1. General Medicine Clinic Care Management Program
Fern Ebeling, RN
Lisa Tang, MEA
Lindsay Evans, LCSW
Julia Finch, BA
Elizabeth 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 CLINIC
Complex Care Management Team
Level 3:
Complex
healthcare needs
Level 2:
Multiple chronic conditions:
diabetes, HTN, COPD
Level 1:
Uncomplicated chronic disease or risk factors: obesity,
pre-diabetes

4. GMC Care Management Team Roles
Team member
Roles
RN Care Manager
Initial assessment and Care Plan
Complex clinical issues and medication issues
Clinical back-up for Health Coach
Medical Assistant
Health Coach
Outreach to patients
Coaching toward care plan goals
Focus on self-management
Primary point of contact for patients
Provider (Resident, attending, or NP)
Refer patients
Collaborate with CM team
Titrate medications, plan diagnostic work ups
Coordinator
Manages referrals, data tracking, reporting
Social Worker
Referrals to entitlements and community-based programs
Physician CM lead
Program development and evaluation
Clinical back-up to team
Lead quality improvement

5. Medication Reconciliation Function ADLs/IADLs Social Support
Home Assessment
Chart Review
Trust building
Self Management
Medication Reconciliation
Function
ADLs/IADLs
Social Support
Get family involved
Behavioral Health
Depression Screening
Substance Use
Safety
IPV and Elder Abuse screen
Home safety

6. GMC Care Management Program: Enrollment and Levels of Care
Intensive case mgmt in 1st and 2nd wk post- discharge.
CRITICAL
CRITICAL
Intensive 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-ins
LEVEL 1
LEVEL 1
> or = 1x/wk check-ins
Check-ins every 2 wks
LEVEL 2
LEVEL 2
Check-ins every 2 wks
WAIT LIST
INITIAL CONTACT AND CHART REVIEW
ASSESSMENT
Check-ins every 3 wks
LEVEL 3
LEVEL 3
Check-ins every 3 wks
Monthly check-ins
LEVEL 4
LEVEL 4
Monthly check-ins
PT DECLINED
LEVELS 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 5
Pt calls team PRN
LEVEL 5
Pt calls team PRN
HAS OTHER SERVICES
Pt graduated from program
GRADUATE
Pt graduated from program

7. Motivational Interviewing Role modeling
Health Coaching
Done over the phone
Freq depends on status
Check-in
Problem-solving
Pharm
DME
Appts
Motivational Interviewing
Role modeling
Patient Education/Symptom Management
Health-O-Meters

8. Health-O-Meter

9. Mr. P, four months later
Upon 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
Strategies
Capacity
Assigning patients to levels
Weekly team discussion
Engagement
System for deciding when to stop trying to engage
Learning from other programs
Communication with PCPs
questions in bold
Huddles
Brochure
Case conferences

11. GMC Care Management Lessons Learned
Interprofessional teams embedded in primary care
Efficient data management
Dashboard key to ongoing improvement
Improvement in utilization and health despite complexity
Effective care management takes time
Partnership with local partners and stakeholders
Patient 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 CM
During CM
Percent reduction
Hospital days per year per patient
9.75
4.53
53.5%
ED Visits per year per patient
3.40
2.49
26.6%
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 Health
Training from UCSF Center for Excellence in Primary Care
San Francisco Health Plan (Medicaid managed care)
Health at Home
In Home Supportive Services
Thank you!