SIOUXLAND COMMUNITY HEALTH CENTERCARE MANAGEMENT

Evolution of Care Management and Population Health at SCHC1992- Episodic provider-patient care, UDS reporting via chart

sampling1995- Empaneling Patients1998- BPHC Health Disparities Collaboratives- RN assigned to

registries2003- i2i- additional case managers, quality manager2005- Added Clinical Pharmacist 2011- EMR implementation, MU, UDS reporting of entire patient

population2012-17- Quality Committee optimization, organization chart changes,

PCMH, Quality Specialist, Health Coach Training

Roles of the Health Coach at SCHC

• Assigned to 3-4 provider teams• Participate in daily provider team huddles• Participate in provider team quality huddles (every 6-8 weeks)• Contact A1c>9 monthly, production expectations (monthly scorecard)• Enroll at risk patients into the Enhanced Care Coordination program

and manage them accordingly• Individual assignments- ER follow up, hospital follow up, procedure

follow up • PTAT, i2i, iTi

Health Coach Training

• Iowa Chronic Care Consortium

http://clinicalhealthcoach.com/siouxland/

Future

• Certified Diabetic Educators• Insulin pump management• Certified Diabetic Education Center- AADE• Importance of Risk stratification• Global Care Management- not just by payor• UDS National Quality Award goal• CCM of Medicare patients

CLINICAL PHARMACY SERVICES

GROUP ACTIVITYWhat is the most costly medication?

Clinical Pharmacy Service Goals• Improve patient outcomes

• Improved disease state status• Identify and reduce adverse drug events• Manage pharmaceutical cost

• Decrease workload on licenses independent practitioners• Increase capacity of licenses independent practitioners

Who Receives Services?• Multiple Comorbid Conditions• Poorly Controlled Disease States• Barriers to Healthcare• Social Determinates of Health• Frequent Flyers• Quality driven initiatives• ER and Hospital Admissions

Top 15 Cause of Admissions1

Pneumonia Congestive Heart Failure

Chest Pain/ Coronary Artery Disease/Heart

Attack

Chronic Obstructive

Lung disease

Stroke Irregular Heart Complication of Procedures Mood disorders

Fluid and Electrolyte Disorders

Urinary Infections Asthma Diabetes

Skin/Systemic Infections

GI Related Disorders Hip Fractures

Medication Misuse 2

Pneumonia Congestive Heart Failure

Chest Pain/ Coronary Artery Disease/Heart

Attack

Chronic Obstructive

Lung disease

Stroke Irregular Heart Complication of Procedures Mood disorders

Fluid and Electrolyte Disorders

Urinary Infections Asthma Diabetes

Skin/Systemic Infections

GI Related Disorders Hip Fractures

Adverse Drug Related EventsDiuretics

NSAID

Anti-diabetic

Antiplatelet/Anticoagulation

Opioids

Antipsychotics/Sedatives

Misadventures in medication• Overuse and Underuse• Expected or Unexpected Side Effects• Drug Interaction• Never Prescribed• Missed laboratory monitoring• Medication Errors

Where can pharmacists help?• Diabetes• Hypertension• Anticoagulation• Asthma/COPD • Polypharmacy• Multiple comorbidities• Hepatitis C

Patient Centers Services• Education

• Medication • Disease State

• Transitions of Care• Medication management/Reconciliation• Disease state monitoring• Goal Setting

Collaborative Practice• Between pharmacist and physician

• Medication Titration• Hypertension• Diabetes• Respiratory Care• Warfarin

• Routine Lab monitoring

62.00%

64.00%

66.00%

68.00%

70.00%

72.00%

74.00%

Seen by Pharmacist Not Seen by Pharmacist

Perc

enta

ge o

f Pat

ient

s

Blood pressure at Goal

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

Historically Blood Pressurewas at goal, above goal

now

Has not achieved Bloodpressure goal

Perc

ent o

f Pat

ient

s

Hypertension Poor Control

Seen byPharmacist

Not Seen byPharmacist

Organizational Centered Services• Pharmacy and Therapeutics• Provider education• Treatment Guidelines

Funding• 340b savings• Incident to Billing– 99211• Chronic Care Management Billing• Annual Wellness Visits• Immunizations• Performance Incentive Payments

References• Elixhaser A. Owens P. Reasons for being admitted to the hospital through the emergency department 2003: Statistical brief #2. 2006 Feb. In: Healthcare Cost and Utilization project: (HUCP) Statistical Briefs Rockville (MD): Agnecy for Healthcare Research and Quality 9US) 2006 Feb-.

• Howard. RL, Avery AJ, et al. Which drugs cause Preventable admissions to hospitals? A systemic review. Br J ClinPharmacol. 2007 Feb; 63(2):136-147. Published online 2006 26.

• Cost of ESRD https://www.usrds.org/2013/view/v2_11.aspx

Huddle ProcessPast and Future

• Care management at PCHC is shared across the care team and involves nurses, aids, health coaches, referral and scheduling staff.

• Communication and sharing pertinent information is important to avoid missed care opportunities.

• Our formal huddle process was initiated in April 2015 as part of our PCMH accreditation.

• The process focuses on age and disease specific care measures. A separate huddle form was developed for adults and pediatrics. A huddle form is completed for each provider and reviewed with that provider at the beginning of the day.

Provider______________________ Date______________

Time_____Name_____________ RFV:

ð Wellness code date_____Due__ ð DM: A1c,LEAP,eye,microalb ð Orders/Referrals: OK / DUE

ð Pop-ups None / Ok / Delete ð 18+ SBIRT, PHQ OK/DUE ð Pap: Ages 21-64 : Last Date

ð HHB/Adv Directives: OK / DUE ð Colon cancer: Age 50-75 DUE ð Mammo: Ages 40-75 : OK /DUE

ð IZ: Flu / Tdap / Pneumovax ð BMP, TSH, LIPIDS OK/ DUE ð Reports: Referral, ER/ Hospital

Zostavax/Prevnar ð HIV/Hep C screening

Example of adult huddle sheet

June 2016 Team Huddles# of pt on

huddle# of pt

reviewed % reviewed

(Provider name) 104 52 50%

NSP Missed 2 (3.8% of reviewed)

Mammo Missed 2 (3.8% of reviewed)

Td Missed 7 (13.5% of reviewed)

Micro Missed 8 (15.4% of reviewed)

AD Missed 26 (50% of reviewed)

Pneumo Missed 1 (1.9% of reviewed)

PAP Missed 1 (1.9% of reviewed)

DM Eye Missed 2 (3.8% of reviewed)

Orders Missed 1 (1.9% of reviewed)

A1C Missed 1 (1.9% of reviewed)

Leap Missed 1 (1.9% of reviewed)

Colon Missed 1 (1.9% of reviewed)

• Labor intensive and dependent on staffing• “No one’s favorite task”• Varied levels of engagement with providers

• Purchased the iTi module for i2i.• Development process for the iTi huddle has been a group effort.• Same idea as the paper huddle sheet: looking at age and disease specific care measures. • Protocols developed for each measure. • Difficulties have included IZs with complex schedules (pneumonia, HPV), and catch up

schedule for IZs. • Goal: to decrease staff time spent in preparing huddles, increase use of huddles to

decrease gaps in care. • Needed to invest in 2 additional color printers to take advantage of the color coding on

the huddle sheets.

• Work continues on refining protocols• Preview was given at last all staff meeting-there was excitement!• Plan to trial the process with a few providers before clinic wide roll-out