades Para El Futuro
If your care plan includes a referral and you have not heard from us
within one week, please call to confirm the referral has been scheduled.
If you have difficulty with following the care plan or filling medications,
or if you have concerns, please call the office at (XXX)XXX-XXXX.
Baseline Measurements, 20 charts
• Evidence of screening for barriers to compliance
• Evidence of linking patients with barriers to
compliance to community resources
• Evidence of screening for CSHCN registry
• Evidence of written care path in the record for
those in CSHCN registry
Monthly Measurements
10 charts general population:
• Were they screened for barriers to compliance?
• Were they screened for CSHCN registry
10 charts with positive barrier to compliance screen:
• Is there documentation of linking patient with a resource to
overcome barrier to compliance?
10 charts CSHCN Registry:
• Is there evidence of the written care plan you have agreed to
use?
Overall AIM Statement
• Involved practices will improve chronic disease registry formation by
50% by the end of data collection.
• 25% of registry patients of involved practices will have a care plan
with therapeutic recommendations and/or goal by the end of data
collection.
• Involved practices will improve screening for risk factors for
noncompliance by 50% by the end of data collection.
• 25% of patients with a risk factor for non-compliance will be linked
with community resources needed to promote compliance by the end
of data collection.
Requirements for MOC participation
Summit Participation
Baseline/follow-up NCQA PCMH Medical Home Survey
Baseline/monthly (4 month) data entry/analysis for
QIDA parameters
Participation in 2 of 4 technical assistance
webinars/conference calls
Participation in final QI Program Synopsis call/meeting