WelcomeThe National Cooperative Agreement on

Advancing Team-Based Care

WEBINAR 6: Complex Care Management in Primary Care

May 5th, 2016

Presented by the the Community Health Center, Inc. & the MacColl Center for Health Care

Innovation

SpeakersFrom MacColl Center for Health Care Innovation, Group Health Research Institute:Ed Wagner, MD, MPH, Director Emeritus Brian Austin, Deputy DirectorKatie Coleman, MSPH, Research Associate

From Daughters of Charity Health CentersRobert Post, MD. Chief Medical Officer Roslyn Arnaud, RN, Chief Nursing OfficerGrace Mena, RN, RN Care Manager/QI Coordinator

From Community Health Center, Inc.:Margaret Flinter, APRN, PhD, Senior Vice President & Clinical Director Kerry Bamrick, MBA, Senior Program Manager

LEARNING COLLABORATIVE APPLICATIONS NOW OPEN!

o Participation in the Learning Collaborative is FREE for health centers.

o 9-month intensive learning collaborative provided by CHCI, it’s Weitzman Institute and partners

o Team Based Care or Post-Graduate Residency Program

How to apply?-Visit www.chc1.com/nca -PDF of the application is available on

our website -Applications due May 20th

Learning Objectives:1. Participants will be able to describe the features that

distinguish effective care management programs.

2. Participants will be able to describe ways that expanded care team members can work with core team members to provide seamless, non-fragmented care to patients.

Get the Most Out of Your Zoom Experience• Send your questions using Q&A function in Zoom• Look for our polling questions• Live tweet us at @CHCworkforceNCA and #primarycareteams and

#HRSAnca • Recording and slides are available after the presentation on our

website within one week• CME approved activity; requires survey completion • Upcoming webinars: Register at www.chc1.com/nca

A Team Approach to Complex Care Management

Learning from Effective Ambulatory Practices

MacColl Center for Health Care InnovationGroup Health Research Institute

May 5th , 2016

Ed Wagner, Director Emeritus Katie Coleman, Research Associate | Brian Austin, Deputy Director

The Key Functions Of Excellent Primary Care

What is a “complex” patient?

• American Geriatrics Society--Persons whose conditions require complex continuous care and frequently require services from different practitioners in multiple settings.

• Robert Wood Johnson Foundation--Patients … with multiple chronic conditions, frequent hospitalizations, and limitations on their ability to perform basic daily functions due to physical, mental and psychosocial challenges.

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The challenges of caring for the patient with multiple chronic conditions

• Limited evidence base – complex, older patients excluded from trials, growing

evidence of poorer outcomes when treated according to disease-specific guidelines.

• Added care complexity – multiple guidelines, multiple registries, difficult co-

morbidities such as psychiatric disorders and substance abuse

• Polypharmacy • Multiple physicians and a poor care coordination culture and

mechanisms.

Percent of patients reporting problems in careby number of doctors seen

Base: Adults with any chronic conditionPercent reported any errors in past 2 years*

Data collection: Harris Interactive, Inc.Source: 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.

What do Patients with Chronic Illness Need to Optimize Outcomes

• Drug therapy and medication management that gets them safely to therapeutic goals. MEDICATION MANAGEMENT

• Effective SELF-MANAGEMENT SUPPORT so that they can manage their illness competently.

• Preventive interventions at recommended times. PLANNED CARE/POPULATION MANAGEMENT

• Follow-up tailored to severity, and more intensive management for those at high risk. CARE MANAGEMENT

• Timely, well-coordinated services from medical specialists and other community resources. REFERRAL MANAGEMENT

But, the multi-problem problem patient likely increases the need for:

• Full implementation of the patient-centered medical home.

• Primary care clinicians willing and able to be accountable for their care.

• Greater sharing (interactive communication*) of care planning and care management between primary and specialty care.

• Clinical care management services integrated with primary care

• More assertive and effective care coordination.

* Foy et al. Ann Int Med 2010; 152:247-258

Care for Patients with Complex Health Care Needs

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Care Management

Logistical

Logistical

Logistical Clinical Monitoring

Care Coordination

Clinical Follow-up Care

Medication managementSelf-management Support

©MacColl Institute for Healthcare Innovation, Group Health Research Institute 2011

Clinical Monitoring

ComplexityLow High

Are care manager interventions effective for multi-problem patients?

