1. Welcome to Learning 2: Care Management October 2011 Connie Sixta, RN, PhD, MBA

2. Objectives Describe care management, care coordination, and the role of the care manager and team. Discuss ER notification process, follow-up criteria, follow-up care, & documentation/communication systems Discuss discharge notification, transition care, and documentation/communication systems Describe highest risk patients, care management registry, care plan, & documentation and communication systems Utilize case studies to discuss follow-up care for ER patients, discharged patients, highest risk patients.

3. Logistical * Clinical Monitoring % of panel <5% 10% 20% Care Coordination Clinical Follow-up Care Clinical Care Management * Clinical Monitoring Navigation, Outreach Transition Care ER visit Follow-up Intense care management intervention * Clinical Monitoring Commonwealth Fund Step-wise Process

4. Philosophy of Case Management The underlying premise of case management is based in the fact that when an individual reaches the optimum level of wellness and functional capability, everyone benefits: the individuals being served, their support systems, the health care delivery systems and the various reimbursement sources. CMSA

5. Case Managememt cont. Advocacy, Communication, Education, Identification of service resources and service facilitation. The case manager helps identify appropriate providers and facilities throughout the continuum of services. Ensures that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the client and the reimbursement source. CMSA

6. Geisinger Clinical Care Manager Serves in an expanded nursing role to collaborate with the Medical Neighborhood and the Medical Home team to provide a model of care that ensures the delivery of quality, efficient, and cost- effective care. Develops systems of care that monitor member progress and promote early intervention in acute care situations. Works effectively with other members of the health care team to optimize interventions. 6

7. Which patients is the CCM Managing? Highest risk patients (starting with highest level) – Admitted/discharged from the hospital – Seen in the emergency room – Assessed in the office as highest risk due to: Top 5% of the panel - “highest” of the high risk patients One FTE CCM per 5000 commercial patients or 800 Medicare patients Case load 150 7

8. CCM Essential Functions Developing/managing tracking and documentation systems for care transitions (i.e. hospital discharges and ED visits). 8

9. CCM Essential Functions Assuring that care coordination and care management is patient-centered and supports informed decision-making. 9

10. CM Essential Functions Identifying and managing the patient’s driver/s that caused the hospitalization or ED visit. 10

11. CM Essential Functions Comprehensively assessing patient’s physical, mental, and psychosocial needs. 11

12. CM Essential Functions Stratifying high risk patients to identify the highest risk patients based on severity of disease, self-care limitations, lack of family support, severe socioeconomic factors, poly- pharmacy, and health care utilization trends. 12

13. CM Essential Functions Maintaining a registry of highest risk patients with documented completion of measures and interventions. 13

14. CM Essential Functions Developing care plans that prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status, and minimize hospital and ER utilization. 14

15. CM Essential Functions Utilizing behavioral strategies to assist patients in adopting healthy behaviors, improving self- care and managing chronic disease. 15

16. CM Essential Functions Assisting patients in problem-solving issues related to the health care system, financial and psychosocial barriers. 16

17. CM Essential Functions Ongoing evaluation/documentation of patient progress/risk status and appropriate scheduling of care manager interventions. 17

18. CM Essential Functions Coordinating care with other care managers across the continuum of care and payers. 18

19. CM Essential Functions Communicating/affirming patient needs, plan of care, and changes in status with the PCP, team and the patient/family. 19

20. CM Essential Functions Developing/managing care coordination systems that support referral, test completion and report receipt, and an integrated plan of care with specialists and other providers across the continuum. 20

21. CM Essential Functions Training of office staff in the coordination of care with specialists and other providers across the continuum. 21

22. Questions? 22