Case Management

THE MISSING LINK Cathy Kauffman-Nearhoof BSN RN CCM LNC

Objectives1. Define Case Management within the context of

Clinical Research2. Explain the role of Case Management process

through a case study scenario3. Demonstrate the impact of strategic collaborative

care coordination4. Describe care coordination processes that optimize

the implementation of seamless healthcare services

Case Management

Definition: Case Management is a collaborative process of assessment, planning, facilitation, care coordination,

evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health

needs through communication and available resources to promote quality cost-effective outcomes.“ (Case

Management Society of America)

Case Management Components

Facilitating the seamless delivery of health care services in a patient centric model of care designed to minimize fragmentation

Single point of contact – Case Manager Case screening – Risk assignment Assessment – Face to face or telephonic Plan of Care – Patient-centric/multidisciplinary Collaboration – Case Management is a team sport! Implementation – Care coordination Evaluation – How did the plan work? Multidisciplinary Team Meetings Facilitated by the Case Manager – Herding cats Implementation – Activation of recommended team interventions Evaluation – Ongoing Care Plan Updates

Case Management Process Deliberate organization of patient care activities Inclusion of PCP, Specialist, Patient, Family, Clinical Research Coordinator

and other clinicians on the Multidisciplinary Team Shared healthcare information among all healthcare team participants Shared goals to achieve safer, more appropriate, more effective care as well as

accurate study outcomes Prioritizing the patient’s needs and preferences Committed Collaborative Multidisciplinary Team Participants - show up to play

Optimize awareness of the patient’s preferences, goals and priorities Embed patient goals into the collaborative plan of care Identify and prioritize strategic interventions Communicate planned and proposed patient interventions, outcomes, and

barriers

Case Management is a Team Sport

Case Management Standard Changes and Healthcare Reform

As the healthcare industry changes - Case management takes the lead The standards for case management address important foundational knowledge and skills of the

case manager within a spectrum of case management practice settings and specialties 1995 – the first standards for CM identified gaps in the health care continuum 2010 – standards updates identified the impact of fragmented health care and included the following revisions:

Minimization of health care fragmentation Use of evidence based guidelines in practice Navigation of transitions of care Incorporate adherence guidelines and other standardized practice tools Expand the interdisciplinary team in planning care for individuals Improving patient safety

Lucy’s Story Lucy is a 66 years old Medical History

Type II Diabetes Hypertension Chronic Anxiety and Depression Obesity – BMI 32.6 Arthritis Cataracts Dyslypidemia

Demographics Widowed Lives alone Daughter lives nearby Does not drive

Medications: Norvasc 10 mg, Paxil 30 mg, Wellbutrin 300 mg, Metformin 1000 mg BID, Atorvastatin 20 mg, Advil, Calcium, and Daily Vitamin

PCP, Endocrinologist, and Psychologist

Lucy’s Story

Elevated blood pressure during a follow up PCP blood pressure check appointment (182/112)

The PCP prescribes Lisinopril 20 mg Lucy fills it at the Rite Aid near her PCP office that same day but doesn’t add to her pill box

Lucy sees her Endocrinologist 2 days later during a scheduled appointment Again, her blood pressure is elevated (180/112) and some pedal edema

This concerns the specialist who was readying Lucy for participation in a diabetic medication clinical trial

Lucy is anxious to participate in a diabetic medication study b/c of the weight loss side effect

She cannot begin until her BP is under control The specialist prescribes Zesturetic 10/12.5

Lucy’s friend picks up the Rx for her at the CVS pharmacy on the way home The Endocrinologist schedules a follow up appointment in 2 weeks to assess her

stabilization of her BP and readiness to participate in the clinical research

Lucy’s Story

She is excited to begin in this 6 month study because she will get $400.00 AND the study medication has been proven to contribute to weight loss She plans to start her new medications immediately She only has to take the medication once a week

Lucy adds her newly prescribed medications to her pill box that evening

She takes her medications as prescribed the following morning At 11 AM after standing up from her recliner Lucy feels dizzy and falls Lucy fractures her hip Ah Oh! What went wrong?

Lucy fell into the BIG BLACK Hole of Care Fragmentation

.

