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in+care CampaignWebinar

February 23, 2012

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Ground Rules for Webinar Participation

• Actively participate and write your questions into the chat area during the presentation(s)

• Do not put us on hold• Mute your line if you are not speaking

(press *6, to unmute your line press #6)• Slides and other resources are available

on our website at incareCampaign.org• All webinars are being recorded

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Agenda

• Welcome & Introductions, 5min• Peer Story from New Jersey, 10min• December Campaign Data and

Improvement Updates Review, 15min• Case Management and the Campaign,

25min• Q & A Session, 5min

The Medical Case Manager Role

In the National in+care Campaign

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On-Site Case Management

Medical Provider

Case Manager

A common Medical Chart, EMR and data storage system

Existing collaboration and access to same patient information facilitates effective communication and strategizing. MCMs and Medical providers attend

multidisciplinary team meetings. The MCM, CM and medical provider data are all entered into the same database, only one report to the In+care Campaign is needed.

Data Manager

Plus With Builds

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Off-Site Case Management• I am a Case Management only program• I am excited about this national campaign

project• Do I have a role in this effort?• How do I participate, how do I contribute?• Unsure if I have sufficient medical information

to respond to the retention indicators• Unsure if I have the skill, expertise, or data to

measure

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Off Site Case

Management

• Stand-alone case management program provides services for patients from 4 RW clinics

• Medical providers refer for case management

• Full medical records reside with medical providers

• All 4 medical providers already participate in the campaign and submit bimonthly data

Northern New JerseyUrban, densely populated, Higher HIV incidence, more HIV services available

Southern New Jersey

More rural, poor public transportation, smaller HIV programs

100% of patients served at CM unit receive care at 1 of 4 HIV clinics

Case Study Model

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Off-Site Case Management

• Campaign role for this CM program is critical, but different.• Emphasis on strategy development

• Potential to design more individualized strategies• CMs play a critical role…..Patients often disclose information to the CM that they do NOT share with the provider. CMs in a unique position to think about strategies.

• De-emphasize data and reporting • Providers who provide the medical care to these patients will be measuring the change, they will see the impact of the CM interventions in their reports from their databases.

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Moving ForwardHow can we make this happen?

• Can help to establish more collaborative relationships• Can help to establish better 2-way communication

• Some communication between medical and case management clinics occurs, but not sufficient to provide each with the info they really need

• Can provide guidance, encouragement, support….Get it started!

Add in the in+Care Campaign Champion!

Case Management Program

RW Medical Provider RW Medical Provider RW Medical Provider

RW Medical Provider

In+Care Campaign Champion

National Database

In+Care Campaign Coach

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Thank you for listening!

The contents of these slides are currently just a vision of the NJ

in+care Campaign Coach and not necessarily endorsed by the National

Quality Center. My name is Jane Caruso and I

approved this message!Jane.caruso@doh.state.nj.us

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Review of February Campaign Data and Improvement Update

Michael Hager, MPH MANQC Manager

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(as of February 21, 2012)

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(as of February 21, 2012)

97%

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(as of February 21, 2012)

100%100%

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(as of February 21, 2012)

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in+care Campaign National Data Snapshot

December and February Data as of 02/22/2012

Dec Average

Feb Average

Dec Patients

Feb Patients

Dec Sites

Feb Sites

Measure 1: Gap Measure 16.25% 16.04% 97,610 90,411 165 139

Measure 2: Visit Frequency Measure 61.58% 68.50% 57,701 50,789 99 80

Measure 3: New Patient Measure 57.26% 59.78% 7,046 7,912 156 135

Measure 4: Viral Suppression Measure 67.46% 69.32% 105,612 106,216 155 135

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Improvement Update Submission ReviewA) New Interventions (not previously mentioned)

•Weekly retention mtgs. in multidisciplinary team•Survey hospital records for new admissions / ER visits•Certified discharge letters to pts. who don’t ans. calls and chronically no-show•CAB input on retention strategies and reminder call freq./timing•Creation of an ‘almost’ lost to care report for intensive outreach•Use of pharmacy pick up lists to see who is not picking up ARVs•Public transportation tokens/cards distributed based on need•Improved data integrity maintenance for use in performance measurement

review•Maintain case mgr. relationship through transition from pediatric to adult care•Join CAB for agencies operating in same community•Standardized welcome program for newly diagnosed adolescents (Show & Tell)•Training consumers to provide Rapid-Rapid Testing

