Presentation on theme: "General Medicine Clinic Care Management Program"— Presentation transcript:
1 General Medicine Clinic Care Management Program Fern Ebeling, RNLisa Tang, MEALindsay Evans, LCSWJulia Finch, BAElizabeth Davis, MD
2 Mr. P is a 49 year old man with congestive heart failure, active methamphetamine use, depression, severe coronary artery disease, and bilateral pulmonary emboli. Over the year prior to enrolling in our program he had been admitted three times (23 hospital days). He frequently missed appointments and did not regularly take his medications.
3 General Medicine Clinic San Francisco General Hospital, UCSF SNAPSHOT OF OUR CLINICComplex Care Management TeamLevel 3:Complexhealthcare needsLevel 2:Multiple chronic conditions:diabetes, HTN, COPDLevel 1:Uncomplicated chronic disease or risk factors: obesity,pre-diabetes
4 GMC Care Management Team Roles Team memberRolesRN Care ManagerInitial assessment and Care PlanComplex clinical issues and medication issuesClinical back-up for Health CoachMedical AssistantHealth CoachOutreach to patientsCoaching toward care plan goalsFocus on self-managementPrimary point of contact for patientsProvider (Resident, attending, or NP)Refer patientsCollaborate with CM teamTitrate medications, plan diagnostic work upsCoordinatorManages referrals, data tracking, reportingSocial WorkerReferrals to entitlements and community-based programsPhysician CM leadProgram development and evaluationClinical back-up to teamLead quality improvement
5 Medication Reconciliation Function ADLs/IADLs Social Support Home AssessmentChart ReviewTrust buildingSelf ManagementMedication ReconciliationFunctionADLs/IADLsSocial SupportGet family involvedBehavioral HealthDepression ScreeningSubstance UseSafetyIPV and Elder Abuse screenHome safety
6 GMC Care Management Program: Enrollment and Levels of Care Intensive case mgmt in 1st and 2nd wk post- discharge.CRITICALCRITICALIntensive case mgmt in 1st and 2nd wk post- discharge.ASSESSMENT: The team RN and health coach conduct a comprehensive assessment, either in the home, in clinic, or by phone. From this information, they develop a care plan and assign the patient a level of care.> or = 1x/wk check-insLEVEL 1LEVEL 1> or = 1x/wk check-insCheck-ins every 2 wksLEVEL 2LEVEL 2Check-ins every 2 wksWAIT LISTINITIAL CONTACT AND CHART REVIEWASSESSMENTCheck-ins every 3 wksLEVEL 3LEVEL 3Check-ins every 3 wksMonthly check-insLEVEL 4LEVEL 4Monthly check-insPT DECLINEDLEVELS OF CARE: The assigned level of care determines the intensity of our care management for each patient. Patients can move up and down the levels of care at any time depending on need.LEVEL 5Pt calls team PRNLEVEL 5Pt calls team PRNHAS OTHER SERVICESPt graduated from programGRADUATEPt graduated from program
7 Motivational Interviewing Role modeling Health CoachingDone over the phoneFreq depends on statusCheck-inProblem-solvingPharmDMEApptsMotivational InterviewingRole modelingPatient Education/Symptom ManagementHealth-O-Meters
9 Mr. P, four months laterUpon enrollment to our program, we focused on building a relationship with Mr. P and with his family. He was hesitant about working with our team, but after three months of intensive involvement, he began to engage. He now feels comfortable calling us with his concerns.Over the first four months, we had 43 conversations with him and his family and had 6 in-person visits. We then decreased to much less frequent contacts.He has had no ED visits or admissions since enrolling in our program, and he has attended almost all of his appointments. At one of these visits, his primary care provider said “This is the first time I have seen him stable. He looks like a different person!”
10 GMC Care Management Challenges StrategiesCapacityAssigning patients to levelsWeekly team discussionEngagementSystem for deciding when to stop trying to engageLearning from other programsCommunication with PCPsquestions in boldHuddlesBrochureCase conferences
11 GMC Care Management Lessons Learned Interprofessional teams embedded in primary careEfficient data managementDashboard key to ongoing improvementImprovement in utilization and health despite complexityEffective care management takes timePartnership with local partners and stakeholdersPatient Advisory Board
12 Resident and Provider Experience All providers surveyed thought quality of care improved with care management"The largest impact that having teams at the GMC has had on me is this feeling that I'm not on my own advocating and caring for our patients--and that has been a huge emotional burden lifted."
13 Patient Experience“Another thing that makes me feel good is when people like Lisa and Fern and Dr. Hurstak reach goals with me. I know there’s someone on the other side fighting for me. I’m not by myself…They convinced me with facts that they are an asset for the patient’s care because they are always there for you.”
14 GMC Care Management Outcomes Year prior to enrollment in CMDuring CMPercent reductionHospital days per year per patient9.754.5353.5%ED Visits per year per patient3.402.4926.6%Utilization data for all patients who have been enrolled in Care Management (n=73). One patient was excluded from this analysis due to incomplete hospitalization data. Utilization data for patients in the program for less than one year was annualized.
15 Key Stakeholders and Partnerships SFGH and the SF Department of Public HealthTraining from UCSF Center for Excellence in Primary CareSan Francisco Health Plan (Medicaid managed care)Health at HomeIn Home Supportive ServicesThank you!