• Care manager interventions improve outcomes in diabetes, depression, bipolar disorder, CHF, etc.

• TEAMcare study suggests effectiveness across conditions.• But a recent meta-analysis* suggests that only patient

satisfaction is improved across studies—not health or costs.

But interventions are very different!

*Stokes et al. PLoS One. 2015; 10(7): e0132340. Published online 2015 Jul 17.

Care management is a function not a person

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Providing follow up, clinical management, and self-management support to patients outside of clinic visits.

Services and intensity of services vary with the severity of the

illness.

Some aspects provided by a staff

person for lower risk patients and by a

nurse or nurse-led team for high-risk

patients.

Works best when the care manager:

• Is an integral member of the practice team

• Has social work support• Can influence drugs• Has a clinical support

structure.

How do effective practices provide follow-up and care outside the office?

• Core teams, care managers, and referral coordinators regularly monitor patients between visits.

• Follow-up can range in intensity from periodic status checks by telephone or e-mail (MA) to active care management (RN).

• Higher risk patients (poor disease control, frailty, recent hospitalization, etc.) receive regular follow-up (monitoring) AND active care management from RN care manager and/or social work. Referral coordinators and community workers help patients get the services they need, and ensure that providers get desired information.

One LEAP Clinic’s Approach to Hospitalized Patients: Primary Care Assuming Accountability!

• Use risk stratification (Modified LACE* tool) to determine who makes the Hospital F/U call.– HIGH Risk-Call is made by RN, automatic referral to Care

Management, F/U visit with PCP in 2 to 3 days– MODERATE Risk-Call is made by RN or MA Health Coach, automatic

referral to Care Management, F/U visit in clinic within 3 to 5 days– LOW Risk-Call made by MA Health Coach, F/U visit in 7 days. MA

Health Coach makes a “touch base call” in a week after F/U

One LEAP clinic’s answer: The Expanded Team Huddle• One hour once/week• All clinic staff attend: front desk, pharmacy, MA, behavioral

health consultants, etc• Clinician selects & presents patient (chart open on EMR

projected on screen)• Front desk staff, health coach, and MA who live in community

asked what do they know?

What can be done if you don’t have a nurse?

Building a Care Management Capacity

1. Think about care management as a function or program, not a person.

2. Shift RN roles toward care management.3. Decide which patients to refer to CM.4. Establish relationships with key hospitals to identify and co-

manage recently hospitalized patients.5. Create protocols, standing orders, and standard workflows,

etc. to guide CM work.6. Develop a support structure for care managers:

1. To discuss challenging problems.2. To assist with psychosocial issues.

www.improvingprimarycare.org

Resource Spotlight #1

Resource Spotlight #2

Resource Spotlight #3

www.improvingprimarycare.org

Daughters of Charity Health Centers

Complex Care Management in Marillac Community Health Centers

Roslyn Arnaud, Robert Post, Grace Mena

The Daughters of Charity have provided compassionate health care in New Orleans for 180 years. After the sale of Hotel Dieu Hospital in 1992, the Daughters transitioned their efforts, establishing a community health ministry known today as Daughters of Charity Services of New Orleans.

The Transformation to Consumer-Driven Healthcare

Daughters of Charity Services of New Orleans offers primary and preventive health services that address the needs of the total individual – body, mind, and spirit. 

Our nine health centers are conveniently located in various geographic region of the greater New Orleans area. Most of our health centers are located near bus lines. We provide care for chronic illnesses such as asthma, cardiovascular disease, diabetes, and depression. Women's health, behavioral/mental health, dental, optometry, pharmacy, podiatry and Women, Infants and Children (WIC) services are also available at select health centers.

We are a proud member of Ascension Health, the nation’s largest Catholic and non-profit health care system. Our mission, similar to that of other Ascension Health ministries, is to improve the health and well-being of our community and to be a presence of the Love of Jesus in the lives of all we serve and with whom we partner.

