1. Managing the Load Connie Sixta, RN, PhD, MBA

2. Logistical Clinical Monitoring % of panel <5% 10% 20% Care Coordination Clinical Follow-up Care Clinical Care Management * Clinical Monitoring

3. Identify Patients with DM in Panel Low Risk Patients BP<130/80 A1c <7.0 LDL <100 Medium Risk Patients BP>130/80 <140/90 A1c >7.0< 8.0 LDL>100<130 High Risk Patients BP>140/90 A1c>9.0 LDL>130 Determine Priority Patient Need Medication Advanced Protocol Titration Upward Monitoring Advanced Self-care DM Education SM Support SM Class Monitoring Functional ability Social Support Transportation $$ for Visit, Meds, co-pays Abuse, etc. Determine Frequency of Patient F/U with Provider Determine Delivery Mode Lab q 3mo Q 6 MO Phone F/U Team management Monitoring (BG, SM Goal, BP) Phone follow-up Disease Clinic (with Provider) Titration BG Monitoring BP Monitoring DM Class DM Education SMS goal Group Visits ( with Provider) DM Education SMS goal Social Worker Q X mo PRN PRN as needed Risk Stratification and Related Interventions Lab q x mo Low risk Medium risk High risk Highest risk Highest Risk Patient BP>210/140 A1c>9.0 LDL>200 Pts in ER Pts Hospitalized Care management Close Monitoring (BG, SM Goal, BP, BMI, etc.) Titration of meds Scheduled phone follow-up All Risk per capacity) KEY

4. Let’s evaluate the load Populations – TOC – ER F/U – Office identified (high versus highest risk?) Volume of patients per each Level of interventions needed per each…

5. Who are your top 5% highest risk patients? Patients with CHF, COPD? Patients with multiple co-morbidities? Patients that are older? Patients that have problems with ADLs? Other??

6. Volume: How many highest risk patients are identified ….. During hospitalization follow-up? During other transitions of care? Post ER visits? During office risk assessments? Reviewing of utilization? Insurer high risk data evaluation? Other?

7. Characteristics: What level of interventions are required for….. Patients being discharged from the hospital? Patients experiencing other TOC? Patients being followed up after an ER visit? Patients being identified as highest risk during the office practice? Patients being identified on the insurer highest risk list?

8. TOC: Hospital Discharges Volume: – Highest risk? – High risk? – Medium risk? – Low risk? Stratifying patients according to interventions: – Continued in-depth assessments – Disease-management education, goal setting – Routine follow-up care – taking meds, office F/U, etc. – Potential for problems minimal – Common complications can be monitored easily – Other??? Do CM interventions decrease after first call? For which patients?

9. ER Follow-up Calls Volume? In-depth assessment needed? Interventions needed? – Getting the patient in for an office appointment? – Immediate RN interventions needed --- teaching, medication reconciliation, communication with PCP What leveling of interventions is possible?

10. Highest risk patients identified in the office? Volume? Who are they? What do the need? Who can best help them? – CDE – Social worker – Patient navigator What continued CM interventions are needed?

11. Which patients require the most time from the CM?

12. Which patients require RN-CM interventions?

13. What level of staff & interventions are needed per population? TOC Patients – Low risk – Medium risk – High risk – Highest risk ---- to CM registry ER Follow-up – High risk – Highest risk Office identified patients – High risk – Highest risk

14. What can you do to stratify the interventions of highest risk patients? Patient volume Patient need – interventions Stratify the interventions Based on the intervention needed, who can best meet the need?

15. Questions?