ic 3 beacon pilot diabetes care coordination training care
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This material was prepared by HealthInsight as part of our work as the Beacon Community, under Cooperative Agreement grant #90BC00006 from the Office of the
National Coordinator, Department of Health and Human Services.
IC3 Beacon Pilot Diabetes Care Coordination
TrainingCare
Sarah Woolsey, M.D.Janet Tennison, PhDHealthInsight, August 16, 2012
Welcome
Pre-work
Today’s Objectives • Understand Care Coordination and Self-Management • How to identify high risk patients with diabetes in
your system• Assessing patients’ needs and goals
– Health Literacy– Motivational Interviewing– Stages of Change– Teach Back– Planned follow-up– ProQual tool
• Starting Care Coordination in your setting
Definition: Care Coordination
“The calculated integration of patient care activities between
two or more participants, to facilitate the suitable provision of
health care services”
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7. McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.
Coordination--Why Do We Need It?
• Determine the patients’ goals • Assist those “high-risk” patients who
have been unsuccessful at managing their own care
• Engage patients to improve their self-care
• Improve the exchange between providers, patients, community services
We Sometimes Get Frustrated
Removing Barriers to Accomplish Goals
Engaging Patients in Their Own Care
Traditional Collaborative
• Professionals are experts, patients passive
• Behavior change externally motivated
• Non-compliance is personal deficit
• Providers experts about disease; patients experts about lives
• Behavior change internally motivated
• Lack of goal achievement requires modifications
Bodenheimer, T., & Abramowitz, S. (2010). Helping patients help themselves: How to implement self-management support. Oakland, CA: California HealthCare Foundation.
DifferencesTraditional Patient Education
• Technical skills• Problems with disease
control• Disease-specific
knowledge• Goal is compliance to
improve outcomes• Health professional is
educator
Self-Management Education
• Skills to act on problems• Problems ID‘d by
patients • Improving confidence
• Goal is increased self-efficacy to improve
• Health team, peers, educators
Bodenheimer, T., & Abramowitz, S. (2010). Helping patients help themselves: How to implement self-management support. Oakland,
CA: California HealthCare Foundation.
DSM
o
Interprofessional Outcomes •Team Self-efficacy •Shared Perspectives •Teamwork • Attitudes towards collaboration
Patient Outcomes •Physiologic •Satisfaction •Functional status
Organizational Outcomes •Culture/climate •Staff satisfaction •Efficiency/cost
Clinical Information Systems1
Decision Support2
Delivery System
Redesign3
Self-Management4
Community Resources5
Clinic Care Coordination
Activated Patients
Healthcare Organization6
Developed by Janet Tennison, PHD,Adapted from Kirsch et. al., 2008
Essential CC Tasks
• Identify high-risk patients• Assess patient• Develop care plan• Identify care participants,
communicate needs• Execute care plan • Monitor and adjust care• Evaluate health outcomes
ESSENTIAL CARE TASKS and Associated Coordination Activity
• IDENTIFY and ASSESS PATIENT Determine Likely Coordination Challenges, determine patients vulnerable to disconnected care
• DEVELOP CARE PLAN Proactive Plan for Coordination Challenges and Follow-up
• IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES Specify Who is Primarily Responsible for Coordination (Medical Home)
• EXECUTE CARE PLAN Implement Coordination Interventions• COMMUNICATE TO PATIENTS /Family AND ALL OTHER CARE
PARTICIPANTS Ensure Information Exchange Across Care Interfaces
• MONITOR AND ADJUST CARE Monitor For and Address Coordination Failures
• EVALUATE HEALTH OUTCOMES Identify Coordination Problems that Impact Outcomes
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7. McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.
Case: Mr. Thomas• Mr. Thomas is a 56 -year old patient with
DM II.• He has private insurance through his
wife’s job. • He is here for a cough and cold visit, has
not been in for 9 months. • You note he has no-shows recorded for
his last 3 visits to you, both education visits and a diabetes check-up.
