Care Management and Clinical Decision Support: The Foundation for a Strong Office Practice March 1, 2007

1. Care Management and Clinical Decision Support: The Foundation for a Strong Office PracticeMarch 1, 2007

2. Objectives for Today • Define Care Management and Clinical Decision Support and their interrelationship • Review three activities that support care management • Suggest strategies to implement Care Management in a small physician office practice

3. Care Management – Not a destination! • A key component in caring for patients –it is an ongoing process • Assists in improving the patient’s health status and functional capacity • Benefits many – • Individual patient • Family and caregivers • The office practice • The larger health care system • Eliminates waste and enhances efficiency

4. The Care Model • Care Management incorporates the components of The Care Model • Organizes delivery of care to meet the six Institute of Medicine quality goals: • efficient • equitable • safe • effective • patient centered • timely ICIC is a national program supported by The Robert Wood Johnson Foundation with direction and technical assistance provided by Group Health Cooperative's MacColl Institute for Healthcare Innovation

5. Care Management—Improving Care Culture Change Draft 4 Improved Practice HIT HIT Plan ClinicalDecisionSupport Office Workflow Redesign Caregivers Patient Do Act Care Team Study HIT Improved Patient Outcomes HIT Self- Management

6. Care Management • Evidence-based, integrated clinical care activities that are patient-specific and ensure that every patient has a coordinated plan of care and services. • The care plan, developed collaboratively by the patient and care providers, is designed and executed to optimize the patient’s health status and quality of life.

7. Key Activities—Enablers • A well-executed care management program must be designed and implemented in a manner that is consistent with the long-term sustainability of the practice.

8. Patient Specific Patient Engagement Assessment Planning Implementation Evaluation and Measurement Coordination Practice Specific Office Redesign Population Identification Adoption of Health Information Technology Adoption of Clinical Decision Support Adoption of Coordination Tools Population Data Measurement 2 Types of Activities / Enablers

9. Patient Engagement (Patient Specific) • Use tools, services and approaches to maximally engage patients and their families in their own care and to support self-management. Elements include: • Relationship building • Exploring patient’s needs and values • Education • Collaborative goal setting • Action planning • Problem-solving • Socioeconomic sensitivity • Assessing competency • Addressing language barriers • Linkage to community supports • Use of new ways of delivering care (e.g. planned visits/group visits)

10. Assessment (Patient Specific) • Assess each patient initially, periodically, and at critical junctures.  • Elements include: • The patient’s clinical condition • Feasibility of completing various interventions • Patient’s values, preferences and readiness to engage in self-management and treatment

11. Planning (Patient Specific) • Create an individualized care plan • Balances best practices for managing the targeted condition(s) with feasibility and patient preference • Optimizes outcomes

12. Implementation (Patient Specific) • Provide services required to implement the care plan • Arranging follow-up and referral • Continually fine-tuning the plan as needed

13. Evaluation and Measurement(Patient Specific) • Measure services and interventions offered • Reason for implementation or non-implementation • Modification and outcomes

14. Coordination (Patient Specific) • Utilize care strategies including health information technology and other tools to communicate and coordinate • with the patient • with other caregivers • Ensure that the care plan is executed safely and efficiently

15. Office Redesign (Practice Specific) • Design and implement new activities and workflows • Increase patient engagement • Improve staff productivity • Optimize financial and clinical efficiency

16. Population Identification (Practice Specific) • Select common clinical conditions • Target cohorts on which to focus in your patient population

17. Adoption of Health Information Technologies (Practice Specific) • Obtain and implement technologies such as EHRs, registries and reporting systems to facilitate data capture, patient tracking and outcomes review

18. Adoption of Clinical Decision Support (Practice Specific) • Deploy electronic and non-electronic tools to effectively make use of best practices and evidence to help guide care efficiently and correctly

19. Adoption of Coordination Tools (Practice Specific) • Design and implement communication and care coordination tools • Ensure that care is consistent among a patient’s many clinicians • Ensure care is consistent for patients between the office and home

20. Population Data Measurement (Practice Specific) • Report on health status, quality metrics, and outcomes for the target population across the practice

21. What is Clinical Decision Support (CDS)? • Providing clinicians or patients with clinical knowledge and patient-related information • Intelligently filtered, or presented at appropriate times • To enhance patient care

22. What is Clinical Decision Support? • Clinical knowledge of interest could include: • Simple facts and relationships • Established best practices for managing patients with specific disease states • New medical knowledge from clinical research, and many other types of information Improving Outcomes with Clinical Decision Support: An Implementers’ Guide. Osheroff JA, Teich JM, Pifer EA, Sittig DF, Jenders RA. 2005. Healthcare Information Management and Systems Society

