Transcript Case Management of “Complex Patients” - PCMH e

Case Management of “Complex
Patients”
Lowry Family Health Center
Denver Health Track, University of
Colorado Family Medicine Residency
Program
Who are we?
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Sarah Hemeida, MD
Dan Lombardo, MD
Betsy Ruckard
Mohanned “Ned” Soud
T.J. Staff, MD
Brad Torok, MD
Who are you?
PCMH 4: Care Management and Support
20.00 points
The practice systematically identifies individual patients and plans, manages and
coordinates care, based on need.
Element A: Identify Patients for Care Management
4.00 points
The practice establishes a systematic process and criteria for identifying
patients who may benefit from care management. The process includes
consideration of the following:
Yes
No
1. Behavioral health conditions.
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2. High cost/high utilization.
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3. Poorly controlled or complex conditions.
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4. Social determinants of health.
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5. Referrals by outside organizations (e.g., insurers, health system, ACO),
practice staff or patient/family/caregiver.
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6. The practice monitors the percentage of the total patient population
identified through its process and criteria. CRITICAL FACTOR)
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University of Colorado Family Medicine Residency
PGY 3 Block Schedule 2014-2015
Resident
June
July
August
September
October
November
December
January
February
March
Joe Adragna (UH)
Derm
FMS
Cards
FMS
PCMH
Elective
PUEE
FMS
Rural
Surgery 2 Winter Park FMS
Elective
Stephanie Gold (DH) FMS
PUEE
FMS
Derm
Elective
PCMH
AFM
Elective
Winter Park
Elective
FMS
Cards
Surgery 2
Meghan Hughes (DH) FMS
Elective
PUEE
Cards
Elective - Ind.
Health Serv.
FMS
Surgery 2
Winter
Park
AFM
PCMH
FMS
Elective - St.
Anthony's OB
Derm
FMS
Elective
FMS
Surgery 2
Winter Park Derm
FMS
PCMH
AFM
PUEE
Elective
Dan Jones (UH)
Rural - Julesburg Cards
April
May
June
Mutki Kulkarni (UH) Elective
FMS
Derm
Rural
FMS
PUEE
FMS
MSK II in
Denver
PCMH
FMS
Cards
Surgery 2
Elective
Daniel Lombardo
(DH)
Surgery 2
PUEE
PCMH
Elective
Cards
FMS
Derm
FMS
Elective
AFM
MSK II
Denver
Elective
FMS
Kari Mader (DH)
Elective Research
FMS
Surgery 2
FMS
Elective - St.
Anthony's OB
Winter Park
Cards??
AFM
Derm
PUEE
PCMH
Elective - Ind.
Health Serv.
FMS
Luke Miller (UH)
PCMH
Rural
FMS
Elective
Surgery 2
Derm
FMS
Winter
Park
Cards
FMS
PUEE
AFM
Elective
Jill Tirabassi (UH)
Cards
Elective
PCMH
FMS
Elective
FMS
Winter Park FMS
Surgery 2
FMS
Derm
Rural - Basalt
PUEE
Surgery 2
Elective
FMS
Derm
Rural
FMS
FMS
Winter
Park
PUEE
Elective
Cards
Karin VanBaak (UH) FMS
PCMH
) Resident QI Project Calendar 2013-2014
Denver Health track
Scheduled QI Team meetings 1st and 4th Friday at 12:30-1:30
- Faculty leaders TJ and Brad
* - team leader
PCMH rotation – Tuesday morning for focused QI project time
June –Alex (Derm)*, Sarah (Elective)
July – Jess (PCMH)* Sarah (Derm)
Aug – Sarah (PCMH)*
Sep – Jess (Elective)*, Alex (Elective), Pam (Sx)
Oct – Alex (PCMH)*, Jess (Sx), Sarah (PUEE), Pam (Elective)
Nov – Alex (Elective)*, Pam (PUEE), Sarah (Sx)
Dec – Sarah (MSK Denver?)*
Jan – Jess (Derm)*
Feb – Sarah (Elective)*
March – Jess (Elective)*, Alex (Sx)
April – Pam (PCMH)*
May – Pam (Derm)*, Alex (PUEE), Jess (Elective), Sarah (Elective
Resident Led Quality Improvement Project
Dynamic Document
This Dynamic Document will be used for developing, implementing and communicating
your resident led QI project.
This Document will assist you in the QI process with using the Plan-Do-Study-Act
(PDSA) cycle. You will find a series of questions under each heading; these questions are
to help guide you through the QI thought process and communicate what tasks have been
completed to the group.
CLyon; 2013
Write your AIM statement
Use the SMART system in writing your AIM;
- Specific: who, what, when, where
- Measurable: numerical goals
- Actionable and achievable
- Relevant to stakeholders and the organization
- Timeframe: we should think in short cycles
Author:
Author:
What are the Team’s Next Steps?
