1. SYSTEMATIC CASELOAD REVIEW (SCR)
Behavioral Health Integration Complex Care Initiative
SYSTEMATIC CASELOAD REVIEW (SCR)

2. What is an SCR?
A regularly-occurring meeting used to provide frequent updates and changes in management to a defined population.
Systematic Caseload Review (SCR) is also known as: Systematic Population Review and Systematic Care Review (SCR).
An SCR is a meeting that occurs during a carved-out time during which the multi-disciplinary team systematically discusses a large number of prioritized patients within the target population.
The entire target population is not discussed, just the subset that is in greatest need of attention.

3. What is an SCR? Patients are prioritized for discussion based on need.
Priority is given to newly enrolled patients, and those with the most significant challenges, or who are not improving as expected.
The objective of the SCR is to develop a “to-do” list for each patient discussed of action items that correspond with changes in health and disease management. This should include a timeline for accomplishing these tasks, as well as when the team will discuss the patient again.
We’ll share some examples of action items during this presentation.
Patients are prioritized for discussion based on need.
The multi-disciplinary care team discusses each prioritized patient case.
A list of action items is created for each patient.

4. What an SCR is Not? It is not a team huddle.
It is not a treatment team meeting.
It is not Supervision.
It’s not a meeting where one patient is discussed, and it’s not a meeting where the day’s schedule is reviewed. It is its’ OWN thing and with a focus on population management.

5. Why do an SCR?
An SCR is an efficient way to discuss your most vulnerable patients on a frequent basis, and make changes in treatment to improve health and wellbeing.
Also a way to make sure that patients who are not showing up for care or those who are doing poorly do not fall between the cracks.
There may be several other occasions to discuss patients, i.e. during huddles, by staff messaging, or by grabbing other team members in the hall, but this is a way to ensure that the population is being cared for.

6. How do we decide whom to discuss?
Team members (CM, BH clinician) review caseload in patient registry and identify patients who are new to BHICCI and those who are not improving.
Clinics can use other internal resources such as reports on ED or hospitalization to identify patients for discussion at the SCR.
The Dashboard and Patient Review tabs can be used to identify patients who are not improving and would benefit from team review and assessment during SCR. You can flag these patients for review in the registry.

7. SCR: Nuts-and-Bolts
WHO – The core BHICCI team including: PCP champion, RN care manager, BH clinician, and care coordinator.
WHERE – A private space ideally with phone and computer access.
WHEN – At minimum 1 hour 2x a month, but preferably 1 hour weekly.
This will be the PCPs favorite meeting of the week! I am really excited for you all to begin this phase of work. The SCR is a new way of taking care of patients and provides is an incredible opportunity to have protected time to discuss the individuals whom you have been most worried about, and to do so with a multi-disciplinary team.
Typically the other members of the team have more opportunities to discuss patients, so the SCR is a way to bring the PCP into the loop in a very structured way.
WHO - May also include: psychiatric consultant, MA, and others.
WHERE - A private space that can accommodate the team and has phone and computer access to facilitate review of the EHR and/or Registry.
WHEN – Often works best to prioritize this meeting first thing in the morning or first thing in the afternoon to minimize the chance of the time getting taken over by other pressing demands.

8. How do we prepare for the SCR?
Identify the:
Meeting leader
Laptop bringer
Timekeeper
Note taker
Identify a leader who runs the meeting and who will give direction for which team member presents first, second, etc. The individual who runs the meeting is also responsible for working with the team to figure out which patients need to be discussed given competing priorities, and identifying other team members who can help keep the meeting running smoothly, i.e. who will bring the laptop, etc. The meeting leader will likely be a Care Manager but could be another member of the team.
Identify a time keeper to ensure you are able to stay on track and get through the patients you have to review.

9. What does the hour look like?
New patients are discussed first.
Follow-up patients are discussed second, and typically take less time.
A “to-do” list is generated for each patient that captures the team’s action items and next date of review. This “to-do” list is entered in the EHR and registry.
The presenters are the team members who have caseloads, typically the BH clinician and RN Care Manager, but a Care Coordinator may have a caseload.
Aim to spend 5-7 minutes on new patients, and 2 minutes or less on follow-ups.
Remember this 5-7 minutes includes the case presentation and discussion time
Initially, it will take longer to present and discuss patients, so the team may only be able to get through 5-10 patients in one hour. However, as the team gets more comfortable with the case presentation, you’ll be able to discuss up to 20 patients in one hour (which is the goal!).
Action item examples:
Team member a (Care Coordinator) will arrange for the patient to get a medi-set by next Monday.
Team member b (RN) will do med reconciliation and try to get a more thorough understanding of what medications the patient is actually taking during the visit scheduled next week.
Team member c (MD) will change the dosage of BP medication and order labs today.
In addition to the “to-do” list, a date will be noted to discuss the patient again, i.e. “We will talk about this person again on March 4th.”

