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BEST PRACTICES IN DISEASE MANAGEMENT Deanna Bell, M.D., F.A.A.P. Medical Director, MHIP Tennessee Chapter of the American Academy of Pediatrics.

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Presentation on theme: "BEST PRACTICES IN DISEASE MANAGEMENT Deanna Bell, M.D., F.A.A.P. Medical Director, MHIP Tennessee Chapter of the American Academy of Pediatrics."— Presentation transcript:

1 BEST PRACTICES IN DISEASE MANAGEMENT Deanna Bell, M.D., F.A.A.P. Medical Director, MHIP Tennessee Chapter of the American Academy of Pediatrics

2 GOALS OF D70 GRANT “... to improve medical home provision for children and youth with special healthcare needs by promoting systems and service integration for children through education of parents and providers on medial home concepts of team-based care, care coordination, and disease management.”

3 Who are Your CYSHCN?


5 WAYS TO ID CYSHCN Screeners (CSHCN Screener, QuICCC, QuICCC-R) ICD-9 lists (NHIS, CAHMI, NDP) Administrative with risk stratification (3M-CRG) Physician Referral Payer referral Pharmacy utilization

6 ADMINISTRATIVE: 3M CRG Combines Dx and consequences based approaches Uses ICD-9 and procedural codes to classify cases Requires:6 months of claims data 2 or more encounters with same Dx code Takes into account: type and number of Dx, recurrences, number of acute exacerbations, cost/type/combination/frequency of services Strengths: identifies population and individuals; assigns severity rating; assigns groupings:

7 SURVEY-BASED METHODS QuICCC: 41 question survey sequence QuICCC-R: 16 question survey sequence CSHCN Screener: 5 questions survey sequence All do not require formal Dx All 3 part sequence: consequences/presence of condition/duration Qualify if positive answers to one or more sequences All identify population cohorts and can identify individuals QuICCC and QuICCC-R: interviewer administered only

8 COMPARISON OF ADMINISTRATIVE AND SURVEY-BASED METHODS Of CSHCN identified by ICD-9 lists Only 52-53% met CSHCN criteria by survey methods Of CSHCN identified by Survey Methods 20-24% were not identified by ICD-9 lists Concordance between CRG/CSHCN Screener/QuICCC-R= %

9 CSHCN IDENTIFIED BY SURVEY AND NOT BY ADMINISTRATIVE DATA ARE LIKELY TO: Have developmental or emotional disorders not coded in encounter records Use services not reimbursed under benefit structure Have multiple health issues that include a range of educational, developmental, and mental health service needs and consequences Be in transition between health plans or PCPs

10 MCHB/AAP DEFINITION CYSHCN “... those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” McPherson M, Arrange P, Fox H, et al. “A new definition of children with spe cial health care needs”, Pediatrics, 1998; 102: 137 ‐ 140.

11 CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN) SCREENER© non-condition specific, consequences- based identifies children across the range and diversity of childhood chronic conditions and special needs identified on the basis of one or more current functional limitations or service use needs Scoring in based on positive cluster (e.g. 5 and 5a= positive; or 1, 1a, and 1b=positive)

