Transcript Slide 1

Integrated Chronic Model
A Foundation to Transform
PCMH Care Delivery
Opportunities for Redesign
Staff have defined
roles/share
responsibility for
outcomes
Leadership support
and vision
Evidence-Based
Guidelines (EBG)
Health System Organization
Delivery
System
Design
Self-Management
Support
Decision
Support
Links to Community Resources
Staff equipped with
needed competencies
Aware of/ encourages linkages
Clinical
Information
Systems
Embed EBG/
identify high risk
patients
ICM:
Driving Principles
Person Centered
Evidence Based
Coordinated
Dignity & Respect
Clinical
Time
Goals Drive Care
Engagement / SMS
Settings
Member of Team
Transitions
Providers
Better Care, Better Health, Lower Costs
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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:
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•
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•
•
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 a. Patient has been admitted
or more times in the past year once in the past year
b. Patient failed teach back, or
the patient or family caregiver b. Patient or family caregiver has
has a low degree of confidence moderate degree of confidence to
to carry out self-care at home carry out self-care at home
PHR: Identifying Gaps
in Home Support
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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
EMR Example of Decision Support -PHQ-9
Prompts
Questions A-I
Care Plan
Meeting Triple Aim Outcomes
Better
care
• Patient satisfaction – 100%
“clinician listens to me”
Better
health
• Re-hospitalization rate reduction of
30%
Better
cost
• Data will be analyzed when trend
holds for one year
So…what do we think has the most
impact???
NCQA Criteria- Patient-Centered Medical
Home
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Patient Engagement and
Self-Management Support
Patient Engagement Defined:
“Actions individuals must take to obtain
the greatest benefit from the health
care services available to them.“
Pt Engagement
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
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
Provider Competencies Needed
Patient Engagement/
Therapeutic Partnerships
Expert in care
coordination- facilitates
effective transitions
Ability to identify/address
patient barriers
Knowledge of current
evidence-based
guidelines
Patient-activated
adult education and
health literacy
Communication skills
& facilitation of behavior change
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
“Can you find the
salt on the label? “
• 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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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 campaign
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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 Life
Specific Enabling Capabilities For Consideration
Staffing
• Dedicated Care Coordinators ?
• Health coaches ?
• Home Health extender ?
Patient
Engagement
• Assessment of barriers ?
• Self management/engagement tools ?
• Patient on the team ?
Care
Coordination
• High risk patient identification ?
• Clinical decision aids ?
• EMR/ Registry ?
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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Considerations
when 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
Medicare
Spending
Per
Beneficiary
(MSPB)
(MSPB) the New Link Between Acute and Post Acute, Remington,
July/August 2012
Contact Information
Paula Suter, BSN, MA, CCP
Clinical Director, Integrated Care Management
Sutter Care at Home
[email protected]