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Improvement Update Submission Review

B) Barriers • Charity care documentation• Long ADAP wait list• Transitional housing makes

patient outreach difficult• Eligibility (re)determination –

lack of necessary paperwork• HIPAA concerns• EMR customization for

retention• De-siloization of services• Huge case mgmt. case loads

• Transitioning from peds to adult care, lack of training for adult providers

• Low health-seeking behavior by youngsters

• Stigma• Medication side-effects• Clients “shopping” for care• Client misunderstanding

funding for treatment vs housing

(not previously mentioned)

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Improvement Update Submission ReviewC) Lessons Learned

• Navigating through changing managed care landscape• Calling day before appt. is high touch and increases retention• Medical provider outreach is often more successful than case mgr.

outreach• Newly diagnosed people have fears that need to be managed before they

can interact productively with the care team• Proactive review of patient appt-keeping behavior to keep ahead of the

game• Patient orientation to clinic alleviates fears• Open access scheduling • Peer to peer counseling at diagnosis helps link people to care

immediately• Patients trust their case managers and med providers – trust in that trust• Less red tape when senior leadership is involved in retention dialogue• Exit interviews with patients after appt. ends to make sure they

understood

(not previously mentioned)

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Improvement Update Submission Review

D) Training/Assistance Needs•Comparison analysis of managed care impact by state

•CAREWare training•Staff QI training, including tools for creation of work plan

•Staff satisfaction assessment tools and training•Information on how to analyze appt reminder system efficacy

(not previously mentioned)

FACES – FACES – CHILDREN’S CHILDREN’S HOSPITALHOSPITAL

Ryan White Part D Ryan White Part D ProgramProgram

Claudia Medina, MD, MHA, Claudia Medina, MD, MHA, MPHMPH

Assisting Director/Quality Assisting Director/Quality ManagerManager

Community Based Medical Case Management Community Based Medical Case Management ModelModel

Ryan White Part D Ryan White Part D Children’s Hospital – FACES ProgramChildren’s Hospital – FACES Program

New Orleans, New Orleans,

Nurse Medical Case

Manager

Social Medical Case

Manager

Intent of Medical Case Management

• Coordinate ALL medically – related care and services.• Diminish barriers to care• Facilitate receipt of medical, social and supportive services to maintain

optimal health.

DEFINITIONMCM is a range of client-centered services that link clients with health care,

psychosocial, and other services. The coordination and follow-up of medical treatments are KEY components.

MCM include the provision of treatment adherence counseling to ensure readiness for, and adherence to, complex HIV/AIDS treatments.

Key Activities of MCM

1. Initial Assessment (Medical, Psychosocial, Literacy, etc)2. Development of Comprehensive, individualized care plan.3. Coordination of service with a multidisciplinary medical

team and community partners. 4. Patient (client) monitoring 5. Interdisciplinary conferencing to assess the efficacy of the

plan.6. Periodic re-evaluation and adaptation of the plan.7. Client advocacy.8. Client education on disease management.9. Follow-up on medication adherence.10. Review of utilization of services.

Rationale Behind the ModelInterpretation of labs, pill box re-fill, adherence

education, disease

management, linkage, etc.

Tracking retention under MCM• WE USE CAREWare

Since billing is done on a monthly basis, when we find out about the medical appointment a month after, and we can’t add as a service, therefore we add it under screening.

Already tracked now what?

Denominator

Numerator

Custom Service Field

Service Category

Numerator

Activities to assure In-Care

Intake Process: •Each client that is referred to the FACES program has to complete an “Intake Process” to be able to be assigned a MCM to become enrolled in the program. •This process is performed by a multidisciplinary group of professionals:

•An Intake Specialist: •who is in charge of assuring “client’s” eligibility through confirmation of income, diagnoses, and residency. (Clients need to live in the EMA) in order to be eligible. •Also they evaluate the housing situation and any psychosocial immediate needs.

•A Mental Health Specialist:•The MH specialist performs the MH assessment and the substance abuse assessment.

•A Nurse Case Manager:•The nurse conducts the medical assessment.

Once the assessment (INTAKE) process is completed an Acuity Scale is filled out by each of the specialists.