12 CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN) SCREENER© 1. Does your child currently need or use medicine prescribed by a doctor (other than vitamins)? ٱ Yes Go to Question 1a ٱ No Go to Question 2 1a. Is this because of ANY medical, behavioral or other health condition? ٱ Yes Go to Question 1b ٱ No Go to Question 2 1b. Is this a condition that has lasted or is expected to last for at least 12 months? ٱ Yes ٱ No 2. Does your child need or use more medical care, mental health or educational services than is usual for most children of the same age? ٱ Yes Go to Question 2a ٱ No Go to Question 3 2a. Is this because of ANY medical, behavioral or other health condition? ٱ Yes Go to Question 2b ٱ No Go to Question 3 2b. Is this a condition that has lasted or is expected to last for at least 12 months? ٱ Yes ٱ No 3. Is your child limited or prevented in any way in his or her ability to do the things most children of the same age can do? ٱ Yes Go to Question 3a ٱ No Go to Question 4 3a. Is this because of ANY medical, behavioral or other health condition? ٱ Yes Go to Question 3b ٱ No Go to Question 4 3b. Is this a condition that has lasted or is expected to last for at least 12 months? ٱ Yes ٱ No 4. Does your child need or get special therapy, such as physical, occupational or speech therapy? ٱ Yes Go to Question 4a ٱ No Go to Question 5 4a. Is this because of ANY medical, behavioral or other health condition? ٱ Yes Go to Question 4b ٱ No Go to Question 5 4b. Is this a condition that has lasted or is expected to last for at least 12 months? ٱ Yes ٱ No 5. Does your child have any kind of emotional, developmental or behavioral problem for which he or she needs or gets treatment or counseling? ٱ Yes Go to Question 5a ٱ No 5a. Has this problem lasted or is it expected to last for at least 12 months? ٱ Yes ٱ No

13 CSHCN SCREENER© GRADING All three parts of at least one screener question (or in the case of question 5, the two parts) must be answered “yes” in order for a child to meet CSHCN Screener© criteria for having a chronic condition or special health care need. The CSHCN Screener© has three “definitional domains:” 1) Dependency on prescription medications. 2) Service use above that considered usual or routine. 3) Functional limitations. The definitional domains are not mutually exclusive categories.

14 ENTRY CRITERIA FOR REGISTRY Positive screen for barriers to compliance Positive CYSHCN screen Physician referral Health plan referral Diagnosis list

15 TRACKING REGISTRY Once your chronic or complex illness cohort is identified, you must decide on a tracking system. Most EMRS have flag systems, so a flag or icon can be added to these patients Many practices on paper charts use stickers of a specific color on the patient’s chart. There needs to be communication of Registry status to patients and staff

16 TNAAP High Risk Registry Tracking Tool Patient Name/DOB Emergency Plan Updated Last Plan of Care Last updated: Disease States Follow up Interval Last appointment Last WCC Influenza Immunization Given? (Y/N) Barrier to Compliance Screen Last Given Disease Specific Plan of Care Up-to-Date? (Y/N) Needs:

17 MOC QI AIM #3 MEASUREMENTS Report baseline registry formation based on objective screening (20 charts, alright if 0). Institute CSHCN screener and/or other Enter children with positive screens into registry. Tag record with identifier positive or negative Monthly, select 10 charts from general population that month to audit for use of CSHCN Screener or other evidence of screening for registry entry.

18 Care Coordination Framework Patient Disease management Case Management Team-based Communication

19 What is Disease Management ?

20 Disease Management “ Disease management supports the physician or practitioner/patient relationship and plan of care, emphasizes prevention of exacerbations and complications using evidence –based practice guidelines and patient empowerment strategies, and evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health” Disease Management Association of America. DMAA Definition of Disease Management. {Accessed: January 26,2007};available from :

21 What are the characteristics of successful disease management programs?

22 Successful Disease Management Programs  Individualized Case Management  In-person contacts  Focus on hospital discharges  Encourage use of cost effective therapies  Simple  Patient Centered  Large/overarching  Identified measurement parameters  Incentives

23 Context of Studies Adult cohorts  Large volumes of same diagnosis  Good evidence base for therapies  Costs/Morbidity center around large volume cohorts Pediatric Cohorts  Few large volume cohorts  Many severe illnesses without standardized evidence base for therapy  Cost/Morbidity located in 10% of children, small cohorts

24 Considerations in pediatrics  Disease management strategies in pediatrics must be applicable across a variety of disease states.  Disease management in pediatrics requires both population approaches and individual case management approaches  Processes in pediatrics must be fluid enough to respond to the situational needs of highly specialized/varied patients.  Formalized disease management in primary care

25 Disease Manager Functions  Support evidence based care and individual plans of care  Disease-specific knowledge a must  Provides education for self-management  Compliance tracking and reassessment a large role  Works with MD and case manager to optimize access, compliance, and education