2. Define the current system (Preplanning)
- Who is currently involved and what is their role?
- Define the processes and identify the key individuals involved in the current
process.
- Develop a team to clarify all processes currently involved.
- Interview regional experts or clinic/hospital stake holders.
- Determine the kind of data can you collect?
3. Baseline Data (Preplanning – continued)
- Clearly define what you will measure; ie what data you will collect and why this
data was chosen.
- Place your data collected in this section.
- Interpretation
- what does your data mean?
Author:
Author:
Author:
What are the Team’s Next Steps?
Author:
What are the Team’s Next Steps?
4. How will you implement change – (Plan the improvement)
Author:
- who is involved; identify the key people to assist with the implementation
- factors to consider – cost, buy-in, informing all parties involved, etc.
- Your teams discussions and recommendations
- stake holders involved; do you have their support
- timeline to implement your change
- how will you monitor the process
- Develop strategies to counteract resistance to change
Author:
Author:
What are the Team’s Next Steps?
6. Outcome Measures – (Study the results)
Author:
What are the Team’s Next Steps?
- After your intervention, what is your data when you re-measure?
- What is the interpretation of your new data?
- did your intervention show an improvement; if so, how much?
- if not, why was there no improvement?
- Describe any balancing measures - what unintended consequences happened?
-Describe any confounders – what factors might have positively or negatively
affected your data or your data collection?
- Summarize what was learned.
Author:
5. Carry out your intervention – (Do the improvement)
- What monitoring needs to be done during the intervention – ie; how will you
know that parts of the system are working as planned?
- When did you start; when did you stop
- What issues, unexpected outcomes happened during your monitoring
- What adjustments did you need to make to continue the intervention
Author:
What are the Team’s Next Steps?
7. Next step (Act to continue to improve)
- What is the next step (next cycle of change) in this project?
- How can this process be improved further?
Author:
8. Sustainability (Act to hold the gains)
- How can you make this change sustainable (if you found an improvement)?
- What adjustments from your project may need to be made to create a
sustainable program?
Advisor Comments:
schedule
• 1st and 4th fridays
• 1st Friday meet with clinic
• 4th Friday meet with entire residency class
(AFW)
• Faculty assigned to assist with the transition
Original
Standard work
Deadlines for Tasks in Preparation for Case Conference (CC)




6 weeks ahead
Date:________
Date:________
Identify pts for CC
including 1 resident
patient (Brewis,
Korny). Fill out CC
Patient Selection form
and give to PN.
Notify PCPs (PN)
Email Marla, Abby,
and Sam the names of
all selected pts
including resident pt
(PN)
Notify Patti Apple of
time/dates of CC +
provider & resident
who will attend each
to put on clinic
schedule (PN)







4 weeks ahead
Date:________
Date:________
Identify who to invite
(outside and at
Lowry), tell PN (PCP)
Call to invite outside
providers (PN)
Invite Lowry
participants by email
(PN)
Start filling out CC
form (PCP)
Call patient (SW)
o Ask about pt goals
o Invite to CC
o Fill out Pre-CC
Questionnaire
Telephone
Encounter form
o Add info to CC
form
Schedule pre-CC visit
for pt if needed (PN)
Contact MH providers
and gather MH info
(psych fellow)
o Add to CC form
o Fill out Pre-CC MH
Information form







2 weeks ahead
2-3 days before
Date:________
Date:________
Date:________
Date:________
Complete CC form
 Confirm with CC
and email to PN
participants (PN)
(PCP)
o Call outside
Make sure info from
providers
SW and psych on CC.
o Talk to Lowry care
Email completed CC
team members
form to CC
o Call patient
participants (PN)
 If outside providers
Remind outside
not going to be
providers by email or
available, tell PCP
letter (PN)
(PN)
Remind invited
o Call and gather
Lowry care team
information from
members by email
outside provider
(PN)
(PCP)
Call pt to remind if to  Prepare and print out
attend CC (PN)
handouts for CC
Pt to have appt with
including CC form
PCP if necessary
and med list (PN)
(PCP)
Schedule interpreter if
needed for CC (PN)







Day of CC
Date:________
Date:________
Remind participants
at morning huddle
(PN)
Make sure space is
prepared
Set up electronics if
needed
Bring handouts (PN)
Order lunch (PN)
Run CC (PN)
Take notes during CC
(PN)
Patient navigator is accountable party that will be responsible for tracking tasks and making sure all participants are aware of their roles and
meet deadlines.
