Managing the Load

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Managing the Load

• Connie Sixta, RN, PhD, MBA

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Clinical Monitoring
of panel
Logistical
lt5
Clinical Care Management
Clinical Monitoring
Logistical
10
Clinical Follow-up Care
Logistical
20
Care Coordination
Clinical Monitoring
3
Risk Stratification and Related Interventions
Identify Patients with DM in Panel
Determine Priority Patient Need
Determine Frequency of Patient F/U with Provider
Determine Delivery Mode
Lab q 3mo
Phone F/U
Low Risk Patients BPlt130/80 A1c lt7.0 LDL lt100
Q 6 MO
Disease Clinic (with Provider) Titration BG
Monitoring BP Monitoring
Lab q x mo
KEY
Low risk
Medication Advanced Protocol Titration Upward
Monitoring
Medium Risk Patients BPgt130/80 lt140/90 A1c
gt7.0lt 8.0 LDLgt100lt130
Medium risk
All Risk per capacity)
DM Class DM Education SMS goal
High risk
Advanced Self-care DM Education SM Support SM
Class Monitoring Functional ability
Highest risk
Group Visits ( with Provider) DM Education SMS
goal
High Risk Patients BPgt140/90 A1cgt9.0 LDLgt130
Social Worker
Q X mo PRN
Team management Monitoring (BG, SM Goal, BP)
Phone follow-up
Q X mo PRN
Highest Risk Patient BPgt210/140 A1cgt9.0 LDLgt200
Pts in ER Pts Hospitalized
Social Support Transportation for Visit,
Meds, co-pays Abuse, etc.
PRN as needed
Care management Close Monitoring (BG, SM Goal,
BP, BMI, etc.) Titration of meds Scheduled
phone follow-up
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Lets evaluate the load

• Populations
• TOC
• ER F/U
• Office identified (high versus highest risk?)
• Volume of patients per each
• Level of interventions needed per each

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Who are your top 5 highest risk patients?

• Patients with CHF, COPD?
• Patients with multiple co-morbidities?
• Patients that are older?
• Patients that have problems with ADLs?
• Other??

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Volume How many highest risk patients are
identified ..

• During hospitalization follow-up?
• During other transitions of care?
• Post ER visits?
• During office risk assessments?
• Reviewing of utilization?
• Insurer high risk data evaluation?
• Other?

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Characteristics What level of interventions are
required for..

• Patients being discharged from the hospital?
• Patients experiencing other TOC?
• Patients being followed up after an ER visit?
• Patients being identified as highest risk during
  the office practice?
• Patients being identified on the insurer highest
  risk list?

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TOC Hospital Discharges

• Volume
• Highest risk?
• High risk?
• Medium risk?
• Low risk?
• Stratifying patients according to interventions
• Continued in-depth assessments
• Disease-management education, goal setting
• Routine follow-up care taking meds, office F/U,
  etc.
• Potential for problems minimal
• Common complications can be monitored easily
• Other???
• Do CM interventions decrease after first call?
  For which patients?

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ER Follow-up Calls

• Volume?
• In-depth assessment needed?
• Interventions needed?
• Getting the patient in for an office appointment?
  
• Immediate RN interventions needed --- teaching,
  medication reconciliation, communication with PCP
• What leveling of interventions is possible?

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Highest risk patients identified in the office?

• Volume?
• Who are they?
• What do the need?
• Who can best help them?
• CDE
• Social worker
• Patient navigator
• What continued CM interventions are needed?

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Which patients require the most time from the CM?
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Which patients require RN-CM interventions?
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What level of staff interventions are needed
per population?

• TOC Patients
• Low risk
• Medium risk
• High risk
• Highest risk ---- to CM registry
• ER Follow-up
• High risk
• Highest risk
• Office identified patients
• High risk
• Highest risk

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What can you do to stratify the interventions of
highest risk patients?

• Patient volume
• Patient need interventions
• Stratify the interventions
• Based on the intervention needed, who can best
  meet the need?

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Questions?