Medical Assistant Check-In• He is taking 3/5 meds
listed in the EMR by report.
• Metformin, Lisinopril and aspirin (unsure what kind).
• He is not on insulin, simvastatin as recorded here.
• He reports no pain or allergies.
• He has not had any office visits elsewhere.
• Temp=98.0• BP 152/90, pulse 88• Weight is 224lb , BMI
29 • O2 sat is 99%• Hba1c = 10 (last time
was 8.9)• Coughing• In his PJ top• Appears well
otherwise
What Are You Thinking Here?
MA point of view
Beacon point of view
Doctor point of view
Care Coordination point of view
More InformationExam :
• Obese• Nasal
congestion• R toenail is
ingrown (you checked)
Labs today:Glucose-333
Old Labs:
• LDL=144• Microalbumin is
abnormal• A1c=8.9
Other• He did not have a
flu shot in 2011• He has never had
a depression screen
• Non-smoker
Is Mr. Thomas High Risk?
• Vulnerable to disconnected care?
• How do you find him in your system?• Name 3 ways
Practice Analytics Tool“Hot Spot” Pilot
• Diabetes Care Severity Index• Composite score of labs,
diagnoses, and know risk of hospitalization
• Option in the CC program
What else do you want to know about Mr. Thomas?
Patient Point of View?
Consider…
WHAT IS his GOAL for his care?Today? Overall?
How do you know?
ESSENTIAL CARE TASKS and Associated Coordination Activity
• IDENTIFY/ASSESS PATIENT Determine Likely Coordination Challenges, determine patients vulnerable to disconnected care
• DEVELOP CARE PLAN Proactive Plan for Coordination Challenges and Follow-up
• IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES Specify Who is Primarily Responsible for Coordination (Medical Home)
• EXECUTE CARE PLAN Implement Coordination Interventions• COMMUNICATE TO PATIENTS /Family AND ALL OTHER CARE
PARTICIPANTS Ensure Information Exchange Across Care Interfaces
• MONITOR AND ADJUST CARE Monitor For and Address Coordination Failures
• EVALUATE HEALTH OUTCOMES Identify Coordination Problems that Impact Outcomes
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7. McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.
Patient Assessment“Why is Mr. Thomas so non-compliant?”
The patient is not yet engaged!
Patient and provider both have responsibility to determine and address barriers.
Three methods:
1. Health Literacy2. Stages of Change3. Motivational
Interviewing (MI)
Health Literacy
• tervisealase kirjaoskuse• अनुवाद करने के लि�ए यहाँ
पाठ दर्ज� करें• בריאות אוריינות• alfabetizasyon sante• Gesundheitskompetenz• y tế biết đọc biết viết
DefinitionHealth Literacy
The capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.
Functional Health Literacy
The ability to read and comprehend prescription bottles, appointment slips, other essential health-related materials required to successfully function as a patient.
Healthy People. (2010). Cited in What is Health Literacy? Retrieved from www.chcs.org
Health Literacy• Only 12% of adults have proficient
health literacy
• 9/10 patients lack skills to manage their health/prevent disease
• Ask Me 3 Advocate for Health Literacy in your organization (n. d.). Quick
Guide to Health Literacy. Retrieved from http://HHS.com
Determine then Support Health Literacy
• Verify understanding by “teach back”
• “Tell me in your own words what we just talked about”
• “Why do you take this medication?”• Provide instructions like you’re
speaking with a friend
MOST IMPORTANT!