10. How do we know what to present at SCR?
Team members prepare brief (2-3 min.) case presentations that provide pertinent information that will allow the team to make an assessment.
A template can be helpful to create structure and consistency across team members.
The success of an SCR is heavily impacted by the case presentation both in terms of the number of the cases you can discuss (i.e. keeping presentations brief), and the ability of the multi-disciplinary team to make an assessment based on the information provided.
So keep it short, but not so short that you miss important details!
Because of the importance of the case presentation, we are going to take the rest of the hour to discuss and practice an effective case presentation.
To start with, we suggest using a template to provide structure and consistency across team members. This is something that you can adapt and tailor to the needs of your team. You will want to continue to modify over time.
We have an example of a template that you can use as a starting place, and we will pass this out for you to use in the exercise.

11. How do we know what to present at SCR?
A case presentation has three components:
Primary concerns: both yours and the patient’s,
Data associated with the conditions that are being monitored by the team, and
Your initial suggestions for action items to initiate team discussion.
There are three key elements to the case presentation.
The first, is to clearly communicate the primary concerns, not only yours as a clinician, but the most important concerns that the patient has
Secondly, it is important to provide clear and concise data that is associated with the conditions that the team is concerned with. This would include BH measures, as well as physical health measures. It also includes medications and dosages, and pertinent dates such as last visit by provider, last hospital and ED visits
The last piece to provide, is some initial action items to propose, and this serves as a good jumping off place for the ensuing discussion.
EXAMPLE:
38 year old Spanish-speaking male with poorly controlled diabetes, food insecurity, and social isolation whose primary concern is lack of employment and estrangement from his family
His BP is 142/85, Hba1c is 10.8, BMI is 25, PHq-9 12, he was last seen in clinic 9 months ago and has been to the ED 5 times in the last 3 months.
His isolation and lack of employment are exacerbating his underlying depression and I have referred him to a job training program and plan to check back with him on how this went when in 2 weeks. Will also continue to discuss strategies to reconnect with his cousin who lives in neighboring town

12. Work together to Improve
EXAMPLE: Perhaps the doctor also would want to know all of the medications he is on, not just the meds for DM (i.e., is he on BP meds). His BP is slightly elevated…is he is taking medications irregularly?
Keep in mind that it takes many weeks to months of tweaking and working with the team members to come up with the template that is right for your team. This process of refining is significantly streamlined when team members expect and welcome feedback, and the feedback is provided in a respectful manner.
Expect modification!
Important to keep in mind that everyone on the team has the same goal:
to share enough information with the team so a clear story is depicted and action plans can be made, and
to allow this process to include a relatively large number of individuals in one hour’s time.
Fine-tune case presentations.
Balance the amount of information needed with the amount of time available to discuss patients.

13. Exercise
Now, we’re going to do an exercise which allows you to spend some time practicing the development and delivery of case presentations
For those of you who have already begun this process, you can use this as a time to hone your skills.
For our exercise, we want you to pair up with someone who has a different area of expertise from your own (ie, BH Clinician with RN or clinic manager)
We have two vignettes prepared and we will pass out copies of the vignettes. Use these examples to get started – feel free to get creative and add other pieces of information based on real patients you know. As you’re developing an idea of an individual, think about what their goals and barriers might be and include that in your presentation.
Have each person in the pair select one of the vignettes and prepare a 2-3 minute case presentation drawing on what you think is the most important information for the team to have to make an assessment.
Keep in mind the three elements described earlier, and we will keep that slide up in the front of the room as a reminder.
We will spend 10 minutes on this, and then come back together to share learnings
What did you learn from this exercise?
What do you plan to do differently based on your experience with this exercise?

14. What’s next? Create and test a case presentation template.
Check in with your Practice Coach.
Stay tuned for more information about the SCR core competency webinar.