Systems support care management protocols disease registries and other tools
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Systems Support: Care Management Protocols, Disease Registries, and Other Tools. Amy M. Kilbourne, PhD, MPH VA Ann Arbor Serious Mental Illness Treatment Research and Evaluation Center Department of Psychiatry, University of Michigan. SMITREC Mental Health Services Research Group.

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Systems support care management protocols disease registries and other tools

Systems Support:Care Management Protocols, Disease Registries, and Other Tools

Amy M. Kilbourne, PhD, MPH

VA Ann Arbor Serious Mental Illness Treatment Research and Evaluation Center

Department of Psychiatry, University of Michigan


Smitrec mental health services research group

SMITRECMental Health Services Research Group

  • Chronic Care Model- chronic mental illness

  • Quality improvement interventions to improve medication adherence

  • Mental health performance measures

  • Primary Care – Mental Health Integration Program

  • Substance abuse in primary care

  • Predictors of suicide

  • Aging and preventable mortality

  • National VA Psychosis Registry

  • National VA Registry for Depression


Implementation

Implementation

  • Care Management Guidelines

  • Patient Registries

  • Other Tools


Systems support care management protocols disease registries and other tools

Wagner Chronic Care Model

Community

Health System

Resources and Policies

Health Care Organization

ClinicalInformationSystems

Self-Management Support

DeliverySystem

Design

Decision

Support

Prepared,

Proactive

Practice Team

Informed,

Activated

Patient

Productive

Interactions

Functional and Clinical Outcomes


Ccm core clinical elements

Leadership

Practice

Design

Clinical

Information

Systems

Vision

Resources

Care management

Protocols- coordinated care

Clinical information tracking

Feedback to clinicians

CCM: Core Clinical Elements


Ccm core clinical elements1

Decision

Support

Self-management

Support

Community

Resources

Guidelines

Expert/specialist consultation

Patient preferences

Information on treatment

Information on and for consumers, groups, etc.

Access to non-provider sources of care

CCM: Core Clinical Elements


Care manager role

Care Manager Role

Care Manager

Self-management Liaison: PCP, MH

Crisis intervention

General Medical (Chronic care, Prevention, Follow-up)

Behavioral Health (crisis referral for ICM, etc.)


Care manager skills

Care Manager: Skills

  • Tracks depressive symptoms and treatment response (PHQ-9)

  • Consults with team psychiatrist

  • Collaborates closely with patient’s primary care provider (PCP)

  • Provides follow-up and recommendations to PCP who prescribes antidepressants

  • Facilitates referrals to specialty, community

  • Prepares for relapse prevention


Care manager skills1

Care Manager: Skills

  • Familiar with commonly used antidepressant medications, doses

  • Patient education about antidepressants

  • Support antidepressant medication adherence

  • Know when treatment is ‘not working’


Cm self management

CM: Self-management

  • Eliciting concerns/barriers

  • Problem-solving

  • Providing information

  • Clarifying preferences

  • Encouraging informed decision-making

  • Teaching skills

  • Monitoring progress

  • Reinforcing self-management

  • Community resources


Cm self management tools

CM: Self-Management Tools

  • Medication lists

  • Pillboxes

  • Appointment reminders

  • Healthy behaviors

  • Pleasure activities list


Cm therapeutic alliance

CM: Therapeutic Alliance

  • Cultural competence

  • Role of families

  • Role of religion/spirituality

  • Competing needs


Cm liaison

CM: Liaison

  • Relay concerns/progress

    • Refills

    • Symptoms and side effects

    • Urgent, emergent protocols

    • Medical record documentation

  • Cue providers if no improvement

  • Supplement, not replace providers


Cm liaison1

CM: Liaison

  • Help patients and providers ID

    • Potentially inadequate doses

    • Ineffective treatment (e.g., persistent depression after

    • Adequate duration of antidepressant trial)

    • Side effects

  • Facilitate patient-provider (e.g., PCP) communication about antidepressant medications

  • Consult about medication questions


Examples of cm provider contact

Examples of CM-Provider Contact

  • Medication toxicity, cross-reactivity

    • Notifying provider of patient concerns, follow-up

  • Fatigue, physical symptoms

    • CM prompted provider to call pt. after missed appt

  • Managing multiple medications, depression, diabetes, and HT (medication lists, pillboxes)

  • Alcohol use and grief management

Kilbourne AM. Bipolar disorders, in press 2008

Kilbourne AM. Psychiatric services, under review, 2008


Provider communication tips

Provider Communication Tips

  • Obtain preferred mode of communication

  • Emphasize as a supplemental service

  • Focus on providing information on changes in treatment response, side effects, etc to inform decisions

    • Baseline, Current PHQ

    • Length of time on medications

    • Problematic symptoms/side effects

  • Adequate contact, but don’t overdo it


Cm crisis intervention

CM: Crisis Intervention

  • Suicidal ideation- coordinate with clinic

    • Protocols

    • On-call numbers

  • Missed appointments

    • Immediate follow-up


Cm suicidal ideation

CM: Suicidal Ideation

If the patient articulates thoughts death/suicide:

  • Where are you now?

  • What is your phone number at the location?

  • Are you alone or with someone?

  • Do you have a plan of how you would do this?

  • Do you have these things available (guns, pills)?

  • Have you actually rehearsed or practiced how you would do this?

  • Have you attempted suicide in the past?

  • Do you have voices telling you to harm or kill yourself?


Care manager registry

Care Manager Registry

  • Registries are . . .

    • Simple tools to track patient progress (K.I.S.S.)

    • NOT EMRs

    • Best if “home-grown”

  • Facilitate structured patient contacts

  • Types of registries, pros and cons

    • Excel file

    • Web-based


Developing registries things to know

Developing RegistriesThings to Know

  • Know your stakeholders and get their input (purchasers, payers)

  • Know your population- case mix, location

  • Know your key data sources

    • What is in the administrative datasets?

    • Do they capture utilization?

  • Know what information technologies are available and whether they can be tailored

    • Web-based patient health risk assessments


Developing registries things to know cont

Developing RegistriesThings to Know (cont.)

  • Know your end users (e.g., care managers, clinic staff, providers), including their work flow, and ensure they can work with the registry on a day-to-day basis

  • Know what stakeholders want in terms of outcomes: What quality and cost measures are they interested in, and use registry to enhance performance measures


Registry sample fields

Registry: Sample Fields

General information (update at each contact):

  • Patient contact info, including emergency contact

  • Providers

  • Best time to call/OK to leave message?

  • Plan to keep then safe/calm

    Contact (Encounter)-specific information:

  • Contact or visit date

  • Current Mood, Speech, Comorbidities

  • Current medications/OTCs, refills needed?

  • Medications not taking and reason

  • Symptoms and side effects

  • Health behaviors (sleeping, drug use, smoking ,exercise)

  • Job/personal problems

  • Education provided

  • Access/barriers, provider engagement

  • Next appt


Registry examples

Registry Examples

  • SMAHRT

  • IMPACT


Care manager toolbox

Care Manager Toolbox

  • Self-management materials

  • Antidepressant medication list

  • Registry file

  • Provider contact sheet

    • Preferences

    • Crisis intervention

  • Operations manual


Care manager initial visit

Care Manager Initial Visit

  • Rapport- providers

  • Patient initial intake

    • Contact preferences

    • Crisis and urgent care protocols

  • Assessment

  • Discuss treatment options / plans

  • Coordinate care with PCP

  • Start initial treatment plan

  • Arrange follow-up contact

  • Document initial visit


Care manager subsequent visit

Care Manager Subsequent Visit

  • Upcoming appointments

  • Registry- ongoing tracking


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