Create a shame-free environment where low-literacy patients can seek help without embarrassment or being stigmatized
Don’t Forget Culture
• Ethnic/racial/population/religious differences affect perceptions, trust, access to medical care
• Poverty, language and communication barriers, other demographics
• Personal bias, prejudices, lack of understanding
Mr. Thomas and Health Literacy
• Visit Summary Example
The Stages of Change
Inappropriate Assumptions About Behavior Change
• This person ought to change, and wants to change.• This patient’s health is the prime motivating factor for him/her.• If he or she does not decide to change, the consultation has
failed.• Patients are either motivated to change, or not.• Now is the right time to consider change.• A tough approach is always best.• I’m the expert. He or she must follow my advice.• A negotiation-based approach is best. Emmons, K. M. , & Rollnick, S. (2001). Motivational Interviewing in health care settings: Opportunities and limitations. American Journal of Preventive Medicine, 20(1)
How To Suppress Change
• Tell patients what to do (give advice)• Misjudge sense of importance regarding
behavior change• Use scare tactics, argue, blame them for no
willpower and self-concern• Overestimate readiness to change and
degree of confidence • Take control away and generate resistance
Is Patient Ready to Change?
Readiness to change: Stages of Change. (2005). Retrieved July 10, 2011, from Well-Fit Bodies Website: http://www.well-fitbodies.com/readiness_for_change
Patient AssessmentsHow ready are you (to improve a behavior)?
0 1 2 3 4 5 6 7 8 9 10
Not ready Ready
How confident are you (that you can)?
0 1 2 3 4 5 6 7 8 9 10
Not at all confident Very Confident
True Change Takes Time
• Some may remain in one phase a long time or forever
• Pre-contemplation—cons of quitting outweigh the pros
• Relapse is expected, should be integrated to normalize it
• Most don’t go from pre-contemplation to action
• Goal—try to move through stages
Success = Positive Relationships & Support
Provider-patient relationship most important determinant of diabetes self-management
Craig, C., Eby, D., & Whittington, J. (2011). Care Coordination Model: Better care at lower cost for people with multiple health and social needs. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement.
Where is Mr. Thomas?
• Contemplation• Pre-contemplation• Preparation• Action• Maintenance
BREAK
Motivational Interviewing
Motivational Interviewing
“A collaborative, patient-centered form of guiding to elicit and strengthen motivation for change”
Miller, W.R. & Rollnick, S. (2009). Ten things that Motivational Interviewing is not. Behavioural and Cognitive Psychotherapy, 37, 129-40.
Motivational Interviewing
• Non-coercive• Non-judgmental• Non-confrontational • Non-adversarial• Explore and resolve inconsistency• Help patients envision a better future,
and become increasingly motivated to achieve it
Why Do We Need MI?
No matter what reasons we might offer to convince individuals of the need to change their behavior,
or how much we want them to do so,
lasting change is more likely to occur when they discover their own reasons and determination to change.
Four Principles of MI
1. Express empathy2. Explore differences3. Roll with resistance4. Support of self-efficacy
OARS•Open-ended questions•Affirmations•Reflections•Summaries
Patient Assessment
Mr. Thomas
Role play referral for insulin use, why was it unsuccessful before?
What would you say and do?
What is his goal?
LUNCH 12:00-12:30
Pro Qual Tool–Patient Experience of Health
Assessment and Barriers
• http://informatics.mayo.edu/proqol (test)
This material was prepared by HealthInsight as part of our work as the Beacon Community, under Cooperative Agreement grant #90BC00006 from the Office of the
National Coordinator, Department of Health and Human Services.
IC3 Beacon Pilot Diabetes Care Coordination Training
Part 2Care
Sarah Woolsey, M.D.Janet Tennison, PhDMichelle Carlson, S.S.W.HealthInsight, 2012
Motivational Interview #2 • Mrs. Smith is a 48 y/o, she has had
DM 2 for 5 years, since her last child was born.
• She is on your list as a patient that has not come in for >12 months.
• Her last A1c was 7.5, and she was up to date on DM care.
• Today’s A1c=9.• You notice she has had no shows a
few times for follow-up for Diabetes.
WHAT MIGHT BE HAPPENING?
