2018 Care Coordination Collaborative Virtual MeetingSeptember 24, 2018

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Care Management BenchmarksPCMH Initiative Participants received an email on Wednesday, September 19 indicating your projected status on the Care Management Improvement Reserve.

Any questions or concerns can be directed to the listserv(MDHHS-SIMPCMH@Michigan.gov).

Agenda 1. Welcome and Overview

2. Today’s Theme: Overcoming Challenges and Barriers to Coordination

3. What Can the Literature Tell Us?

4. St John Partners in Care: Creatively Building Resources for Care Collaboration (Roseanne Paglia, PharmD, Stacey Bartell, MD and Antatol Tolchinsky , PhD)

5. Integrated Health Associates (IHA): Coordination Via Alternative Visits: Laying the Building Blocks (Maureen Braun, RN and Andy Pritchard, MPH)

6. Wrap-Up and Summary

Today’s Theme: Overcoming Challenges and Barriers to Coordination

What the Literature Tells Us About Challenges and Barriers –Supper, et al.

Findings: What Care Managers and Coordinators Report That They Do Most

• Reaching out to patients

• Conducting face-to-face patient encounters

• Providing social support to patients

• Collecting, managing, and exchanging patient data

• Supporting physicians

• Backing up other practice staff

Supper, I., Catala, O., Lustman, M., Chemla, C., Bourgueil, Y., & Letrilliart, L. (2014). Interprofessional collaboration in primary health care: a review of facilitators and barriers perceived by involved actors. Journal of Public Health, fdu102.

What the Literature Tells Us About Challenges and Barriers –Supper, et al., cont.Barriers By Professional Type – Examples

Pharmacists: • Barriers: Lack of funding, time and team support for integration; legal limits

• Facilitators: Definition of roles; “bottom-up” process building; adaptation of workspace; training; developing value from integration

Behavioral Health Providers• Barriers: Stereotypes about providers and patients; illness-oriented frameworks

• Facilitators: Flexible, adaptable and horizontal model; regular, structured meetings

Supper, I., Catala, O., Lustman, M., Chemla, C., Bourgueil, Y., & Letrilliart, L. (2014). Interprofessional collaboration in primary health care: a review of facilitators and barriers perceived by involved actors. Journal of Public Health, fdu102.

What the Literature Tells Us About Challenges and Barriers –Supper, et al, cont.

Recommendations for Improving Collaboration

• Separate responsibility for panel (population) management

• Have a system to update community resources and social agencies information

• Participate in regular team huddles

• Deliberately focus on good relationships with physicians and external facilities

• Maintain and improve motivational interviewing (MI) skill (e.g., monthly “MI club or call” to role playing

helping patients with many challenges

• Practice self-care (e.g., yoga, meditation, etc.) to relieve stress and increase resiliency.

Supper, I., Catala, O., Lustman, M., Chemla, C., Bourgueil, Y., & Letrilliart, L. (2014). Interprofessional collaboration in primary health care: a review of facilitators and barriers perceived by involved actors. Journal of Public Health, fdu102.

What the Literature Tells Us About Challenges and Barriers-Friedman, et al.

Friedman, A., Howard, J., Shaw, E. K., Cohen, D. J., Shahidi, L., & Ferrante, J. M. (2016). Facilitators and Barriers to Care Coordination in Patient-centered Medical Homes (PCMHs) from Coordinators Perspectives. The Journal of the American Board of Family Medicine,29(1), 90-101. doi:10.3122/jabfm.2016.01.150175

Organizational/System-Level: Workload (esp. for cases involving behavioral health, end of life planning, social support, health care coverage, homelessness

Technology: Necessary functionality was lacking; desire to not have to search for individual patients

Community Resources: Finding resources anew without a directory; keeping information current

Interpersonal: Discomfort with reaching out to agencies; having to “win over” physicians

What the Literature Tells Us About Challenges and Barriers-Friedman, et al, cont.

