Care Management 101

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 11th 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