integrated chronic model a foundation to transform pcmh care delivery
TRANSCRIPT
Integrated Chronic Model
A Foundation to Transform PCMH Care
Delivery
Delivery SystemDesign
DecisionSupport
Clinical InformationSystems
Self-Management Support
Health System Organization
Links to Community Resources
Leadership support and vision
Evidence-Based Guidelines (EBG)
Embed EBG/ identify high risk patients
Staff have defined roles/share responsibility for outcomes
Staff equipped with
needed competencies
Opportunities for Redesign
Aware of/ encourages linkages
ICM:Driving Principles
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Person Centered
Dignity & RespectGoals Drive CareMember of Team
Evidence Based
ClinicalEngagement / SMS
Transitions
Coordinated
TimeSettings Providers
Better Care, Better Health, Lower Costs
Key Components of Our High Risk Program
• Population – patients meeting IHI criteria for high risk• Service delivery – in hospital if identified as appropriate, and
in the community• Key interventions – Follow clinical EVG, behavioral
interventions, barrier assessment and intervention planning, referrals as appropriate
Key Components of High Risk Program
In hospital interventions:• Hospital-based patient assessment
completed by a home health nurse liaison– Depression– Literacy level– Medication error risk– Personal assessment of risk
• Ensures a medical appointment within 7 days of discharge
• Initiation of red flags teaching using “teach-back” technique
• Integration of care givers in discharge process/ PHR
• Initiation of in-home high risk protocol
Key Components of High Risk Program
Interventions provided in the home:• Nursing assessment of self-management ability, home environment,
care giver support, psychosocial issues• Medication reconciliation• Ensures a medical appointment within 7 days of discharge /method
of transportation/ visit preparation• Initiation/ reinforcement of red flags teaching using “teach-back”
technique• Visits front loaded with first visit emphasis on care transition
interventions• Self-management support and coaching to continue to engage
patient/ family/ care giver• Remote monitoring
A Simple Method of Risk Stratification: Institute for Health Improvement
High-Risk Pts Moderate Risk Pts
a. Patient has been admitted two or more times in the past year
b. Patient failed teach back, or the patient or family caregiver has a low degree of confidence to carry out self-care at home
a. Patient has been admitted once in the past year
b. Patient or family caregiver has moderate degree of confidence to carry out self-care at home
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PHR: Identifying Gaps in Home Support
Detecting Early Exacerbation:Remote Patient Monitoring
Patient Surveillance
Multidisciplinary Conference
• Led by Model Champion• SBAR Format• Risk assessment/ review &
intervention discussion• Care plan projected along
with telehealth data• Pt-centered goal emphasis
Prompts
Questions A-I
EMR Example of Decision Support -PHQ-9
Care Plan
Meeting Triple Aim Outcomes
•Patient satisfaction – 100% “clinician listens to me”
Better care
•Re-hospitalization rate reduction of 30%
Better health
•Data will be analyzed when trend holds for one year
Better cost
So…what do we think has the most impact???
NCQA Criteria- Patient-Centered Medical Home
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Patient Engagement andSelf-Management Support
Patient Engagement Defined:
“Actions individuals must take to obtain
the greatest benefit from the health care
services available to them.“ Center for
Advancing Health
The provision by health professionals of
“self-management support” as defined
by Dr. Wagner supports the activation of
patients to take action.
SMS
Pt Engagement
Patient Engagement through the provision of Evidence-Based SMS
Review of 4 Chronic Care Model (CCM) components in 39 studies – results: 19 out of 20 studies with improved outcomes included self management support (SMS). Source: Bodenheimer, et al. JAMA Oct. 2002
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Engagement Implications
• Engagement levels strongly correlate with satisfaction rates (78% of engaged patients rate their quality of care highly, compared with 43% of non engaged patients
• Every visit offers opportunity to build or break your relationship with your patient
• Hard to manage financial risk if patient doesn’t remain with the provider over time
• Physicians often lack the time and tools to adequately educate and engage patients over time.
• With more clinical and financial risk – partners are needed to extend the physicians influence and reach
Obstacles to Engagement
• Failure to appreciate the potential impact of engagement efforts
• Some clinicians still possess the “blame-the-patient” mentality
• Reluctance to move away from conventional roles to one of collaboration
• Using patient-facing materials that create confusion and hinder access to information and services
Getting Out of Our Comfort Zone
• Where we tend to focus:– Adherence to clinical guidelines– Patient education– Directing
• Where new focus is needed:– Using behavior change interventions– Building patient confidence– Guiding
Ability to identify/addresspatient barriers
Communication skills & facilitation of behavior change
Patient-activatedadult education and
health literacy
Expert in care coordination- facilitates
effective transitions
Provider Competencies Needed
Knowledge of current evidence-based
guidelines
Patient Engagement/ Therapeutic Partnerships
What is Self-Management Support?
A collaborative process to help people to:
• Understand
• Choose among treatments
• Identify and set goals
• Adopt and change behaviors
• Cope and overcome barriers
• Follow-through
Competencies for Improving Understanding and Retention
Patient Activated Adult Education
• Identification of literacy issues
• Interventions to address low literacy
• Learning is relevant
• Problem solving/ scenario based learning
• Competent in “teach-back” technique
• Patient directed learning
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“Can you find the salt on the label? “
Removing Barriers For Understanding
Revised Form
Goal Setting : Putting the Patient’s Priorities Front and Center
Request patient answer these questions prior to face to face encounter with MD.
1. What is most important for you to accomplish during your visit?
2. What concerns you the most about your condition?
3. What specifically would you like to work on to manage your condition?
• IHI Ask me 3 campaign27
Ensuring Patient Choice
These are some things you can do to help you with your long term goal. What would you like to work on?
Ultra-Brief Goal Setting Process
Bringing the PCMH to LifeSpecific Enabling Capabilities For Consideration
•Dedicated Care Coordinators ?•Health coaches ?•Home Health extender ?Staffing •Assessment of barriers ?•Self management/engagement tools ?•Patient on the team ?
Patient Engagement
•High risk patient identification ?•Clinical decision aids ?•EMR/ Registry ?
Care Coordination
Possible Physician Role
• Start the conversation/ set the tone
• Engage the patient/ ask about personal goals : using open ended questions & collaboration
• “Warm” hand off to the team
• Stay in touch/ review at each encounter
Possible Team Role
• Continue to educate/no jargon• Check understanding, clarify,
teach back• Identify/ resolve barriers• Collaboratively complete the
action plan• Problem-solve • Plan for follow-up• Offer positive reinforcement and
support – affirm in their ability to succeed
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Considerationswhen resources are limited
• Identify a small high risk sub group to maximize outcomes while minimizing resource need
• Use a tightly structured process• Train MA’s/ Community
volunteers in health coaching• Have Home Health function as
your SMS/ DM team
We’re in this together
Quiring, C. and Thompson, S. Medicare Spending Per Beneficiary (MSPB) the New Link Between Acute and Post Acute, Remington, July/August 2012
Medicare Spending Per Beneficiary (MSPB)
Contact Information
Paula Suter, BSN, MA, CCP
Clinical Director, Integrated Care Management
Sutter Care at Home