Friedman, A., Howard, J., Shaw, E. K., Cohen, D. J., Shahidi, L., & Ferrante, J. M. (2016). Facilitators and Barriers to Care Coordination in Patient-centered Medical Homes (PCMHs) from Coordinators Perspectives. The Journal of the American Board of Family Medicine,29(1), 90-101. doi:10.3122/jabfm.2016.01.150175

Patient-Facing: Patient lack of trust; inability to take responsibility for self-management; insufficient patient understanding of coordinator role

Self-Facing: Feeling that self-care cannot be a priority

Recommendations:

• Maintain a focus on provider acceptance and effective team integration

• Optimize knowledge of community and interprofessional resources

• Define optimal job activities and caseloads

• Establish some boundaries and adopt self-care practices

Effective Use of Care Team Members to Remove Barriers and Optimize Patient Outcomes ST. JOHN PROVIDENCE PARTNERS IN CARE

STACEY BARTELL, MD & ANATOL TOLCHINSKY, PHD

MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES

Stacey Bartell, MD Anatol Tolchinsky, PhD

Time to Get to Know Each Other: A Few Polling QuestionsIn meeting the needs of your patients, which of the followingbehavioral health areas causes your clinic to struggle the most?

1) Substance abuse

2) Developmental delay/Autism spectrum

3) Lifestyle modification/behavior change

4) Severe and persistent mental illness

5) Other

Which of the following team members would you want added to your integrated care team?

1) Case Manager

2) Psychiatrist/Psychiatry resident

3) Embedded Psychologist

4) Pharmacist

5) Other

Time to Get to Know Each Other: A Few Polling Questions

When you have lost or gained a new team member, which of the following was most helpful to improve the team's functioning?

1) Doing a organized needs analysis, such as a SWOT analysis.

2) Cross train employees.

3) Create new work-flow processes and policies.

4) Leverage general existing system policies.

5) Other

Time to Get to Know Each Other: A Few Polling Questions

South Lyon Medical Center – Who We Are

Patients

Physicians Family Medicine Residents

Psychiatry Resident

Behavioral Care

Specialist

Behavioral Health

StudentNurse

PractitionerNurse

Care Manager

Medical Assistants

Practice Manager

Patient Family

Advisory Committee

What We DoCare Team Member Primary Role(s)Faculty Physicians Refer patients to care teamFamily Medicine Residents Refer patients to care teamPsychiatry Resident Onsite consultant (chart and med review) Behavioral Care Specialist Behavioral health consultant, primary care behavioral health modelBehavioral Health Student Grad students in Masters Program--practicum experienceNurse Practitioner Wellness Exams, High intensity Care management, DMNurse Support care management activity, med assistance programsCare Manager Care Management, SDoH follow up, Transitional Care VisitsMedical Assistants Outreach after ER visits, daily QM updates, GAPS outreachPractice Manager Coordination of rolesPatient Family Advisory Committee Provides Feedback on SDoH, patient interactions with officeQuality Coordinator Obtains data for CM outreach, Population Health Coordinator

How We Work• All care team members add value and

contribute to the needs of the population.• Care team members participate in care

team meetings. Ideas, concerns, progress toward meeting goals and work flow issues are regularly addressed at meetings.

• Processes and activities regularly evolve as a result of PDSA cycle evaluations.

• Barriers to care and effective use of resources are regularly evaluated.

Patient Case60 year old female (non-English speaking)

History of Diabetes Mellitus, Hypertension, history of Coronary Artery Bypass Grafting

History of mood disorder in native country, not on medications currently, presents with increased agitation

Daughter concerned about depression, anxiety and OCD-like behaviors

Care Team Response• Resident physician saw patient, engaged with family member.

• Behavioral health/clinical psychologist able to interview patient and daughter to assess risk, discuss techniques for anxiety, will check in with family within 1-2 weeks to follow starting of new medicines.

• Psychiatry resident able to assist with restarting psychiatric medications, previously on 3, he had consultation with Behavioral Health and resident to review options.

• Plan to engage interpreter system at next visit, to hear directly from patient and not via family member as translator.

• CM available for diabetic teaching as needed.

Importance of Linking Patients to Community Resources • Some barriers to care are non-medical in nature and better supported by collaboration with

community partners.• Identify social/environmental needs of the patients in your practice.• Finding community partners that can help address the majority of the needs of the practice is

essential.• County and state health departments.• Programs offered by local hospitals (classes, wellness facilities, support groups, etc.).• Medicaid Health Plans• Health and wellness facilities, particularly nonprofit organizations such as the YMCA.• Faith-based health programs

• Connect, communicate and evaluate effectiveness of community partners.• South Lyon community partners for this patient, include possible counseling at Active Faith

and Senior Center activities to help keep patient active and involved.