23. 5 Rights of Clinical Decision Support 1.The right information • evidence-based where evidence is available, responsive to the need at hand, practical to implement, ideally context and patient-specific, current, etc. 2.To the right person • including all those involved in providing care to the patient as well as the patient and their caregivers as appropriate

24. 5 Rights of Clinical Decision Support 3. In the right intervention format • alerts, guidelines, data presentations, reference information, order sets, documentation template or flowsheets, whichever is most appropriate to the situation at hand 4. Through the right channel • via clinical information systems, mobile devices, desktop workstations, the internet, etc. 5. At the right point in workflow • at an opportune time to influence a key decision or action without negatively impacting flow

25. CDS Facilitators • Multidisciplinary forms • Condition specific forms/templates • Patient specific tools – data and graphs, care plan • Real time alerts – based on guidelines • Order entry • Order sets – disease specific • Links to resources on the web

26. Getting Started • Assess what you’re currently doing • Identify the target population and area of focus • Evaluate the flow and decide where you can make a change • Self Management strategies to engage the patient • Include the whole team in your redesign!!

27. What are you currently doing? • Use a simple tool • Is the functionality present? • Are they using the functionality?

28. Assessment of Care Management Activities • Do you generate lists of eligible patients for each disease? • Do you generate a list of patients requiring intervention? • Do you prompt clinicians to order lab tests? • Do you prompt clinicians to order immunizations and other services? • Do you produce reminders for patients about needed lab tests?

29. Assessment of Care Management Activities 6. Do you produce reminders for patients about immunizations and other services? • Do you prompt clinicians and patients to review self-management plans during office visits? 8. Do you generate specific care plans for your patient’s ongoing care? 9. Do you create written action plans that are personalized to the patient’s condition? 10. Do you modify self-management plans as needed as follow-up to the patient’s visit?

30. Identify the target population and area of focus • Initial stratification based on diagnosis or problem list • Pick the population and dig deeper • Specific medication use • Lab values

31. Evaluate the flow

32. Alerts & Evidence Based Guidelines

33. Flow Sheets and Alerts • Key criteria for a specific condition • Triggers based on diagnosis or from a core use template • Color coded to assist in identification of overdue labs or procedures

34. Diabetes Specific Treatment Plan

35. Care Plan - Templates Self-Management Action Plan Clinical Care Plan

36. Care Plan Example John Doe 10-12-1964 MRN Healthy Living Goals (Includes all parts of plan that are specific patient behaviors) • Healthy Eating—I will focus on carb counting each day at dinner • Healthy Eating—I will keep a food record for 3 days in a row and bring to next visit • Follow monitoring schedule • Follow meal plan • Make better food choices • Reduce fat intake

37. Care Plan Example (continued) Clinical Plan: • Diabetes • Refer to Medical Nutrition Therapy • Refer to DSMT • Blood Pressure • Begin home BP monitoring once daily or “x” times weekly at home • Labs Today – Lipid profile, CBC, Urine, Microalbumin • Future Labs – A1c • Medication changes/update -Changes to medications – stop/start/increase/decrease; include insulin

38. Follow Up Appointments: Care Plan Example (continued) This plan has been mutually determined and agreed upon with myself, Lauren, Jones, Hospital Care Partner and the Dr. Winter. I commit to doing my best to follow my care plan. I know who to contact in the event I have any questions.

39. Care Plan Example (continued)

40. Care Plan Example (continued) • Insulin Prescription All insulin doses in units

41. A Care Plan Example (continued) • Current Medications

42. A Care Plan Example (continued) Resources/How to Reach us Clinical Support - 617-222-3333 • Jane Richards, MA • Lisa Rogers, MOC • Tabitha Stevens, MOC • Jessica Littlehale, MA Patient Care Coordinator • Lauren Jones RN, CDE 617-222-3333 Physician – Dr. Bob Nickles Nurse Practitioner – Hope Miller, ANP Appointments - 617-222-4444 to schedule or cancel appointments

43. Strategies for Success • Don’t just collect data – measure something meaningful and know how you got it • Share your data often and in a user friendly format • Make it easy for providers to do the right thing – forms, prompts, reports • Involve providers, staff and patients through out the process. Don’t rely on just one person or group to achieve the goal, share responsibilities • Change your model – engage the patient – share the standards and their own information. Help them to be prepared and proactive

44. Questions?