Team-based Care ECHOSession 6

Wednesday, March 3, 2021

12:00pm-1:00pm ET

Disclaimer

The views, opinions, and content expressed in this presentation do not

necessarily reflect the views, opinions, or policies of the Center for

Mental Health Services (CMHS), the Substance Abuse and Mental

Health Services Administration (SAMHSA), or the U.S. Department of

Health and Human Services (HHS).

www.samhsa.gov

Introductions

Jeff Capobianco, PhD, LLPIntegrated Health Sr. Consultant, National

Council for Behavioral Health

John Bischof, MDMedical Director,

Behavioral Health, Care Oregon

Angela Pinheiro, MDMedical Director,

Community Mental Health of Central

Michigan

Measurement-Based Care Pathways

Goals

1. Define Care Pathway

2. Discuss key components in Care Pathway design and

implementation

3. Explain how to measure Care Pathway quality, fidelity and

outcomes

4. Consider the role of Quality Improvement processes in the life

cycle of a Care Pathway

5. Review Care Pathway examples

6. Resources

Defining Care Pathways

• A standard set of processes or management guidelines, usually in the form of a flow chart or process map, applied to a group of clients with similar conditions as they move through a treatment episode

• Care Pathways include:• Clinical workflows (Engagement, screening,

stepped evidence-based treatment, clinical and functional outcomes)

• Administrative workflows (Who is doing what –role definition-, documentation needs, billing codes, costs)

Defining Care Pathways

• Fundamental components:• Designed for a

• Well-defined group of patients or clients• Well-defined period of time

• Identifies key elements of care that are grounded on evidence-based practices

• Sets forth the sequence of activities, communication channels and team member tasks to assure quality, person centeredness and efficiency

• Includes measurement-based tools and measures to guide members of the team in decision-making (triage, indicators to escalate treatment interventions)

https://triarqhealth.com/wp-content/uploads/2019/04/Care-Pathways.jpg

Defining Care Pathways

• Aids in the identification of appropriate resources

• Allows for monitoring and evaluation of variances and outcomes• Clinical indicators

• Process indicators

• Team functioning indicators

• Financial indicators

Examples of Indicators

• Clinical: • Problem-specific outcome achieved with in a time frame• Functional outcome (QoL measures, DLA-20)• Patient satisfaction and perception of the quality of care• Morbidity, mortality, complications, side effects

• Process:• Adherence and variance from Care Pathway (Engagement, services

delivered/completed, events showing care coordination, appointments scheduled within a time frame, etc.)

• Data collection, documentation, and flow

• Team Functioning:• Communication and coordination• Efficiency• Team and staff satisfaction

• Financial:

Poll #1 - Who has implemented?

• Clinical indicators

• Process indicators

• Team functioning indicators

• Financial indicators

https://www.thenationalcouncil.org/wp-content/uploads/2018/12/A-Path-to-Value-Strategies-for-Developing-Care-Pathways.pdf?daf=375ateTbd56

https://www.thenationalcouncil.org/wp-content/uploads/2018/12/A-Path-to-Value-Strategies-for-Developing-Care-Pathways.pdf?daf=375ateTbd56

https://www.ajmc.com/view/lessons-from-the-front-designing-and-implementing-clinical-pathways-by-and-for-clinicians

Steps for Designing and Implementing a Care Pathway

1. Identify and clearly define a patient population

2. Convene an inter-disciplinary team

3. Review the evidence-based literature & Define target outcomes

4. Map the current state of service provision and identify areas of improvement

5. Develop the revised Care Pathway

6. Pilot the new Care Pathway and evaluate for effectiveness and efficiency

7. Implement Care Pathway, making adjustments based on pilot & Routinely monitor Care Pathway metrics and EBP literature for QI opportunities

Poll #2 - Which Steps have you found most difficult?

• Identify and clearly define a patient population

• Convene an inter-disciplinary team

• Review the evidence-based literature & Define target outcomes

• Map the current state of service provision and identify arears of

improvement

• Develop the revised Care Pathway

• Pilot the new Care Pathway and evaluate for effectiveness and efficiency

• Implement Care Pathway, making adjustments based on pilot & Routinely

monitor Care Pathway metrics and EBP literature for QI opportunities

Identify & Clearly Define a Patient Population

IDCV

RiskBMI A1C BP pO2

Last Appt

Next Appt

PHCP ER HospCrisis

Contacts

1 3 45 6.5180/95

A 0

2 5 32 B 5 3

3 2 89 None

4 0 B 12 25

Care Pathway Step 1

Identify & Clearly Define a Patient Population

ID DX PHQ9 ER HospCrisis

ContactsLOCUS SDoH

Care Pathway Step 1

Identify & Clearly Define a Patient Population

•Care Pathway engagement metric

• # of patients in Care Pathway/ # of patients who qualified for Care Pathway

• # of patients who improved within X time/ # of patients in Care Pathway

OR

# of patients who improved within X time/ # patients who qualified for Care Pathway

Care Pathway Step 1

Convene an Inter-Disciplinary Team

•Participants across agency roles and levels• Trust and transparency

• Subject matter experts

• Staff using care pathway

• Executive leadership for resource and buy-in

• Patient/family

• Information Technology- incorporation into EMR

• Community partners

• Others

•Specify each participant’s role within the team

Care Pathway Step 2

Review the Evidence-Based LiteratureDefine Target Outcomes

• Treatment modalities• Supporting resources easily accessible to users

• Take into account:• Level of Engagement

• Level of Risk

• Comorbidities

• Social Determinant of Health (SDoH)

