Implementing Care Management into Usual Care

1. Implementing Care Management into Usual Care Bea Herbeck Belnap, Dr Biol Hum School of Medicine University of Pittsburgh

2. Learning Objectives 1. To understand the different functions and tools required to effectively implement the Chronic Care Model for depression management in primary care 2. To identify the core roles and qualifications of care managers, particularly as liaisons to providers and for patient self-management support 3. To understand the role and function of care manager registries and their utility in fostering provider and patient communication

3. Wagner Chronic Care Model Health System Community Health Care Organization Resources & Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Functional and Clinical Outcomes

4. Leadership Practice Design Clinical Information Systems Vision Resources Care management Protocols- coordinated care Clinical information tracking Registry Feedback to clinicians CCM: Core Clinical Elements

5. 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

6. Care Manager RoleEncompasses CCM core elements Care Manager Self-management CM/Liaison: PCP, MH Community linkages Crisis intervention Registry General Medical (Chronic care, Prevention, Follow-up) Behavioral Health (crisis referral, complexity, etc.)

7. Care Manager: Core Functions • Patient education • Registry tracking • Provider communication • Community linkages

8. Care Manager: Patients • Patient education about depression, treatment options • Familiar with commonly used antidepressant medications, doses • Support medication adherence and recovery • Brief interventions • Theory-based approaches (MI, PST, etc.) • Monitor treatment progress • Know when treatment is ‘not working’ • Structured symptom assessment (PHQ-9) • 8-12 week trial • Provider recommendations  MHS, PCP

9. CM: Goals of a Registry • Identify, manage, and track patients • Facilitate patient contacts • Provide patient visit summaries • Provide real-time data on tx response, etc. • Reminders • Performance feedback

10. CM: Provider Liaison • Relay concerns/progress • Symptom monitoring • Refills • Symptoms and side effects • Urgent, emergent protocols • Medical record documentation • Cue providers if no improvement • Supplement, not replace providers

11. CM: Community Linkage Cooperation with MHS Supervision Referral Self-help groups Support for comorbidities, psychosocial problems Financial resources

12. Care Management: Patient Support

13. CM: Customization • Cultural competence • Role of families • Role of religion/spirituality • Competing needs

14. 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

15. CM: Self-management Tools • Workbooks • Medication lists • Appointment reminders • Healthy behaviors • Pleasure activities list • Pillboxes • Medication information • Websites

16. Care Management: Provider Communication

17. CM: Provider Liaison • Help patients and providers identify • 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

18. Care Manager: Providers • Tracks depressive sx and treatment response (PHQ-9) • Screens for co-occurring MH conditions • Alcohol use (e.g., AUDIT-C) • PTSD (e.g., PC-PTSD) • Consults with team psychiatrist • Provides follow-up and recommendations to PCP who prescribes antidepressants • Collaborates closely with patient’s (PCP) • Facilitates referrals to specialty, community • Formal and informal connections • Prepares for relapse prevention

19. 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, et al. Bipolar Disorders, 2008 Kilbourne AM, et al. Psychiatric Services, 2008

20. CM: Provider Resource • CMs as a resource for clinic, providers • Dissemination of specific guidelines • Ask providers for suggestions on specific topics • Hold CME, lunches, or disseminate information • Examples • Bipolar disorder in pregnancy • Depression treatment in late life

21. 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

22. Care Management: Registries

23. Care Manager: Registry • Registries are . . . • Simple tools to track patient progress • Integrated into routine clinical care • Easily updated • NOT EMRs • NOT research-focused • Best if “home-grown”

24. Registry Functions • Patient risk stratification • Tracking and management • Patient characteristics facilitating treatment • Acute phase • Continuation, maintenance • Performance feedback • Patient process and outcomes

25. Registries • Other data sources (e.g., pharmacy, EMR) should NOT replace a registry • BUT can be used to: • Improved patient identification (top conditions) • Enhance performance measurement • Challenges to using electronic data • Cumbersome to update and merge • Time lag • Data not available on all patients • Privacy and security issues

26. Key Registry Variables • Dates • Patient contact information • Best number, time to call, and leave message • Status • No shows • Treatment stage • Current medications (dose, duration) • Self-management materials • Depression severity score, MD assessment • Referral status (MHS, community resources) • Next contact, date

27. 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

28. Care Management: Crisis Intervention

29. 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?

30. CM: Crisis Intervention • Suicidal ideation- coordinate with clinic • Protocols • On-call numbers • Missed appointments • Immediate follow-up

31. Care Management: Implementation Tips

32. Care Manager TimelineInitial 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

33. Care Manager TimelineSubsequent Visits • Registry- ongoing tracking • Reminders for upcoming appointments • Regular contact with providers

34. Implementing Registries • Adequate staffing, who should update? • Research vs. clinical use • Integrating into routine care • How identified patients are entered • Involving PCP • IRB issues

35. Types of Registries • Formats (pros and cons for each) • Excel file • Web-based • Examples • SMAHRT • IMPACT • REACH-NOLA

36. Care Manager Toolbox • Manual: provider interactions • Contacts, location, communication preferences • Medication info • Protocols to ID treatment response, side effects • Manual: patient interactions • Brief interventions (e.g., PST, MI, others) • Crisis intervention • Self-management materials • Medication information • Behavioral change information (e.g., pleasure activities) • Registry file

37. Bottom Lines • The CCM for depression includes key elements • Self-management • Care management • Community linkages • Registries • Guidelines • BUT the CCM is most effective if customized to local settings . . . . .