Case Conference – Patient Selection
To be completed by Richard Kornfeld or Patty Brewis 6 weeks prior to the case conference.
Patient #1:
Patient name: ____________________________________________
MR# __________________________
Date of CC: _____________________
PCP:___________________________
Patient #2:
Patient name: ____________________________________________
Pre-Case Conference Mental Health Information
To be completed by MH provider at least 2-4 weeks before the case conference.
Patient name: ____________________________________________
MR# ___________________
Date: _____________________
Goals:
 Define if patient has any mental health problems
 Contact any outside mental health providers to discuss patient’s ongoing care. Invite
outside MH providers to case conference.
 Get outside mental health records
 Confirm any psychiatric medications
1. Does the patient carry any mental health diagnoses?
MR# __________________________
Date of CC: _____________________
PCP:___________________________
2. Does the patient see any outside MH providers? Who? Can they attend the case
conference?
Patient #3:
Patient name: ____________________________________________
MR# __________________________
3. Currently, how well controlled are the patient’s MH conditions?
Date of CC: _____________________
PCP:___________________________
4. How are the patient’s MH conditions currently affecting their overall quality of care?
Resident patient:
Patient name: ____________________________________________
MR# __________________________
5. What treatment(s) (pharmacologic and non-pharmacologic) is/are the patient on? How well
are they working?
Date of CC: _____________________
PCP:___________________________
After completing this form:
Give completed form to PN.
6. Does the patient have any safety threats? (Ex. Suicide attempts, mania)
ROLES FOR PREPARING FOR CASE CONFERENCE (CC)
Patient Navigator
 Patient navigator is accountable party that will be responsible for tracking tasks
and making sure all participants are aware of their roles and meet deadlines
 Distribute list of patients for each month’s CC to others involved in prep work
(PCP, SW, psychology fellow)
 Coordinate participation in actual CC including inviting and reminding intended
attendees
o Attendees to always include: PN, RN (Cheryl or Meredith), Kornfeld,
PCP, SW, and BH (Sam and/or fellow). Other attendees to be designated
by PCP (including +/- patient).
o Arrange interpreter if needed
 Schedule appt for patient prior to CC if requested by PCP. See pt with PCP at
appt.
 Compile info from SW and psych to add to CC form filled out by PCP. Email out
completed CC forms
 Prepare handouts for CC including CC form, med list. Arrange for lunch at CC.
 Run CC and take notes at CC
PCP
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Fill out past medical history on CC form (problem list, last PCP visit, # of IP
visits over past 6 mo, and # ED visits over past 6 mo). Give to PN.
Determine other attendees (ex: patient, clerk, HCP, pharmD, outside providers)
and tell PN who to invite to CC
Attend CC
Behavioral health
 Fill out Pre-Case Conference Mental Health Information form. Copy and give to
PN. Add info to CC form.
o Chart review of patient’s MH hx
o Contact patient’s MH providers to gather more information. Invite to CC.
o Get outside MH records about patient prior to CC.
 Attend CC
Social Work
 Call patient prior to case conference. Discuss with patient barriers to care and
patient goals for care. Fill out Pre-Case Conference Questionnaire Telephone
Encounter form. Copy and give to PN. Add info to CC form. Invite pt to CC.
 Attend CC
Patty Brewis and Dr. Kornfeld
 Select attending/provider patients each month for next month’s CC including 1
resident patient. Fill out Case Conference Patient Selection form and give to PN.
Phone call script
Prior to phone call:
1. Print out Med list
2. Review Problem List in LCR--- Put problems in Case conference sheet (see attached #1)
3. Review Last PCP visit. Write date of visit and provider under #3
4. Review recent hospitalizations/ED visit within the last Year --Write in Case conference sheet
(see attached #3)
Patient Navigator /RN High Risk Patient Screening.
1.
Hi My name is ___________________. I work with Dr.__________________.
Dr.__________asked me to call you to review your recent health care. The goal of my phone
call today is to see if there are health concerns that you have that we are not addressing.
2.
Do you need an interpreter for todays telephone call or any of your doctors visits?
(complete item #4)
3. Confirm patient phone number and contact information. (complete item #5)
4. Do you have problems paying for your medicines or problems getting your medications?
(adherence #6)
5. Where are you living right now? Are you worried you may not have a place to live in the future?
(homeless #7)
6.
Do you have problems getting to your doctor appointments? (transport #8)
7. Do you have or have you had problems with your mental health in the past?
Do you have a dr. or therapist that you see for mental health problems? (#9)
Have you been feeling down depressed or hopeless?
____________________________________________________8. Do you now or have you ever had a trouble with alcohol or drugs? #10
9. What can your doctor do to make your life better ? #11
1. What do think prevents you from being healthy? #12.
Thank you for your time. I will pass all this information on to your doctor.
