Care Management Implementation

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Care Management Implementation

• Sara Greenwood, PCMHI Program Office
• Erin Ingram, Philadelphia BHL
• Johanna Klaus, Philadelphia BHL

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What is care management again?
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Care Management

• Algorithm-based care that includes routine
  monitoring/assessment of patients focusing on
• Psychoeducation encourage self-management skills
• Brief treatment including (but not limited to)
  medication
• Adherence to medication, treatment plan
• In consultation with the supervising clinician,
  provide relevant information to the PCP to allow
  collaboration for appropriate care decisions

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Key Components of CM

• Offer telephonic contact
• Much appreciated by patients
• Stepped Care Approach
• Strong ties to mental health supervision
• Initial decisions and prescribing in primary care
  
• Assessment based
• Tracking important
• Emphasis on patient self-management support
• Care manager facilitates communication

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And one other thing to mention.
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It Works!!

• Decreases symptoms
• Improves patient functional status
• Greater adherence to treatment engagement in
  care
• Reduces mortality (yes, mortality)

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Care management?
Mr. McDuffy Comes in for his primary care
appointment and screens positive on the PHQ2.
After he meets with the PCP, there is a warm
handoff to the PCMHI provider. In the
assessment, he mentions that his biggest issues
are a lack of sleep and low motivation. They set
up a behavioral activation plan and go over sleep
hygiene. He is appreciative but ambivalent about
coming back to the VA to meet again, so she
suggests that Mr. McDuffy can call if would like
another appointment. She puts in a note in CPRS.

How would this look if it was care management?
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Time to ponder and discuss
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• What do you see as the benefits of care
• management?

• What patients do you think would benefit from
  care management?

• What barriers do you anticipate to implementing
  
• care management?

• How could you respond?

• How could you start to add/expand care
• management in your program?