1. 1 in+care Campaign Webinar February 23, 2012

2. 2 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

3. 3 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

4. The Medical Case Manager Role In the National in+care Campaign

5. 5 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 PlusWith Builds

6. 6 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

7. 7 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 Jersey Urban, 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

8. 8 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.

9. 9 Moving Forward How 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 In+Care Campaign Champion National Database In+Care Campaign Coach

10. 10 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

11. 11 Review of February Campaign Data and Improvement Update Michael Hager, MPH MA NQC Manager

12. 12 (as of February 21, 2012)

13. 13 (as of February 21, 2012) 97%

14. 14 (as of February 21, 2012) 100%

15. 15 (as of February 21, 2012)

16. 16 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%97,61090,411165139 Measure 2: Visit Frequency Measure 61.58%68.50%57,70150,7899980 Measure 3: New Patient Measure 57.26%59.78%7,0467,912156135 Measure 4: Viral Suppression Measure 67.46%69.32%105,612106,216155135

17. 17 Improvement Update Submission Review A)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

18. 18 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)

19. 19 Improvement Update Submission Review C) 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)

20. 20 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)

21. FACES – CHILDREN’S HOSPITAL Ryan White Part D Program Claudia Medina, MD, MHA, MPH Assisting Director/Quality Manager

22. Community Based Medical Case Management Model Ryan White Part D Children’s Hospital – FACES Program New Orleans, Nurse Medical Case Manager Social Medical Case Manager

23. 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. DEFINITION MCM 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.

24. 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.

25. Rationale Behind the Model Interpretation of labs, pill box re- fill, adherence education, disease management, linkage, etc.

26. Tracking retention under MCM WE USE CAREWare

27. 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.

28. Already tracked now what?

29. Denominator Numerator Custom Service Field Service Category Numerator

30. 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.

31. 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.

32. 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.

33. 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.

34. 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

35. Other Activities Include 1.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.

36. 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.

37. 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: Specific M: Measurable A: Attainable R: Realistic T: Timely

39. 39 Time for Questions and Answers

40. 40 Announcements New CAREWare build is available for all 4 Campaign Measures – go to www.incarecampaign.orgwww.incarecampaign.org Visit www.nationalqualitycenter.org to learn more about NQC Awards Program or to applywww.nationalqualitycenter.org 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

41. 41 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 Montague March 14, 2012 at 3:00pm ET Next Steps

42. 42 Campaign Headquarters: National Quality Center (NQC) 90 Church Street, 13 th floor New York, NY 10007 Phone 212-417-4730 incare@NationalQualityCenter.org incareCampaign.org youtube.com/incareCampaign