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Managing the Load

Managing the Load. Connie Sixta , RN, PhD, MBA. Clinical Monitoring. % of panel. Logistical. <5%. Clinical Care Management. Clinical Monitoring. Logistical. 10%. Clinical Follow-up Care. Logistical. 20%. Care Coordination. * Clinical Monitoring.

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Managing the Load

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  1. Managing the Load Connie Sixta, RN, PhD, MBA

  2. Clinical Monitoring % of panel Logistical <5% Clinical Care Management Clinical Monitoring Logistical 10% Clinical Follow-up Care Logistical 20% Care Coordination * Clinical Monitoring

  3. Risk Stratification and Related Interventions Identify Patients with DM in Panel Determine Priority Patient Need Determine Delivery Mode Determine Frequency of Patient F/U with Provider Lab q 3mo Phone F/U Low Risk Patients BP<130/80 A1c <7.0 LDL <100 Q 6 MO Disease Clinic (with Provider) Titration BG Monitoring BP Monitoring Lab q x mo KEY Low risk Medication Advanced Protocol Titration Upward Monitoring Medium Risk Patients BP>130/80 <140/90 A1c >7.0< 8.0 LDL>100<130 Medium risk All Risk per capacity) DM Class DM Education SMS goal High risk Advanced Self-care DM Education SM Support SM Class Monitoring Functional ability Highest risk Group Visits ( with Provider) DM Education SMS goal High Risk Patients BP>140/90 A1c>9.0 LDL>130 Social Worker Q X mo PRN Team management Monitoring (BG, SM Goal, BP) Phone follow-up Q X mo PRN • Highest Risk Patient • BP>210/140 • A1c>9.0 • LDL>200 • Pts in ER • Pts Hospitalized Social Support Transportation $$ for Visit, Meds, co-pays Abuse, etc. PRN as needed Care management Close Monitoring (BG, SM Goal, BP, BMI, etc.) Titration of meds Scheduled phone follow-up

  4. Let’s evaluate the load • Populations • TOC • ER F/U • Office identified (high versus highest risk?) • Volume of patients per each • Level of interventions needed per each…

  5. Who are your top 5% highest risk patients? • Patients with CHF, COPD? • Patients with multiple co-morbidities? • Patients that are older? • Patients that have problems with ADLs? • Other??

  6. Volume: How many highest risk patients are identified ….. • During hospitalization follow-up? • During other transitions of care? • Post ER visits? • During office risk assessments? • Reviewing of utilization? • Insurer high risk data evaluation? • Other?

  7. Characteristics: What level of interventions are required for….. • Patients being discharged from the hospital? • Patients experiencing other TOC? • Patients being followed up after an ER visit? • Patients being identified as highest risk during the office practice? • Patients being identified on the insurer highest risk list?

  8. TOC: Hospital Discharges • Volume: • Highest risk? • High risk? • Medium risk? • Low risk? • Stratifying patients according to interventions: • Continued in-depth assessments • Disease-management education, goal setting • Routine follow-up care – taking meds, office F/U, etc. • Potential for problems minimal • Common complications can be monitored easily • Other??? • Do CM interventions decrease after first call? For which patients?

  9. ER Follow-up Calls • Volume? • In-depth assessment needed? • Interventions needed? • Getting the patient in for an office appointment? • Immediate RN interventions needed --- teaching, medication reconciliation, communication with PCP • What leveling of interventions is possible?

  10. Highest risk patients identified in the office? • Volume? • Who are they? • What do the need? • Who can best help them? • CDE • Social worker • Patient navigator • What continued CM interventions are needed?

  11. Which patients require the most time from the CM?

  12. Which patients require RN-CM interventions?

  13. What level of staff & interventions are needed per population? • TOC Patients • Low risk • Medium risk • High risk • Highest risk ---- to CM registry • ER Follow-up • High risk • Highest risk • Office identified patients • High risk • Highest risk

  14. What can you do to stratify the interventions of highest risk patients? • Patient volume • Patient need – interventions • Stratify the interventions • Based on the intervention needed, who can best meet the need?

  15. Questions?

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