November 2012 Webinar

1. November 2012 Webinar Data Review Risk Stratification Working with Specialists

2. Data Review How are we doing in each region?

3. Why Trending Wrong Way?

4. Things to Consider • Self management support • Who are these patients? • Have they been in recently? • Depression screening? • Need to start insulin? • Diabetes educators

5. GREAT JOB! What’s working?

6. WOW! …How Can We Build on Success?

7. How Can We Close the Gap?

8. LDL Control Tips • Lowers risk of heart disease and STROKE • Can get non-fasting lipids • What % on statins vs. need to titrate more? • Most myalgias not from statin

9. Risk Stratification Key to Your Return on Investment

10. Why risk stratify? • Identify patients with highest needs – prioritize. • Utilize limited practice resources effectively. • Use to determine visit frequency. • Maintain access to care. • Biggest bang for the buck is to focus on high risk! • Prevent unnecessary transitions in care for the patient (ER visits and hospitalizations) – prevent sentinel events. • Decrease the utilization of resources downstream. • Decrease the overall cost of care. • Shift resources to PCP.

11. Delivery System Design • Define roles and distribute tasks among team members. • Give “planned care” at every visit — planned interactions that routinely use evidence-based care. (Team and MD/Provider Role) • Intensify patient medication if goals not reached —stepped care. (MD/Provider Role) • Follow-up care for medium/high risk patients. (MD/Provider and Team Role) • Care management intervention for highest risk patients. (Care Manager Role) • Give patient-centered care that patients understand and that fits their culture.

12. Care Management • Someone whose job is to work with high-risk patients. • Usually a nurse. • Who in your practice can do this? • Good people skills • Good listener • Problem solver • Empathetic

13. Decision Support • Utilize standing orders for team members. • Use stepped care protocol for medications. • Integrate specialist expertise and primary care. • Complete risk assessment at every visit.

14. BOTTOM LINE:YOU ARE TRYING TO IDENTIFY YOUR SICKEST 5-10%.

15. Risk Criteria • Degree of Disease Severity- PICK A NUMBER AND DO SOME CALCULATIONS • BP • A1c • LDL

16. Other Factors to Consider • Utilization Frequency • Office Visits • Phone calls to the office • ER visits • Hospitalization • Self-care Deficit • Taking of meds • Following diet • Activity • Social Issues • Phone • Transportation issues • Lack of support at home • Lack of resources $$$$$

17. High Risk Patient Categories • Patients with hospital admissions and ER visits. • Patients with co-morbidities. • Patients with depression. • Patients with functional or cognitive issues. • Patients who have high utilization rates for office services(e.g., frequent visits, phone calls).

18. Looking at Your Highest Risk • A1C >9? • LDL >130? • BP >160/95? • Calculate how many you have? • Maybe you need to start even higher. • Have they been seen in last 6 months? • BRING THEM IN! • What can be done different? • SELF-MANAGEMENT SUPPORT!

19. S TE P 4 Identifying Patients at Highest Risk, Determining Need, Initiating Care Manager Intervention STEP 3 Getting Medium and High Patients in for Follow-up Visits Step-wise Approach to Risk and Intervention Stratification STEP 2 Giving DM Planned Care at Every Visit STE P 1 Building Registry Functionality for Patients with DM

20. A Few Risk Stratification Tools Ninth Street Internal Medicine Birdsboro Family Medicine

22. Birdsboro Family Medicine

23. NCQA Requires Risk Stratification and Care Management PCMH 3: Plan and Manage Care

24. PCMH 3: Plan and Manage Care • Element B: Identify High-Risk Patients • Factor 1: Establish criteria and a systematic process to identify high-risk or complex patients. • High resource use (visits, medications, costs) • Frequent urgent care/ER visits (2+ in 6 months) • Frequent hospitalizations • Multiple comorbidities • Noncompliance with prescribed treatment, meds • Terminal illness • Psychosocial issues (social, financial support) • Advanced age, frailty • Multiple risk factors

25. PCMH 3: Plan and Manage Care • Element B: Identify High-Risk Patients • Factor 2: Determine the percentage of high-risk or complex patients in your patient population. • Must show criteria and process for selecting. • Must provide report showing numerator/denominator and percentage of high-risk or complex patients.

26. PCMH 3: Plan and Manage Care • Element C: Care Management [MUST PASS!] • Based on sample of high-risk patients identified. • Must: • Do pre-visit planning. • Develop individual care plans and review/update at each visit. • Give patients written plan of care. • Assess and address barriers when goals not met. • Give patients clinical summary at each visit. • Identify and refer patients to community resources. • Follow up with missed appointments.

27. Questions?

28. Working with Specialists It’s All About Communications!

29. Communications • 62% of PCPs report getting consults from specialists. • 81% of specialists report sending info to PCP. • Lack of clarity of respective roles. • 69% PCPs provide history and reason for consult ‘always’ or ‘most of the time.’

30. Definitions • Referral: transfer of care • Consultation: one-time or limited time • Collaboration: ongoing co-management

31. Using Consultants Effectively • When to consult: • Trouble making a diagnosis • Specialized treatment • Goals of therapy not met • Make your consultants partners • 1st principle of partnership - communication • Communication begins with you • Ask a specific question • Specify type of consult: ongoing (referral), one time only, duration of specific problem Adapted from material by Steve Simpson, MD, at Kansas University.

32. Example of an Agreement: Primary Care Side Primary Care State that you are requesting a consultation. The reason for the consultation and/or question(s) you would like answered. List of any current or past pertinent medications. Any work-up and results that has been done so far. Your thought process in deciding to request a consult. What you would like the specialist to do. Source: HealthPartners, MN

33. The Specialty Side Specialty Care State that you are returning the patient to primary care for follow-up in response to their consult request. What you did for the patient and the results. Answers to Primary Care Physician questions in their consult request. Your thought process in arriving at your answers. Recommendations for the Primary Care Physician and educational notes as appropriate. When or under what circumstances the Primary Care Physician should consider sending the patient back to you. Source: HealthPartners, MN

34. Questions?

35. Upcoming Meetings • December Webinar • Thursday, December 20: 12-1pm • PDSA Sharing and some fun;) • January Learning Sessions • South Central: Tuesday, January 22 5-9pm, Penn State Hershey Conference Center • Northwest: Tuesday, January 29 5-9pm, Location TBA

36. Here to help you! • South Central – Sharon Adams 814-344-2222, sadams@scpa-ahec.org • North West – Patty Stubber 814-217-6029, pstubber@nwpaahec.org