Our Mission

Integrated Team Care

Patient’s Desires & Needs

PatientPanels

Outcome and ResultsMeasures

PopulationRegistries

Open Access

Primary Care Team

Care Management

MD/MANP/MACare Coordinator

Nurse CMBH CMPharmD

PROACTIVE TREATMENT

Project Collaboratives

PATIENT CENTRIC SERVICES

Continuous Quality Improvement

Continuous Quality Improvement

Adapted from David Dorr, MD, Care Management Plus

Complex Care Team• Nurse Care Manager

– Intensive Case Management– High Risk Patients

• Behavioral Health Consultants– Immediate consultations– Focused on outcomes

• Other Members of the Team– Clinical Pharmacists – Established CHD

Complex Care Team• Referrals

– Poor Control – Chronic Illness (Care Managers use the Clinical Event Manager in the EMR)

– ED/IP Utilization– Coordination of Care – home health, hospice– CNS Barrier – Neurologic, Behavioral, Substance– Perceived Risk by Primary Care Team

Other Responsibilities – Care Managers• Abnormal Cancer Screen Tracking• Hepatitis C Patients• CMS Chronic Care Management• NCQA – PCMH• Clinical Resource to Medical Assistants• Clinical Staff Training• Quality Assurance

– Medical Assistant Chart Audits

Community Health Center, Inc.

Foundational Pillars1. Clinical Excellence- fully Integrated teams,

fully integrated EMR, PCMH Level 3

2. Research & Development- CHC’s Weitzman Institute is the home of formal research, quality improvement, and R&D 3. Training the Next Generation: Postgraduate training programs for nurse practitioners and postdoctoral clinical psychologists as well as training for all health professions students

CHC Profile:•Founding Year - 1972•200+ delivery sites•130k patients

What is Complex Care Management?Complex Care Management is the deliberate organization of patient care activities and sharing of information with the main goal of meeting patients' needs and preferences in the delivery of high-quality, high-value health care (AHRQ, 2015).

At CHC, Complex Care Management includes:• CCM Tools: Dashboard, Scorecard, Structured Templates, Standing

Orders• Project ECHO Complex Care Management• Dedicated Education Unit

***CHC Ratios are 1 RN per 2 provider panels

• Goal: to improve the quality and coordination of care delivered to our most complex patients

• Patients: identified through dashboards either by hospital admissions, high ED utilization, chronic illness (uncontrolled or 4+) or individually by a care team member

• Consent: patients consent to be enrolled in CCM• Essential elements of the role:

• Transition Care (ie. hospital to home)• Medication Reconciliation• Having patients set their own goals and work with the care

team to meet them• Individualized Care Plan • Monitoring and adjustment of treatment regimens

• Discharge: once goals are met, transition is complete, care plan is fully implemented, or patient opts out

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Reason for Complex Care Management

• Basic Demographics (Age, Gender)• Smoking status• Clinical Markers (A1c, recent BP)• Important Dates (CCM start/end date, last PCP visit, last BH visit)• Self Management (last date self management goal set or MI done)• Any Actions Due? (Subject of the action and due date)• Patient Engagement (Portal Enabled?)

Scorecard Creation• Enrollment Data (Ever & Current)• HTN & DM Control Rates• Transition Contact• Coming Soon! Self-Management Goal Tracking

Additional Actionable Dashboard Data

Project ECHO Complex Care Management First session on 9/24/15 Duration: 2 hours; 1 didactic and ~2 cases All 12 sites involved – Approx. 33 nurses Faculty consists of:

Nurse Practitioner and Nurse Executive Homecare Nurse Medical Provider Pharmacist Behavioral Health Provider Complex Care Management Specialist and

Certified Diabetes Educator Registered Dietician and Certified Diabetes

Educator Access to Care Coordinators

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- Support for further developing the role of the CCM- Diverse Faculty Expertise- Improve Nurse self-efficacy/ leadership- Improve collaboration across all disciplines and supporting agencies- Increase interactions with nursing colleagues - Improve educational experience for students

8/25/2015

Goals of Project ECHO CCM

Q & A, Discussion

RemindersSign up for our next webinar in this series:

Achieving Full Integration of Behavioral Health and

Primary CareThursday, May 19th, 3–4 p.m. EST

Dissolving the Walls: Clinic Community Connections

Thursday, June 2nd, 3-4 p.m EST

Complete our survey!

Sign up at www.chc1.com/NCA