Activities to assure In-Care

Intake / Partnership Agreement: •All “clients” that are enrolled into the program have to sign a “Partnership Agreement”. This agreement is a document that explains the partnership relation between the MCM and the client, including rights and responsibilities.

MDI Assignment•The cases are presented weekly at the Multidisciplinary Intake Meeting, where each interviewer presents the client and through a discussion and analysis the case is assigned to the MCM or the Non-Medical Case Manager based on the client’s needs and Acuity Scale.

Primary Care Tracking•Regardless of the level of case management (MCM/nMCM) FACES tracks medical HIV appointments for ALL of the clients.

Assisting Client during Medical Appointment: •The MCM will attend at least once and when needed to the medical appointment with the client. This helps not only create a relationship with the medical provider, but also helps form the MCM to become advocates for their “clients”.

•After this relation has been established many times the medical provider will directly call the MCM to help them intervene with the patients.

Activities to assure In-Care

Treatment Adherence Rate•Any client taking medication will be assessed for medication adherence rate. If needed the MCM will work with clients filling pill boxes, creating schedule charts, assuring that environment is suitable for medication intake, discussing with providers barriers and secondary effects.

Service Plans:•The Service Plan includes Goals, Objectives, Client’s action steps, MCM’s action steps. •It is reviewed every three months to assure achievements.

Activities to assure In-Care

Performance Data Management•Each MCM is responsible for tracking the performance measures for each of their clients.

•CAREWare allows case managers to track performance measures by individual and as a case load.

•Once the MCM identifies that a client has fallen out of the PM they will immediately react proactively and work with the client and address, barriers to assure retention.

•FACES has a bi-monthly QM meeting where PM measures are analyzed and compared with previous months. During this meeting a list of clients that are falling out is given to each responsible MCM for follow-up.

•The Performance Measurement activity is also described in each MCM job description and it’s part of their performance evaluation.

Supporting the In Care Campaign• Tracking Retention from the MCM perspective:

– Each MCM knows exactly how many of their patients are in care and which ones are following out of care.

– When a MCM does not hear or have contact with a “client” during the past 30 days and can’t be reach, the case is referred to Case Finding.

– A outreach specialist receives the referral and initiates the search through: • Phone calls• Home Visits• Clinic Visits

– The case finding outreach worker has 30 days to respond to the referral. – The outcomes could be:

• Lost to follow-up• Not interested in Service• Linked back

Other Activities Include1. Informing clients about resources such as “Med Action Plan” .2. medication and medical appointments through phone messages. 3. Involving “clients” in their own care. 4. Support and Peer groups.5. Transportation Assistance.6. Educational conference, lunch and meeting with clients. 7. Employees participation in quality activities.

MCM & InCare Campaign

• We decided that if we reported our numbers to the campaign, we will be duplicating the data of our local providers.

• Decided not to report.• We track the Retention in Care of patients enrolled in MCM• We participate in the in+care Campaign Local Retention Group• As grantee we encourage our Primary Care Providers to participate and we

help them to track their patients. • Locally, it will be ideal to track NOT only patients that are in-care; but also

of those patients in-care, how many are working with MCM.• REMEMBER the MCM’s primary PURPOSE is the

LINKAGE to and RETENTION in CARE.

MEDICAL CASE MANAGEMENT

There are MANY ways to go but ………..

There is only ONE target! QUALITY OF CARE

Just be SMART with your GOALS:

S: SpecificM: MeasurableA: AttainableR: RealisticT: Timely

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Time for Questions and Answers

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Announcements

• New CAREWare build is available for all 4 Campaign Measures – go to www.incarecampaign.org

• Visit www.nationalqualitycenter.org to learn more about NQC Awards Program or to apply• Award for Performance Measurement• Award for Quality Improvement Activities• Award for Quality Management Infrastructure

Development• Award for Leadership in Quality• Award for Consumer Involvement in Quality

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• Office Hours: Every Monday and Wednesday, 4-5pm ET

• Improvement Update Submission Deadline: March 15, 2012

• Data Submission Deadline: April 2, 2012

• Meet the Author, Dr. Michael Mugavero: March 15, 2012 at 12:00pm ET

• Webinar on Incarceration: Dr. Brian MontagueMarch 14, 2012 at 3:00pm ET

Next Steps

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Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floorNew York, NY 10007Phone 212-417-4730incare@NationalQualityCenter.org

incareCampaign.orgyoutube.com/incareCampaign