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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
  • Care Management Guidelines
  • Patient Registries
  • Other Tools

Wagner Chronic Care Model


Health System

Resources and Policies

Health Care Organization


Self-Management Support







Practice Team






Functional and Clinical Outcomes

ccm core clinical elements








Care management

Protocols- coordinated care

Clinical information tracking

Feedback to clinicians

CCM: Core Clinical Elements
ccm core clinical elements1







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
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