How to Get Resources for Your Practice• Assess current needs and resources.• Develop a “wish list” for services available in your practice.• Evaluate opportunities to incorporate any services with existing infrastructure.• Reach out to local medical schools to explore partnerships with existing residency

programs.• Reach out to Colleges and Universities to inquire about internship and/or clerkship

opportunities for disciplines of interest (nutrition, social work, behavioral health, etc.).

• Identify individuals in your practice that will serve in clinical and administrative leadership roles.

• Assure that goals of the educational program as well as the practice are met.• Obtain patient feedback on new services.• Monitor and improve processes.

Challenges we faced along the journey• Institutional, we work within large institution

• Turnover : RN, BHS

• Burnout in roles

• Coordination in care, not overlap, learning how to work as a group

• Cross training

Questions?

Implementation of Alternative Visits at IHA Practices

INTEGRATED HEALTHCARE ASSOCIATESMAUREEN BRAUN, RN BSN CCM & ANDY PRITCHARD, MPH

Alternative Visit Types at IHA to Overcome Coordination and Care ChallengesShared Medical Appointments

e-Visits

Home visitsVisits for patients at SNFs/ECFs

Other efforts to improve access & coordination:◦ Extended office hours◦Video visits◦ SIM Hublet

Some Questions to StartHave you implemented or do you have plans to implement within the next year

Shared Medical Appointments Yes OR No

e-Visit Yes OR NoHome Visit Yes OR NoVisits to Nursing Home or Extended Care Facilities Yes OR No

Shared Medical Appointments

Shared Medical Appointments (SMAs)Background◦ SMAs began in 2011◦ Typically 2 to 3 SMAs are held monthly◦ 90 minute visit◦ Providers identify patients from their panel to invite to sessions◦ 10 to 12 participants attend (~75% of those invited)

Multidisciplinary Team◦ Provider◦ Medical Assistant◦ Dietitian◦ One group visit charge pushed by PCP – no medical nutrition therapy is billed

Shared Medical Appointments (SMAs), cont. Implementation challenges and solutions

Retention◦ Important to schedule patients for next SMA at checkout ◦ Patients can “fall through the cracks” if they leave without having the next SMA planned

Meeting logistics◦ At least 2 MAs are needed for rooming to go smoothly◦ 1 MA stays in the room with provider during the entire visit to send prescriptions, place orders, etc.◦ Checkout can become a bottleneck. One clerical staff watches for finalized notes/orders and prepares

checkout documentation ahead of time

Staff / Manager support and buy-in◦ Office staff should be trained in SMA benefits, and workflows ◦ Strong support from office manager is important to set the tone among staff and help with scheduling,

etc.

Shared Medical Appointments (SMAs), cont. Structure◦Meeting is facilitated by the Dietitian◦ Educational topics covered by Dietitian and provider triggered by

patient interest or may be prepared in advance◦Brief Action Planning and patient-led goals established ◦Routine labs, medication refills/adjustments completed during visit◦ Point of Care A1c, foot exam, flu shots completed if indicated◦ Transparency – patient labs, vitals projected on a screen for the

patients to view

Shared Medical Appointments, cont.Impact◦ SMAs create an excellent opportunity to provide self-management education

– the SMA/SME combo helps control A1c◦ Patients appreciate the social outlet, which helps with retention as well◦ Patient satisfaction – SMAs allow patients to receive support and learning

from peers in a relaxed atmosphere – not just their provider’s point of view◦ Providers 1 ½ to 2 hours of learning, not just 15 minutes you’d have during a

1:1 visit◦ Clinical outcomes – program has not been formally evaluated, but lab reviews

show good improvement in A1c, renal function and lipids

e-VisitsBackground◦ E - visits began approximately 3 years ago◦ Approximately 100 visits per month◦ Patients can call anytime – physicians are available between 8am and 10pm◦ Patients are charged a flat rate of $35 per visit (insurance is not billed)◦ Common, non-urgent medical conditions that can be safely treated virtually.