We will be calling you back with your next appointment in the near future or
Your next appointment is _____________________________-
Month
October 2013
Dates of CC’s
October 22nd
October 29th
Provider patients
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2.
3.
PCP’s
Resident
Sledd
November 2013 November 19th ?
November 26th
1.
2.
3.
Bull
December 2013 December 17th
1.
Hemeida
January 2014
January 21st
January 28th
1.
2.
3.
Bull
February 2014
February 18th
February 25th
1.
2.
3.
Pam
March 2014
April 2014
May 2014
June 2014
Resident patient
Case Conference Pilot 60-day follow-up discussion topics
What have we learned?
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What is the best way to allocate CC work (pre-conference, conference and post-conference)
among various members of the care team?
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How do patients react to being CC’ed?
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Care plans
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CCs are time intensive.
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Many of the highest cost patients on the CC lists have social and behavioral barriers that make it
more difficult for them and their care teams to manage their (typically) multiple chronic
conditions.
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How do CCs alter existing care plans?
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How are care plans executed?
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CC pre-work can open a Pandora’s Box of social and behavioral barriers that can provide a
patient’s care team new perspectives on his/her condition and what might help.
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Some of the patients selected for CCs are at a point in their lives where it is unlikely that CMMI
interventions will reduce their future use of hospital care and, thus, help meet CMMI goals.
Do care plans include activities that are likely to persist for a relatively long period of
time (e.g., improved self-management skills) or do they consist primarily of short-term
action items (e.g., a follow-up appointment, a transportation voucher, a one-time
titration of medications, etc.)?
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Many of the issues identified in CCs can be addressed solely or partly by non-PCP members of
the care team.
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Some high-cost patients do not get the care they need because of transportation
barriers that can be addressed by social workers and/or patient navigators.
CCs can drive additional PCP visits, yet these visits may be more effective and efficient due
issues identified through the CC process and the collaboration of other members of the care
team.
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Medication management is a serious challenge for many high-cost patients and their
doctors and that clinical pharmacists can identify strategies for improving medication
management.
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What impact has the CC process had on selected patients’ utilization – hospital (ED and IP), PCP,
CMMI resources, specialty, other (SNF, HCBS, Home Health, hospice)?
What should we do next?
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Develop the case for recommending continuation (and spread?) of CC intervention to Clinical
Design December meeting.
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Refine patient selection procedures
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For example, CCs can generate “integrated visits” where a CC’ed patient’s follow-up
appointment consists of visits with several members of the care team (PCP, RN,
PharmD, SW, BHC) following the primary appointment.
Most care team members find CC work engaging. In the short term CC work appears to be a
morale booster from many care team members. (It is uncertain whether this boost will outlive
the “honeymoon” phase of the intervention.)
What would we like to know?
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How to better select patients for CCs: Which patients are most likely to benefit and which are
least likely to benefit?
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How many patients can be CC’ed per month per clinic without disrupting or overburdening
other clinic work?
Improve criteria for identifying patients who are unlikely to benefit (in terms of CMMI
goals) from the CC “treatment”.
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Current proposals include
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Dialysis
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Active cancer treatment
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Substance abuse (alcohol, drugs) (The CC intervention is unlikely to be
effective until rehab has been completed.)
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Morbid obesity
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Mental health condition (?)
Improve criteria for identifying patients who are likely to benefit (in terms of CMMI
goals) from the CC “treatment” – i.e., patients who are “beginning to unravel” vs. those
who have already “unraveled” to a point where it is very difficult to return them to a
healthier, less costly state.
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Current proposals include
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Patients newly added to Tier 4 (3 IP or 2 IP MH stays in last 6 months)
and not assigned to IOC and patients newly added to Adult high risk (>=
3 ED visits in last 6 months).
Other outstanding issues
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Do CC team members understand intervention objectives (improved health, lower costs) and
keep these in mind as they do CC work?
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What role should predictive modeling vs. clinical judgment play in patient selection?
o
Content and format of CC patient lists.
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Clarification of scope of practice for members of the care team, especially patient navigators.
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Collaboration with managed care for high-cost patients with DHMC insurance.
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Could a refined pre-conference screening script be developed to identify patients not suitable
for CC?
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Can patients tell us when they are “unraveling”?
How should CC work be documented?
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To facilitate the work of the care team?
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To facilitate the work of the evaluation team?
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How standardized should CC work be across clinics?
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Is a CC “successful” when it identifies and addresses any issue that benefits the patient and/or
his/her care team, or is it “successful” only if it provides a long-term benefit in terms of patient
health and health system costs?
Final
Lessons learned
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Time
Value of “case conference” for education
Asynchronous
Patient buy-in
Limitations, data only within our system
Other
Questions?