Implementing Care Management into Usual Care

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Implementing Care Management into Usual Care

• Bea Herbeck Belnap, Dr Biol Hum
• School of Medicine
• University of Pittsburgh

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Learning Objectives

• 1. To understand the different functions and
  tools required to effectively implement the
  Chronic Care Model for depression management in
  primary care
• 2. To identify the core roles and qualifications
  of care managers, particularly as liaisons to
  providers and for patient self-management support
• 3. To understand the role and function of care
  manager registries and their utility in fostering
  provider and patient communication

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Wagner Chronic Care Model
Health System
Community
Health Care Organization
Resources Policies
ClinicalInformationSystems
Self-Management Support
DeliverySystem Design
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Functional and Clinical Outcomes
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CCM Core Clinical Elements

• Leadership
• Practice
• Design
• Clinical
• Information
• Systems

• Vision
• Resources
• Care management
• Protocols- coordinated care
• Clinical information tracking
• Registry
• Feedback to clinicians

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CCM Core Clinical Elements

• Decision
• Support
• Self-management
• Support
• Community
• Resources

• Guidelines
• Expert/specialist consultation
• Patient preferences
• Information on treatment
• Information on and for consumers, groups, etc.
• Access to non-provider sources of care

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Care Manager RoleEncompasses CCM core elements
Care Manager Self-management CM/Liaison PCP,
MH Community linkages Crisis intervention Registry
General Medical (Chronic care, Prevention,
Follow-up)
Behavioral Health (crisis referral, complexity,
etc.)
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Care Manager Core Functions

• Patient education
• Registry tracking
• Provider communication
• Community linkages

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Care Manager Patients

• Patient education about depression, treatment
  options
• Familiar with commonly used antidepressant
  medications, doses
• Support medication adherence and recovery
• Brief interventions
• Theory-based approaches (MI, PST, etc.)
• Monitor treatment progress
• Know when treatment is not working
• Structured symptom assessment (PHQ-9)
• 8-12 week trial
• Provider recommendations ? MHS, PCP

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CM Goals of a Registry

• Identify, manage, and track patients
• Facilitate patient contacts
• Provide patient visit summaries
• Provide real-time data on tx response, etc.
• Reminders
• Performance feedback

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CM Provider Liaison

• Relay concerns/progress
• Symptom monitoring
• Refills
• Symptoms and side effects
• Urgent, emergent protocols
• Medical record documentation
• Cue providers if no improvement
• Supplement, not replace providers

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CM Community Linkage

• Cooperation with MHS
• Supervision
• Referral
• Self-help groups
• Support for comorbidities, psychosocial problems
• Financial resources

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Care Management Patient Support
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CM Customization

• Cultural competence
• Role of families
• Role of religion/spirituality
• Competing needs

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CM Self-management

• Eliciting concerns/barriers
• Problem-solving
• Providing information
• Clarifying preferences
• Encouraging informed decision-making
• Teaching skills
• Monitoring progress
• Reinforcing self-management
• Community resources

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CM Self-management Tools

• Workbooks
• Medication lists
• Appointment reminders
• Healthy behaviors
• Pleasure activities list
• Pillboxes
• Medication information
• Websites

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Care Management Provider Communication
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CM Provider Liaison

• Help patients and providers identify
• Potentially inadequate doses
• Ineffective treatment (e.g., persistent
  depression after
• Adequate duration of antidepressant trial)
• Side effects
• Facilitate patient-provider (e.g., PCP)
  communication about antidepressant medications
• Consult about medication questions

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Care Manager Providers

• Tracks depressive sx and treatment response
  (PHQ-9)
• Screens for co-occurring MH conditions
• Alcohol use (e.g., AUDIT-C)
• PTSD (e.g., PC-PTSD)
• Consults with team psychiatrist
• Provides follow-up and recommendations to PCP who
  prescribes antidepressants
• Collaborates closely with patients (PCP)
• Facilitates referrals to specialty, community
• Formal and informal connections
• Prepares for relapse prevention

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Examples of CM-Provider Contact

• Medication toxicity, cross-reactivity
• Notifying provider of patient concerns, follow-up
• Fatigue, physical symptoms
• CM prompted provider to call pt. after missed
  appt
• Managing multiple medications, depression,
  diabetes, and HT (medication lists, pillboxes)
• Alcohol use and grief management

