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