26 Disease Management Team Tasks  Patient screening and registry formation  Evaluates patient/family comprehension of plan of care  Performs disease education as appropriate  Refers patient to case manager as risks for noncompliance identified

27 Disease Management Team Tasks  Tracks and monitors patient compliance with care plans by registry  Augments communication by keeping team members aware of patient status  Assists with transitions to/from hospital/adult care  Authority to schedule override

28 Disease Management Workflow Assess Evidence-based plan Maintain Registry Execute Link Community Resources Support self Management Monitor/Evaluate /Adjust Communicate Plan

29 Keep it Simple  Form your registry  Support the evidence base with process  Educate and involve the team  Use Tools  Continually reassess  Set regular communication times

30 Record which diseases in your practice are leading to increased service utilization or functional capacity limitation Review the evidence base for these diseases Form your registry (General or disease-specific) Assess

31 Support evidence base with process Identify essential action steps that will support evidence base Form office procedure around information exchange that must take place to support evidence-based intervention Describe the responsibilities in this work-flow by job description Don’t forget case management plan Evidence-based plan

32 Physician Disease Management Case Management/Linkage with Resources Referral coordinator/other staff Patients PHYSICIAN MUST HAVE WRITTEN CARE PLAN FOR PATIENTS Communicate Plan

33 Processes for a diagnosis cohort or individual patient executed Patient expectations communicated to patients Team aware of plan and monitoring compliance Execute

34 Screen for barriers to compliance Create care plan for overcoming barriers Monitor patient compliance with this plan Follow-up and reassess Link Community Resources

35 Written plan of care to patients Assessment of health literacy for self management Disease or patient-specific patient education for self management Referral to case management as needed. Support Self Management

36 Follow-up interval specified in patient plan of care or part of evidence-based care path Track no shows and compliance with referrals Maintain patient contact/Assure follow-up occurs Reassess response to interventions Adjust plan accordingly Continually reassess for barriers to care Monitor/Evaluate/Adjust

37 A written plan of care is essential to communicating patient specific expectations to all team members.

38 Three types of plans for CYSHCN  Patient Summary: Problem list, PMH, Meds, Allergies, Specialists, Therapies, Typical Laboratory Values and Exam, Cultural and Social Considerations, Legal  Action Plan: today’s additions, changes  Emergency Plan

39 MOC QI Aim # Written plans of care for team

40 MOC QI Aim #4 Measurements  Report baseline proportion of chronic disease registry patients with written plans of care on chart (20 patients from baseline chronic illness registry, alright if 0)  Institute team management strategies  Monthly, select 10 charts from patients seen in the chronic/complex disease registry to audit for presence of written plan of care

41 Example Forms


43 Baseline Measurements, 20 charts Evidence of screening for barriers to compliance Evidence of linking patients with barriers to compliance to community resources Evidence of screening for CSHCN registry Evidence of written care path in the record for those in CSHCN registry

44 Monthly Measurements 10 charts general population: Were they screened for barriers to compliance? Were they screened for CSHCN registry 10 charts with positive barrier to compliance screen: Is there documentation of linking patient with a resource to overcome barrier to compliance? 10 charts CSHCN Registry: Is there evidence of the written care plan you have agreed to use?

45 Overall AIM Statement Involved practices will improve chronic disease registry formation by 50% by the end of data collection. 25% of registry patients of involved practices will have a care plan with therapeutic recommendations and/or goal by the end of data collection. Involved practices will improve screening for risk factors for noncompliance by 50% by the end of data collection. 25% of patients with a risk factor for non-compliance will be linked with community resources needed to promote compliance by the end of data collection.

46 Requirements for MOC participation  Summit Participation  Baseline/follow-up NCQA PCMH Medical Home Survey  Baseline/monthly (4 month) data entry/analysis for QIDA parameters  Participation in 2 of 4 technical assistance webinars/conference calls  Participation in final QI Program Synopsis call/meeting

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