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Implementing Care Management into Usual Care

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Bea Herbeck Belnap, Dr Biol Hum School of Medicine University of Pittsburgh Adequate staffing, who should update? Research vs. clinical use Integrating into routine ... – PowerPoint PPT presentation

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Title: Implementing Care Management into Usual Care


1
Implementing Care Management into Usual Care
  • Bea Herbeck Belnap, Dr Biol Hum
  • School of Medicine
  • University of Pittsburgh

2
Learning Objectives
  • 1. To understand the different functions and
    tools required to effectively implement the
    Chronic Care Model for depression management in
    primary care
  • 2. To identify the core roles and qualifications
    of care managers, particularly as liaisons to
    providers and for patient self-management support
  • 3. To understand the role and function of care
    manager registries and their utility in fostering
    provider and patient communication

3
Wagner Chronic Care Model
Health System
Community
Health Care Organization
Resources Policies
ClinicalInformationSystems
Self-Management Support
DeliverySystem Design
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Functional and Clinical Outcomes
4
CCM Core Clinical Elements
  • Leadership
  • Practice
  • Design
  • Clinical
  • Information
  • Systems
  • Vision
  • Resources
  • Care management
  • Protocols- coordinated care
  • Clinical information tracking
  • Registry
  • Feedback to clinicians

5
CCM Core Clinical Elements
  • Decision
  • Support
  • Self-management
  • Support
  • Community
  • Resources
  • Guidelines
  • Expert/specialist consultation
  • Patient preferences
  • Information on treatment
  • Information on and for consumers, groups, etc.
  • Access to non-provider sources of care

6
Care Manager RoleEncompasses CCM core elements
Care Manager Self-management CM/Liaison PCP,
MH Community linkages Crisis intervention Registry
General Medical (Chronic care, Prevention,
Follow-up)
Behavioral Health (crisis referral, complexity,
etc.)
7
Care Manager Core Functions
  • Patient education
  • Registry tracking
  • Provider communication
  • Community linkages

8
Care Manager Patients
  • Patient education about depression, treatment
    options
  • Familiar with commonly used antidepressant
    medications, doses
  • Support medication adherence and recovery
  • Brief interventions
  • Theory-based approaches (MI, PST, etc.)
  • Monitor treatment progress
  • Know when treatment is not working
  • Structured symptom assessment (PHQ-9)
  • 8-12 week trial
  • Provider recommendations ? MHS, PCP

9
CM Goals of a Registry
  • Identify, manage, and track patients
  • Facilitate patient contacts
  • Provide patient visit summaries
  • Provide real-time data on tx response, etc.
  • Reminders
  • Performance feedback

10
CM Provider Liaison
  • Relay concerns/progress
  • Symptom monitoring
  • Refills
  • Symptoms and side effects
  • Urgent, emergent protocols
  • Medical record documentation
  • Cue providers if no improvement
  • Supplement, not replace providers

11
CM Community Linkage
  • Cooperation with MHS
  • Supervision
  • Referral
  • Self-help groups
  • Support for comorbidities, psychosocial problems
  • Financial resources

12
Care Management Patient Support
13
CM Customization
  • Cultural competence
  • Role of families
  • Role of religion/spirituality
  • Competing needs

14
CM Self-management
  • Eliciting concerns/barriers
  • Problem-solving
  • Providing information
  • Clarifying preferences
  • Encouraging informed decision-making
  • Teaching skills
  • Monitoring progress
  • Reinforcing self-management
  • Community resources

15
CM Self-management Tools
  • Workbooks
  • Medication lists
  • Appointment reminders
  • Healthy behaviors
  • Pleasure activities list
  • Pillboxes
  • Medication information
  • Websites

16
Care Management Provider Communication
17
CM Provider Liaison
  • Help patients and providers identify
  • Potentially inadequate doses
  • Ineffective treatment (e.g., persistent
    depression after
  • Adequate duration of antidepressant trial)
  • Side effects
  • Facilitate patient-provider (e.g., PCP)
    communication about antidepressant medications
  • Consult about medication questions

18
Care Manager Providers
  • Tracks depressive sx and treatment response
    (PHQ-9)
  • Screens for co-occurring MH conditions
  • Alcohol use (e.g., AUDIT-C)
  • PTSD (e.g., PC-PTSD)
  • Consults with team psychiatrist
  • Provides follow-up and recommendations to PCP who
    prescribes antidepressants
  • Collaborates closely with patients (PCP)
  • Facilitates referrals to specialty, community
  • Formal and informal connections
  • Prepares for relapse prevention

19
Examples of CM-Provider Contact
  • Medication toxicity, cross-reactivity
  • Notifying provider of patient concerns, follow-up
  • Fatigue, physical symptoms
  • CM prompted provider to call pt. after missed
    appt
  • Managing multiple medications, depression,
    diabetes, and HT (medication lists, pillboxes)
  • Alcohol use and grief management

