Community Health Team Care Management Process PinnacleHealth Systems Becky E. Zook RN, BSN, MS, CCP...
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Transcript of Community Health Team Care Management Process PinnacleHealth Systems Becky E. Zook RN, BSN, MS, CCP...
Community Health TeamCare Management Process
PinnacleHealth Systems
Becky E. Zook RN, BSN, MS, CCP
Grace Eaton, LPN
Community Health Team Members
• Physician Champion
• Nurse Care Manager
• LPN Disease Manager
• Medical Social Worker
• Behavioral Health Counselor
• Information Technologies Specialist
Care Manager Qualifications
Referral Process
• Patient identification– Manually- encounter with office staff
• Provider
• MA
• CHT member
• Self
– Automatically- high risk stratification report• Quarterly on DM, HTN, CHF, CVD, COPD, Depression,
Frail Elderly
• Daily- transitional care report
Identify Patients with DM in Panel
Determine
Low Risk 0-2 ptsBP<130/80A1c<8.0LDL<100
Medium Risk 3-5 ptsBP>130/80<140/90A1c 8.0-9.0LDL>100<130BMI 30-35
MedicationMonitoringTitration up
Labs q6 months
Determine Priority Patient
Need
Labs q3 months
Advanced Self CareDM EducationSM SupportMonitoringFunctional AbilityTransition Care
Delivery Mechanisms
Pt F/U with Provider
Phone F/U Q6 months
Care ManagementMonitoring (BG, BP, BMI, SM goals, etc)
Titration of medsHome visit &/or phone F/U
Q3 months
Class with ADE
Social Worker
Behavioral Health
prn
prn
Social IssuesTransportation$$ for MedsAbuseInsurance, etc
High Risk >5 ptsBP>140/90A1c > 9.0LDL>130BMI >35Seen in ER/Hosp
*Having two or more of the concomitant factors (tobacco use, LDL>130 or HDL<40) moves patient up in risk stratification
Stage A:Asymptomatic
CHF Stage B:Structural heart diseasew/o symptoms
Stage C:Structural heart disease with prior/ current symptomsMild activity intolerance, fatiguePalpitationsDyspnea/angina with activityComfort at rest
Stage D:Refractory CHF requiring specialized interventionsSevere activity intolerance, fatigueDyspneaAngina FatiguePalpitations at rest
Refer to Care Manager
Low Risk*Pre-HTNSystolic <120-139Diastolic 80-89
Moderate Risk*Stage 1Systolic 140-159Diastolic 90-99
High Risk*Stage 2BP> 160/90
Identifying and Managing High Risk Patients
HTN
COPDHigh Risk patients will have additional diagnosis and:OV for acute bronchitisOV for acute sinusitis>4 OV in 1 year for COPDER or hospitalization for COPD in last 1 year2 or more other chronic diagnosis
Refer to Care Manager
Frail ElderlyHigh Risk patients will have metrics and / or diagnosis of:Age > 65 yearsBMI < 15Dementia or dementia related diseasePersonal history of falls
Acute CareHigh Risk patients include:In-patient FacilityHome Health CareTransitional CareDiagnosis of Sepsis
CVDHigh Risk patients will have additional diagnosis of:DVTPECVACAD or MI or PVDStage 1 or 2 Hypertension2 or more other chronic diagnosis
Depression, Mental HealthHigh Risk patients will have additional diagnosis of:Substance AbuseDrug and/or Alcohol abuseTobacco useMDI 10 score of severe or major depression2 or more other chronic diagnosis
Referral Process
• Triage and Assignment– Per task status- STAT or Routine– Manually by CM- based upon risk
stratifications and qualifying diagnosis, transitional and STAT referrals priority
– Initial outreach• 1-2 days for STAT referrals• 10 days for routine referrals• 1-2 days from notification of discharge of
transitional referrals
Referral Process
• Successful contact– Documented in EMR following intake or follow
up process
• Unsuccessful contact– 3 Attempts documented in the EMR– CHT Unable to Contact letter– Close if no response in 10 days to letter– Task provider
Initial Patient Screening
• Patient identified as appropriate for contact from CM– Introduce CHT, scope and practice, role of
CM and self management skills– Discuss trigger diagnosis– Assess prior knowledge of diagnosis– Assess use of hospital or ED in last 4 weeks
Initial Patient Screening
• Patient identified as appropriate for contact from CM– Assess PHQ2 from G.O. intake assessment– Identify needed behavior / lifestyle changes
and blockers to change– Identification of care driver- PCP vs specialist– Set initial goals, time to next contact, plan for
intake assessment
Intake Assessment
• Initial assessment completed
• Pt in agreement with services from CHT
• Documented in the EMR under the appropriate templates for guided assessment
• Plan for continued Disease Management
Care Management Registry
• Excel file
• Demographics, Dx, dates of referral, contacts, open/closure of case, interventions, f/u appts, surveys, declination or exclusion criteria
• LPN- all Disease Management
• RN- all Hospital and Transitional care
• Schedule managed in OutLook
Admission information received daily through BI (Business Intelligence) reports
List reviewed for qualifying admissions Transitional care completed and
documented
Re-Admission Tracking
Re-Admission Tracking Exclusion Criteria
Younger than 18 or older than 75 Inactive patient Patient receiving skilled services in facility or
from agency (SNF, rehab, HH) Planned procedures/hospitalizations Active ESRD, St 3 or 4 CHF, Chemotherapy Hospice/palliative services Refused services or received from provider alone NOTE- All excluded patients are eligible for CM
services but are not counted in re-admission rates
Transitional Care Management
• Documented using intake process• Access hospital and ER records through PHS Connect (HIE) or Soarian in-
patient documentation system. Scan to EMR
• Review hospitalization or ER visit• Review safety• Schedule PCP follow up appts• ID of gaps• Care Coordination• Self-management skills• POC and follow up schedule
Transitional Care Management
• Simple transitional care, completed in 1 contact and case closed
• Moderate to Complex transitional care, CM with RN for 30 days, then pass to LPN for disease management
Monthly Provider Meetings
• Review of Spread Report
• Brainstorm regarding areas not at goal
• Discuss difficult cases
• Review of new processes or reportables
• Review of Hospitalizations
• BI Registry review
• CHT feedback
Outcomes
30 Day Re-Admissions; CHT vs non-CHT
0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
20.0%
7.0%
0.0%
30.0%
25.0%
10.0%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
Jan/Feb Feb/Mar Mar/Apr Apr/May May/June June/July
CHT
non-CHT
Outcomes
Diabetes Population Comparative data
Measures for Adult DM Patients Practice Goal
April 2010 Data (%)
Last Month’s Data Aug 2011(%)
Current DataSept 2011(%)
•A1C>9 <5% 17 5.5 6.5
•A1c<7 >70% 44 63.5 <8 =85.4
•BP<130/80 >70% 52 82.7 84.8
•BP<140/90 >90% 65 97.4 97.7
•LDL<100 >70% 46 59.2 60.3
•LDL<130 >90% 63 77 78.9
•Smoking cessation counseling >90% 92 100 100
Outcomes
Patient Satisfaction Survey Results 2010
78%
80%
82%
84%
86%
88%
90%
Goal 75% or Greater
CHT Staff
Ed. Materials
Better Informed
Overall Exp.
Perception
Future Goals
• Expansion to 2 more FPs by early 2012
• Hire 2 additional staff by early 2012 (RN, LPN)
• Involve MAs for administrative support
• Fine tune reportables and report processes
• Complete P/P manual
Final Results