Care Management and the role of the Health Coach Gettysburg Adult Medicine/Brockie Internal Medicine Pamela Brant, RN Nurse Care Manager Julie Assi, LPN Health Coach Amy Mummert, LPN Health Coach

Care Manager RN Provides service to 3 medical group practices On site for 12 hours a week at Gettysburg Adult Med Provides follow up services to the high risk population Monitors population management Provides education/goal setting/action plan development to diabetic patients with A1c > 9 % Provides psychosocial/economic interventions in collaboration of community services/Hospital care managers/social workers

High Risk Criteria ED/Hospital visits related to a fall if over the age of 65 Any patient visiting the ED/Hospital for the same diagnosis > 1 time in 3 months Diabetic patients with A1c > 9% Frail elderly (FTT) Referrals from Transition Care Manager (CRNP) Referrals from Health Coach Provider referrals: where a home visit may be indicated

Health Coach Guiding Principles STEEEP: Safe, timely, efficient, effective, equitable, patient centered Triple AIM: Better health Better care Reduce the cost curve Chronic care model—prepared, proactive care teams, engaged, activated patient

Why do we need this? Primary care clinicians are “struggling to fit multiple agenda items into the 15 minute visit – cannot meet every need of their patients with chronic conditions.” ( Bennett, Coleman, aafp.org/2010) “Half of patients leave primary care visits not understanding what their doctor told them.” ( Bennett, Coleman, aafp.org/2010) Average adherence rates for prescribed medications are about 50 percent, and for lifestyle changes they are below 10 percent.” ( Bennett, Coleman, aafp.org/2010) “Although clinical research is still being amassed,…..Health coaching has been proven in randomized trials to make a difference…People can be helped using motivational techniques.” (Buckley, 2010)

Health Coach Model: Role Expectations Call ED/Hosp discharge patients within 48 hours Referral to CM Follow up on self-management action plans New med follow up Address barriers to treatment plan/goals F/u of referrals from CM Population management

Health Coach Program Mid July Selection process completed. July 25, 2011– training day August 1, HC began on a part-time status September 1, HC began full-time 1 HC to 3 providers Transition phone calls– population management– patient goals Phone conferences

Health Coach Program HC patient census= 104 patients (mostly transition of care) 3 HF 6 DM 20 Physician referrals 4 Self management Majority of time is spent on transition of care First program audit is underway

Cerner Message ED/Hospital D/C

HC Tracking Form

Discharge Transition F/U Questions Patient Name: Date: ___________ DOB/MRN:_____________________ Provider: ED or Hospital D/C date: _________ F/U appointment Date: Admitting diagnosis: __________________________ 1. Are there any barriers to communication? (Language, hearing, comprehension, literacy) 2. Name of support/contact person: ______________________ Phone Number: _______________________ Relationship to patient: ________________ 3. How is the patient feeling today? 4. Did the patient receive written discharge Instructions when they left the hospital/ED?  No  Yes Review the instructions on the form with the patient (teachback). 5. Is the patient able to identify any warning signs or symptoms for their condition. (Hypo/hyperglycemia, CHF, A- fib, pneumonia, chest pain, etc.)  No  Yes  N/A 6. Does the patient have any restrictions in activity?  No  Yes  N/A Details: 7. Does the patient require assistance with ambulation?  No  Yes  N/A Details: 8. Does the patient have diet instructions or fluid restrictions? Details.  No  Yes  N/A Details: 9. Complete medication reconciliation: ask patient to get pill bottles for review, retrieve discharge summary from chart and discharge instructions from PowerChart, if available. Be specific and review with the patient how they take them, how often and what they are taking each medication for. ____Medication reconciliation completed—no changes needed ____Medication reconciliation completed—changes made to eCare medication record. ____Discrepancy from discharge summary regarding “resume home meds”. Medication changes since hospital admission: 10. If the patient is not following medication regime determine the eason and provide intervention. Intervention: 11. If any gaps are identified provide education or instruct them to follow up with their PCP or make an office appointment with Health Coach or Care Manager ____Additional interventions: _____No additional interventions needed. 12. Are there any other services ordered? (Home Health, Outpatient therapy, etc) List name of service; _______________________________________________ HC Signature: ______________________________________ Date: ________________________ MedicationDoseFrequency

Upcoming Care Management Projects Transition Care Manager (TCM)– CRNP Pilot completed Currently recruiting for position See patient in hospital F/U at home Refer to additional services as necessary Refer to Nurse Care Manager Hospital Social Workers to begin joint service to hospital and medical group practices Pilot running in 2 medical group practices SW will spend specific amount of hours in practice weekly

Care Management Swim Lane Diagram