1. Care Management 101 Governor's Office of Health Care Reform October 28, 2010 Cathy Gorski, RN, BS, CCM

2. What is Care Management ? Care Management Programs apply systems, science, incentives, and information to improve medical Practice and assist consumers & their support systems to become engaged in a collaborative process to manage medical / social/ mental health conditions more effectively. The goal is to achieve optimal level of wellness & improve coordination of care while providing cost effective, non-duplicative care. R. Mechanic. Will Care Management Improve the Value of U.S. Health Care? Background Paper for 11 th Annual Princeton Conference

3. Care Management Key Components Identification Triage Assessment –Barrier Analysis / –Problem Identification Planning and Intervention –Plan of Care (POC) Evaluation

4. Case Selection Focus on patients who would benefit from CM services. Criteria may include : –Low functional status or cognitive deficits –Chronic, catastrophic or terminal illness –Repeated admissions/ER visits –Need for admission or transition to a post-acute facility. –Use of multiple services/providers/agencies

5. Assessment Document the assessments using standardized tools. Assessment may include: –Physical/Functional/Cognitive status –Medical history/Current medication use and knowledge –Patient strength and abilities –Family or support system –Spiritual/Cultural/Financial issues –Transitional or Discharge Plan –Transportation capability/constraints –Life Care Planning

6. Identifying Barriers to Care Potential Problems: –Non-adherence to plan of care –Lack of education or understanding of disease, medications –Financial barriers –Lack of support system –Transportation or access issues –Cultural or Health Literacy concerns –High Cost injury or illness

7. Development of the Care Plan With the Patient: –Identify immediate needs, short term goals and on-going needs –Set goals Specific Meaningful ( to member) and measurable Agreed upon and action- oriented Timely –Identify patient’s preferred role in decision-making and expected outcomes –Provide information and resources necessary to make informed decisions. –Ensure patient “buy-in” and agreement of plan –Establish appropriate and realistic actions that will help the patient make progress in meeting goal

8. Implementation of the Plan Develop a written self-management care plan in collaboration with the Patient/Physician Complete medication reconciliation and medication teaching Obtain Specialist diagnosis and recommendations Confirm and/or coordinate testing/appointments and follow up with member that test was completed or appointment was kept. Plan for additional teaching/coordinate home services as needed. Discuss preventive care needs

9. Evaluation of the Plan Have needs been met, goals achieved? Have barriers to care been addressed such that the patient receives the care and medication required? Measure patient satisfaction. Is the patient in the right care setting with adequate support? If the patient is not progressing –Why? –Reassess patient willingness to address this goal –Re-educate and reinforce –Re-negotiate timeline and/or expectations with patient, as appropriate Consider different approach, or “baby steps”

10. Monitoring, Reassessment, and Re-evaluation Monitor readmissions Monitor ER utilization Monitor lab results Monitor compliance with appointments Monitor compliance with and understanding of medications Monitor for new barriers to care and address timely Monitor for changes in status

11. Chronic Care Self Management Key principles –Illness management skills are learned and behavior is self- directed. –Motivation and self-confidence in management of illness are important determinants of patients' performance of self-care. –Patient’s social contacts including family/friends, workplace, and healthcare providers impact ability for self-care. –Monitoring and responding to changes in disease state, symptoms, emotions, and functioning improves adaptation to illness.

12. Chronic Care Self Management Patient interventions focused on: –Decision-making –Healthy behaviors –Self-monitoring –Social supports Agreed upon Patient Self-Management Teaching Plan –Educate patient on disease process and medications use materials –Educate on recommended physician follow-up and screening recommendations –Identify barriers and work with patient on resolving

13. Closing Care Management Ensure patient / caregiver is comfortable with self- management plan Confirm that goals have been met Transition to other support systems as indicated –Consider utilizing health plan disease management and wellness programs and staff –Home care and community support Feel comfortable with “discharging patients’ to self-care –The patient will continue to have access to you through the office and the physician –You can always re-open them if something happens to increase their risk / needs for care management