Part 2 Learning Objectives
• Developing a Care Plan• Identify roles• Communicating (information
exchange)• Monitor and Adjust • Data collection• Resources
ESSENTIAL CARE TASKS and Associated Coordination Activity
• IDENTIFY/ASSESS PATIENT Determine Likely Coordination Challenges, determine patients vulnerable to disconnected care
• DEVELOP CARE PLAN Proactive Plan for Coordination Challenges and Follow-up
• IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES Specify Who is Primarily Responsible for Coordination (Medical Home)
• EXECUTE CARE PLAN Implement Coordination Interventions• COMMUNICATE TO PATIENTS /Family AND ALL OTHER CARE
PARTICIPANTS Ensure Information Exchange Across Care Interfaces
• MONITOR AND ADJUST CARE Monitor For and Address Coordination Failures
• EVALUATE HEALTH OUTCOMES Identify Coordination Problems that Impact Outcomes
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7.McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.
The Mr. Thomas Care Plan
Provider wants to re-start Insulin that patient agreed to start prior
What is the current workflow at your site?
How do we succeed?
Care PlanBasic Clinic Example of a Working Care Plan
For next visit: (To be completed by Physician /Care Coordinator and Patient) Patient Name__________________ Chart ID____________ Patient Goal:Medical Plan:• Care Coordination Needs/Referrals: __________________________________________ • Labs Needed: ___________________________________________________________ • New Meds/ Education Needed: ______________________________________________ • Ref letters/Contact needs for patient: ________________________________________ • Follow Up Needed: Call (Who/date/subject) ______________________________________________ Next Visit (Schedule period/date) _______________________________________ Next Visit agenda ___________________________________________________ Care Plan: Patient will: ____________________________________________________ By:(Date)_____________ Care Coordinator/Clinical Team will: ____________________________________________________ By:(Date)_____________ Reviewed Date __________ Care Team or Physician Signature Patient signature- plan
Adapted from the Utah Medical Home Portal www.medicalhomeportal.org, 2009
Care Plan Brainstorm
ESSENTIAL CARE TASKS and Associated Coordination Activity
• IDENTIFY/ASSESS PATIENT Determine Likely Coordination Challenges, determine patients vulnerable to disconnected care
• DEVELOP CARE PLAN Proactive Plan for Coordination Challenges and Follow-up
• IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES Specify Who is Primarily Responsible for Coordination (Medical Home)
• EXECUTE CARE PLAN Implement Coordination Interventions• COMMUNICATE TO PATIENTS /Family AND ALL OTHER CARE
PARTICIPANTS Ensure Information Exchange Across Care Interfaces
• MONITOR AND ADJUST CARE Monitor For and Address Coordination Failures
• EVALUATE HEALTH OUTCOMES Identify Coordination Problems that Impact Outcomes
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7.McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.
Roles at Your Clinic
Who is going to coordinate the patients?
When will the work get done?Initiation? Follow-up?
Who is responsible for X patient?
St Mark’s Pilot Success
ESSENTIAL CARE TASKS and Associated Coordination Activity
• IDENTIFY/ASSESS PATIENT Determine Likely Coordination Challenges, determine patients vulnerable to disconnected care
• DEVELOP CARE PLAN Proactive Plan for Coordination Challenges and Follow-up
• IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES Specify Who is Primarily Responsible for Coordination (Medical Home)
• EXECUTE CARE PLAN Implement Coordination Interventions• COMMUNICATE TO PATIENTS/FAMILY AND ALL
OTHER CARE PARTICIPANTS Ensure Information Exchange Across Care Interfaces
• MONITOR AND ADJUST CARE Monitor For and Address Coordination Failures
• EVALUATE HEALTH OUTCOMES Identify Coordination Problems that Impact Outcomes
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7.McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.
Communication
• TEMPLATE DEVELOPMENT• How will you share this
information with all team members?
• Where Does the Care Plan Go in the Chart?