Kilbourne AM, et al. Bipolar Disorders,
2008 Kilbourne AM, et al. Psychiatric Services,
2008
20
CM Provider Resource
  • CMs as a resource for clinic, providers
  • Dissemination of specific guidelines
  • Ask providers for suggestions on specific topics
  • Hold CME, lunches, or disseminate information
  • Examples
  • Bipolar disorder in pregnancy
  • Depression treatment in late life

21
Provider Communication Tips
  • Obtain preferred mode of communication
  • Emphasize as a supplemental service
  • Focus on providing information on changes in
    treatment response, side effects, etc. to inform
    decisions
  • Baseline, Current PHQ
  • Length of time on medications
  • Problematic symptoms/side effects
  • Adequate contact, but dont overdo it

22
Care Management Registries
23
Care Manager Registry
  • Registries are . . .
  • Simple tools to track patient progress
  • Integrated into routine clinical care
  • Easily updated
  • NOT EMRs
  • NOT research-focused
  • Best if home-grown

24
Registry Functions
  • Patient risk stratification
  • Tracking and management
  • Patient characteristics facilitating treatment
  • Acute phase
  • Continuation, maintenance
  • Performance feedback
  • Patient process and outcomes

25
Registries
  • Other data sources (e.g., pharmacy, EMR)
  • should NOT replace a registry
  • BUT can be used to
  • Improved patient identification (top conditions)
  • Enhance performance measurement
  • Challenges to using electronic data
  • Cumbersome to update and merge
  • Time lag
  • Data not available on all patients
  • Privacy and security issues

26
Key Registry Variables
  • Dates
  • Patient contact information
  • Best number, time to call, and leave message
  • Status
  • No shows
  • Treatment stage
  • Current medications (dose, duration)
  • Self-management materials
  • Depression severity score, MD assessment
  • Referral status (MHS, community resources)
  • Next contact, date

27
Registry Sample Fields
  • General information (update at each contact)
  • Patient contact info, including emergency contact
  • Providers
  • Best time to call/OK to leave message?
  • Plan to keep then safe/calm
  • Contact (Encounter)-specific information
  • Contact or visit date
  • Current Mood, Speech, Comorbidities
  • Current medications/OTCs, refills needed?
  • Medications not taking and reason
  • Symptoms and side effects
  • Health behaviors (sleeping, drug use, smoking
    ,exercise)
  • Job/personal problems
  • Education provided
  • Access/barriers, provider engagement
  • Next appt

28
Care Management Crisis Intervention
29
CM Suicidal Ideation
  • If the patient articulates thoughts
    death/suicide
  • Where are you now?
  • What is your phone number at the location?
  • Are you alone or with someone?
  • Do you have a plan of how you would do this?
  • Do you have these things available (guns, pills)?
  • Have you actually rehearsed or practiced how you
    would do this?
  • Have you attempted suicide in the past?
  • Do you have voices telling you to harm or kill
    yourself?

30
CM Crisis Intervention
  • Suicidal ideation- coordinate with clinic
  • Protocols
  • On-call numbers
  • Missed appointments
  • Immediate follow-up

31
Care Management Implementation Tips
32
Care Manager TimelineInitial Visit
  • Rapport- providers
  • Patient initial intake
  • Contact preferences
  • Crisis and urgent care protocols
  • Assessment
  • Discuss treatment options / plans
  • Coordinate care with PCP
  • Start initial treatment plan
  • Arrange follow-up contact
  • Document initial visit

33
Care Manager TimelineSubsequent Visits
  • Registry- ongoing tracking
  • Reminders for upcoming appointments
  • Regular contact with providers

34
Implementing Registries
  • Adequate staffing, who should update?
  • Research vs. clinical use
  • Integrating into routine care
  • How identified patients are entered
  • Involving PCP
  • IRB issues

35
Types of Registries
  • Formats (pros and cons for each)
  • Excel file
  • Web-based
  • Examples
  • SMAHRT
  • IMPACT
  • REACH-NOLA

36
Care Manager Toolbox
  • Manual provider interactions
  • Contacts, location, communication preferences
  • Medication info
  • Protocols to ID treatment response, side effects
  • Manual patient interactions
  • Brief interventions (e.g., PST, MI, others)
  • Crisis intervention
  • Self-management materials
  • Medication information
  • Behavioral change information (e.g., pleasure
    activities)
  • Registry file

37
Bottom Lines
  • The CCM for depression includes key elements
  • Self-management
  • Care management
  • Community linkages
  • Registries
  • Guidelines
  • BUT the CCM is most effective if customized to
    local settings . . . . .
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