Other conditions are referred to urgent care or ED◦ Patient initiates treatment online, and phone, video, or lab services are as

pulled in as needed

e-Visits, cont.Implementation challenges and solutionsCompliance◦ Challenge: Michigan law requires “real time” appointments with new patients, and in

order to prescribe medication. ◦ Solution: Took some time to sort out the legal details. New patients are contacted by

phone before being treated through ZipNosis. Patient satisfaction◦ Challenge: Initial concern among PCPs that the service would syphon patients away

from practices. ◦ Solution: This has not been an issue due to relatively low volume, and fact that a

solid subset of patients still prefers in-person visits. EMR integration◦ Challenge: How can data from ZipNosis visits be integrated into the EMR?◦ Solution: Currently visits generate a PDF summary which is scanned in.

e-Visits, cont.ImpactExpanded access to careConvenience for patients Optimized for common smart phones/tabletsLargely positive feedback from patients

Home Visits

Home Visits, cont.Background

Began in 2015 as part of the BCBSM High Intensity Care Management program

Expanded in 2018 to include all patients; providers can refer patients

Visit types◦ Medicare Wellness Visits◦ Transitions of Care Visits◦ 21 day hospital follow up visits for patients with Heart Failure

Team◦ Geriatric NP◦ Social Worker

Home Visits, cont.Implementation

Challenges◦ Hiring◦ Scheduling◦ Large geographic area

Solutions◦ Patience◦ Creative recruitment ◦ Communication, Communication, Communication

Home Visits, cont.ImpactStrong provider engagementPositive feedback from patients and providersConvenience for patientsIdentify SDoH concerns and provide resourcesIdentify and reduce risks by completing a home safety evaluationAccurate medication reconciliationEducation about and assistance with Advance Care Planning

Visits for patients at Skilled Nursing Facilities (SNFs)/Extended Care Facilities (ECFs)

Background◦Providers provide primary care visits to patients during stays at several area SNF/ECFs◦Typically 60 – 70 visits to patients in SNFs each week

Visits for patients at SNFs and ECFs, cont.Implementation challenges and solutions

Challenges:◦ Each facility varies in terms of resources and support during visits◦ The process for tracking who needs to be seen where is manual

Solutions:◦ Engage leadership at each site to identify solutions to issues as they

arise◦ Implement scheduled IDRs

Visits for patients at SNFs and ECFs, cont.

Impact◦Patient satisfaction◦Reduced readmissions◦Supporting best practice standards within the SNFs◦Provider satisfaction

Other efforts to improve access & coordinationExtended Office HoursBackground◦ Most practices are open 7:00am to 7:00pm◦ Most offer Saturday appointments◦ Same day and walk in appointments◦ Specialist appointments within 7 days◦ 24 hour RN call center available 365 days/year

Implementation◦ Evening hours requires creative scheduling ◦ Providers and staff are typically scheduled for morning or evening “shifts”

Other efforts to improve access & coordination, cont.

Video visits◦ Piloted with a handful of providers◦ Impact◦ Providers liked trying something new◦ Patients really enjoyed it

SIM Hublet◦ Enhanced coordination and collaboration with 11 other community

agencies ◦ Shared documentation system◦ CHWs available to support care managers in the community

“Wrap-Up”: Considerations for Problem Solving and Improving Decision-Making

THE WRAP FRAMEWORK

oWIDEN YOUR OPTIONS

oREALITY-TEST YOUR ASSUMPTIONS

oATTAIN SOME DISTANCE BEFORE DECIDING

oPREPARE TO BE WRONG

Heath, C., Heath, D., & Heath, D. (2014). Decisive: How to make better choices in life and work. London: Random House Business.

Wrap-Up: Roles and Collaboration Across Care Team Practices - The Basics◦ Identify your partners

◦ Identify key subpopulation/patient care need areas for collaboration• Social determinants gap• High cost/utilization patient• Special need population, (end of life etc.)

◦ Creating Relationships with partners

◦Defining workflows with shared understanding

Wrap Up and Next Steps◦ Remember to look at the resources provided to supplement the session

◦ Thanks to our presenters….and thanks to you!

◦ Next in the Care Coordination Collaborative series◦ In-person spring 2019 meeting(s)◦ Will reach out for your feedback

◦ Looking for your ideas on focus areas for the in-person session(s)

◦ Do you have a recommendation for a presenter or a great collaboration success with community resources, Medicaid Health Plans, etc.?

Questions?