Kilbourne AM, et al. Bipolar Disorders,
2008 Kilbourne AM, et al. Psychiatric Services,
2008
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CM Provider Resource

• CMs as a resource for clinic, providers
• Dissemination of specific guidelines
• Ask providers for suggestions on specific topics
• Hold CME, lunches, or disseminate information
• Examples
• Bipolar disorder in pregnancy
• Depression treatment in late life

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Provider Communication Tips

• Obtain preferred mode of communication
• Emphasize as a supplemental service
• Focus on providing information on changes in
  treatment response, side effects, etc. to inform
  decisions
• Baseline, Current PHQ
• Length of time on medications
• Problematic symptoms/side effects
• Adequate contact, but dont overdo it

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Care Management Registries
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Care Manager Registry

• Registries are . . .
• Simple tools to track patient progress
• Integrated into routine clinical care
• Easily updated
• NOT EMRs
• NOT research-focused
• Best if home-grown

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Registry Functions

• Patient risk stratification
• Tracking and management
• Patient characteristics facilitating treatment
• Acute phase
• Continuation, maintenance
• Performance feedback
• Patient process and outcomes

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Registries

• Other data sources (e.g., pharmacy, EMR)
• should NOT replace a registry
• BUT can be used to
• Improved patient identification (top conditions)
• Enhance performance measurement
• Challenges to using electronic data
• Cumbersome to update and merge
• Time lag
• Data not available on all patients
• Privacy and security issues

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Key Registry Variables

• Dates
• Patient contact information
• Best number, time to call, and leave message
• Status
• No shows
• Treatment stage
• Current medications (dose, duration)
• Self-management materials
• Depression severity score, MD assessment
• Referral status (MHS, community resources)
• Next contact, date

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Registry Sample Fields

• General information (update at each contact)
• Patient contact info, including emergency contact
• Providers
• Best time to call/OK to leave message?
• Plan to keep then safe/calm
• Contact (Encounter)-specific information
• Contact or visit date
• Current Mood, Speech, Comorbidities
• Current medications/OTCs, refills needed?
• Medications not taking and reason
• Symptoms and side effects
• Health behaviors (sleeping, drug use, smoking
  ,exercise)
• Job/personal problems
• Education provided
• Access/barriers, provider engagement
• Next appt

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Care Management Crisis Intervention
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CM Suicidal Ideation

• If the patient articulates thoughts
  death/suicide
• Where are you now?
• What is your phone number at the location?
• Are you alone or with someone?
• Do you have a plan of how you would do this?
• Do you have these things available (guns, pills)?
• Have you actually rehearsed or practiced how you
  would do this?
• Have you attempted suicide in the past?
• Do you have voices telling you to harm or kill
  yourself?

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CM Crisis Intervention

• Suicidal ideation- coordinate with clinic
• Protocols
• On-call numbers
• Missed appointments
• Immediate follow-up

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Care Management Implementation Tips
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Care Manager TimelineInitial Visit

• Rapport- providers
• Patient initial intake
• Contact preferences
• Crisis and urgent care protocols
• Assessment
• Discuss treatment options / plans
• Coordinate care with PCP
• Start initial treatment plan
• Arrange follow-up contact
• Document initial visit

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Care Manager TimelineSubsequent Visits

• Registry- ongoing tracking
• Reminders for upcoming appointments
• Regular contact with providers

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Implementing Registries

• Adequate staffing, who should update?
• Research vs. clinical use
• Integrating into routine care
• How identified patients are entered
• Involving PCP
• IRB issues

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Types of Registries

• Formats (pros and cons for each)
• Excel file
• Web-based
• Examples
• SMAHRT
• IMPACT
• REACH-NOLA

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Care Manager Toolbox

• Manual provider interactions
• Contacts, location, communication preferences
• Medication info
• Protocols to ID treatment response, side effects
• Manual patient interactions
• Brief interventions (e.g., PST, MI, others)
• Crisis intervention
• Self-management materials
• Medication information
• Behavioral change information (e.g., pleasure
  activities)
• Registry file

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Bottom Lines

• The CCM for depression includes key elements
• Self-management
• Care management
• Community linkages
• Registries
• Guidelines
• BUT the CCM is most effective if customized to
  local settings . . . . .