Healthcare Silos Communication Collaboration Untoward side effects Preventable admissions Preventable complications Preventable emergency department visits Preventable readmissions Complications Increased care costs Medication Errors Patient education gaps

Care coordination

The Missing Links Lack of a single point of contact

Un-effective model of care Failure to consider patient priority

Missing team collaboration and communication No patient engagement No patient education Duplication of services

Team Members out of theloop

Single Point of Contact

Minimizes healthcare fragmentation and navigation confusion Facilitates Multidisciplinary Team collaboration Coordinates discharge planning Coordinates transitions of care Establishes safe and effective outpatient care services Identifies home safety issues Breaks down barriers to optimal care Connects the communication dots Prevents duplication of services Ensures compliance with clinical guidelines Engages the patient in healthcare goals and decisions Incorporates the Member’s priorities into the health care plan design

Patient Centered Model of Care Promotes active involvement of patients and their families in

decision-making about individual options for treatment. "Providing (coordinating) care that is respectful of and

responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. “(The IOM definition of Patient Centered Care - Institute of Medicine)

Enables active patient engagement at every level of care design and implementation.

Lucy’s Care Coordination Gaps

Case Analysis: What if Lucy had a Case Manager? She sees her PCP and an Endocrinologist regularly – Missing Link The PCP prescribes Lisinopril 10 mg– Missing Link Lucy sees her Endocrinologist 2 days later during a scheduled

appointment – Missing Link The specialist prescribes Zesturetic 10/12.5 for Lucy Her friend fills the RX at a CVS pharmacy near her home – Missing Link She is excited to begin this 6 month study because she will get

$400.00 AND the study medication has been proven to contribute to weight loss – Missing Link

Lucy adds her new medications to her pill box the evening after her specialist appointment – Missing Link

She takes all her medications as prescribed the following morning – Missing Link

Case Management Impact in Clinical Research

Deliberate organization of patient care activities Inclusion of Clinical Research Coordinator on the Multidisciplinary Team Shared healthcare information with all healthcare team participants. Team understanding and agreement on shared goals to achieve safer, more

appropriate, and more effective care Prioritizing the patient’s needs and preferences

The healthcare team seeks to discover medication to lower A1C How does Lucy’s weight loss goal fit into the plan of care?

Committed Collaborative Multidisciplinary Teams – Sharing the same sheet of music Optimize awareness of the patient’s preferences, goals and priorities Create a collaborative and focused plan of care Identify and prioritize strategic interventions Coordinate planned and proposed patient interventions Agreement related to breaking down barriers

Collaboration Communicates with all Team Members – Multidisciplinary Team Meetings and Individually

PCP Specialist Clinical Research Coordinator Case Manager Patient Daughter Others selected by the Patient

Prevents duplication so lab tests Prevents duplication of BP medications Prevents dizziness, falls, fracture and concussion due to medication complications Ensures all treatment team members have the same information Ensures that the daughter is educated regarding her mother’s conditions and treatments Collaborates with the Clinical Research Coordinator regarding Member readiness for study;

ensures Coordinator has all appropriate healthcare information Ensures that he Endocrinologist had complete healthcare information relevant to Lucy’s

status and her PCPs concerns

Lucy on Care Coordination The Case Manager (Payer) Completed Case Manager comprehensive assessment

Calculation of healthcare risk Enrollment in disease specific programs Validation of patient demographics Care Plan shared with the PCP and patient Inclusion of Lucy’s healthcare priorities (weight loss) in the plan of care PCP and Specialist input into the plan of care Communication of healthcare information, clinical study participation and scheduled

appointments Inclusion of Lucy’s healthcare priorities (weight loss) Seamless circle of shared healthcare information Considers impact of Lucy’s depression Shared focus on closure of key gaps in care

Lucy’s A1C is high – is she testing? Does she understand her diet? What role does exercise plan? When did she last have blood tests? Were results of all testing shared among the healthcare team?

References

http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html

www.pcpcc.net Colorado Systems of Care/Patient Centered Medical Home Initiative: Colorado Primary Care – Specialty Care Compact

www.pcmh.ahrq.gov www.caaretransitions.org The Care Transitions Program. Eric Coleman, MD, MPH by The

MacColl Institute for Healthcare Innovation Affordable Care Act Medicare-Medicaid Regulations/care coordination standards The Clinical Trials Office of Henry Ford www.wmsa.org www.ncqa.org/NCQA Care Coordination Standards Medicare-Medicaid Program Dual Eligible Regulations https://en.wikipedia.org/wiki/Case_management_(USA_health_system)