• How is a patient flagged?
Communication
• When should I call you or have you come in (to check on progress)?
• Reinforce Change Plan at every visit/opportunity
• Share plan with all team members• Assist with problem solving as
needed
ESSENTIAL CARE TASKS and Associated Coordination Activity
• IDENTIFY/ASSESS PATIENT Determine Likely Coordination Challenges, determine patients vulnerable to disconnected care
• DEVELOP CARE PLAN Proactive Plan for Coordination Challenges and Follow-up
• IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES Specify Who is Primarily Responsible for Coordination (Medical Home)
• EXECUTE CARE PLAN Implement Coordination Interventions• COMMUNICATE TO PATIENTS/FAMILY AND ALL OTHER CARE
PARTICIPANTS Ensure Information Exchange Across Care Interfaces
• MONITOR AND ADJUST CARE Monitor For and Address Coordination Failures
• EVALUATE HEALTH OUTCOMES Identify Coordination Problems that Impact Outcomes
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7.McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.
Monitor and Adjust
• Set strong boundaries with patients: role/purpose, time constraints
• Discuss “problem patients” with care team: decide if appropriate for care coordination
• Discuss other potential failure reasons with team
• Reassess patients, as needed
ESSENTIAL CARE TASKS and Associated Coordination Activity
• IDENTIFY/ASSESS PATIENT Determine Likely Coordination Challenges, determine patients vulnerable to disconnected care
• DEVELOP CARE PLAN Proactive Plan for Coordination Challenges and Follow-up
• IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES Specify Who is Primarily Responsible for Coordination (Medical Home)
• EXECUTE CARE PLAN Implement Coordination Interventions• COMMUNICATE TO PATIENTS /Family AND ALL OTHER CARE
PARTICIPANTS Ensure Information Exchange Across Care Interfaces
• MONITOR AND ADJUST CARE Monitor For and Address Coordination Failures
• EVALUATE HEALTH OUTCOMES Identify Coordination Problems that Impact Outcomes
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7.McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.
Health Outcomes Data Collection
• Excel Database • Document your
success• Assist us in
program evaluation• Learn to measure
what you do• Develop your
capacity to show the quality you deliver
Knowing Your Community
Resources and Referrals
Beacon Website Resources
Beacon Clinic Resources
Public Benefit Programs
• SSI (Social Security Income)• SSDI (Social Security Disability
Income)• Medicare (Over 65 years-old,
and disabled)• Medicaid and CHIP (Low
income)
Support Groups
• Disease-based (Cancer, Mental Health)
• On-line groups (Women’s, Grief, Addictions)
• Agency-based (Red Cross, United Way)
• 2-1-1
Community Resources
• Religion affiliated (LDS, Catholic Community)
• Aging and elder care• Pharmacy Assistance Programs• Homeless services• Donated dental
Home Health
• Home health referrals and criteria (Skilled need, homebound status)
• Pre-authorizing services through insurers
• DME (FWW’s, potty-chairs, electric WC’s)
Long-Term Care
• Skilled Nursing Facility (SNF) - Skilled needs vs. “custodial”• Extended Care Facility (ECF)• Independent/Assisted Living• Medicare versus private pay• Referral processes/paperwork
How to Succeed• ID the right patients reliably• Track patients• Care Plan in place for patients with a
patient goal in place• Follow-up in place for care plan items• Resources list available, if needed• Improving DM measures in patients and
meeting their goals for care• Patient Satisfaction, experience of health
and support
Wrap-Up and Next Steps
• HealthInsight Assistance• Feedback on self-assessments • Data collection tool assistance• Monthly visit with team (if
desired)• Proqual assistance
Wrap-Up and Next Steps
• Action Plan• What can you do by next
Tuesday? (ideas) -- Finish assessments -- Team meeting -- Begin using ProQual tool on patients
Wrap-Up and Next Steps
• Evaluations
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