• Timeline

• EB data tools• Outcome measures, indicators to change treatment intensity

• Care pathways process metrics

• Staff Qualifications required by treatment modality and insurance status

Care Pathway Step 3

Review the Evidence-Based LiteratureDefine Target Outcomes

• Look for required elements:• Transitions of Care example

• Medication management• Medication reconciliation

• Prescriptions filled

• Coordination and transition planning between providers (within or outside the organization)

• Patient engagement in transition process

• Information exchange• Information flow

• Process to ensure information incorporated

• Follow-up care w/i defined time• Process if follow-up did not occur

• Shared Accountability

Care Pathway Step 3

21

Care Pathway Dashboard

TRACKING PROGRESS AND ADJUSTING TREATMENT

BASED ON RISK

FREE UW AIMS Excel® Registry (https://aims.uw.edu/resource-library/patient-tracking-spreadsheet-example-data )

Care Pathway Step 3

Map the Current State of Service Provision & Identify Arears of Improvement

Care Pathway Step 4

• Well defined population

• Evidenced-based key aspects of care

• Sequence of clinical and administrative activities/communication flow/data flow

• Who is responsible for what

• Incorporates measurement-based treatment/ treatment to target tools to assist in decision-making re delivery of care

• Includes applicable process and outcome indicators (including financial) to assess for efficacy, efficiency and value

Map a Revised Care Pathway

Care Pathway Step 5

Care Pathway Step 5

Copyrights apply

Care Pathway Step 5

Copyrights apply

Care Pathway Step 5

Copyrights apply

Care Pathway Step 4

Conduct a Data Tracer Analysis

• WHAT data is collected?

• WHY is the data being collected?

• WHEN is the data being collected?

• WHERE is the data being documented?

• WHO needs access to the data to make either clinical or administrative decisions?

• HOW is the data to be used by the clinicians, patients, administrators, funders, and accrediting bodies?

Care Pathway Step 6

https://michmed-public.policystat.com/policy/8093108/latest/

Care Pathway Step 6

Pilot the New Care Pathway and Evaluate for Effectiveness and Efficiency

• Identify• Team

• Duration

• Training needs

• Data to be collected

• Evaluate results• Data

• Lessons learned

• Modify Care PathwayThis Photo by Unknown Author is licensed under CC BY-ND

Care Pathway Step 6

Implement Care Pathway

• EHR incorporation• Visual display, location, # of clicks and documentation burden

• Prioritization

• Transparency, Trust, and Training• Identify training needs based on pilot experience

• Supporting resources easily accessible within EMR

• “Open” Care Pathway Review Committee

• Issue of multiple Care Pathways

Care Pathway Step 7

This Photo by Unknown Author is licensed under CC BY-SA-NC

Care Pathway Step 7

Monitor Care Pathway Metrics and EBP Literature for QI Opportunities

• Identify a team or committee to regularly review Care Pathways. Reviews should be routinely scheduled and include consumer feedback

• Frequency of reviews based in part on clinical developments in the area

• Assign a clinical lead to monitor for developments in between scheduled reviews-example of First Episode Psychosis and impact on delay of assessment

• Perform routine data analytics on each Care Pathway

This Photo by Unknown Author is licensed under CC BY-NC

Care Pathway Step 7

Lessons Learned

1. Care Pathways are not to be applied in a cookie-cutter manner but must be guided by clinical input

2. “Usual suspects” are often identified in the process of developing Care Pathways

3. Ownership among all stakeholders, from management to front-line, is key

4. Documentation and administrative burden has to be lessened

5. Measuring patient reported outcomes (PROs) is essential

6. Care Pathways are living documents

Poll #3 - Do you want to come back to this topic of Care Pathway in a future session? Yes/No

• Yes

• No

Poll #4 - If you answered yes, which aspects of care pathways would you most like to discuss in the next ECHO session?

• Identifying which care pathways need to be developed

• Designing and implementing measurement-based care pathways

• Developing and using a registry

• Interfacing the BH center's care pathways with the PC provider’s pathway

Open Discussion

• If you are interested in submitting a case to present during a session, download and complete this template form linked here and submit to RaymondaT@thenationalcouncil.org.

• Please make sure to indicate which session you would like to present on.

Submit your case presentation today!

Resources • Toolkit for Designing and Implementing Care Pathways, National Council Toolkit-for-

Designing-and-Implementing-Care-Pathways.pdf (thenationalcouncil.org)

• A Path To Value: Strategies for Developing Care Pathways, 2018 PowerPoint Presentation (thenationalcouncil.org)

• Schrijvers, The Care Pathway: Concepts and Theories: An Introduction, International Journal of Integrated Care, 2021 (PDF) The care pathway: Concepts and theories: An introduction (researchgate.net)

• Vanhaecht, The Leuven Clinical Pathway Compass, Journal of Integrated care Pathways, 2003 The Leuven Clinical Pathway Compass - Kris Vanhaecht, Walter Sermeus, 2003 (sagepub.com)

• Latina, Towards a New System for the Assessment of the Quality in Care Pathways: An Overview of Systematic Reviews, International Journal of Environmental Research and Public Health, 2020 (PDF) Towards a New System for the Assessment of the Quality in Care Pathways: An Overview of Systematic Reviews (researchgate.net)

• Optimizing the Psychiatric Workflow Within a Team-Based Care Framework

• Making the Case for High-functioning, Team-based Care in Community Behavioral Health Care Settings

• https://pathways.nice.org.uk/

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Thank You

Questions?

Email RaymondaT@thenationalcouncil.org

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