Care Management: Experience from MCHD

1. Care Management: Experience from MCHD Multnomah County Health Department Casey Grabenstein RN, MSN Disease Management Coordinator CareOregon Mindy Stadtlander, MPH Clinical Systems Innovation Program Manager

2. Overview of Multnomah County Health Department • 8 Primary Care Clinics • Specialty HIV Primary Care Clinic • Homeless Clinic • Oregon Refugee Receiving Center • ~45,000 patients generating >170,000 visits • Working on PC Medical Home Initiative since 2007 • On Epic EHR

3. Our Vision Building Better Care Patients have improved health outcomes through a team based approach that is proactive, patient centered, and relationship based. Delivery of care is coordinated and organized to promote and sustain this relationship. Access is centered on patient needs. The environment is one of continual learning and sustaining improvements.

4. Team Based Care • 2 PCPs – 1.3 – 1.8 FTE (MD, NP, or PA) • 1 Team Nurse (RN) • 2 Support Staff (CMA) • 1 Panel Manager (CMA or LPN) • 1 Team Clerical Assistant (non-clinical Office Assistant)

5. Medical Home Journey

6. Chronic Disease Management and Care Management The Chronic Disease Management program is a comprehensive approach to patients with Diabetes: • Medical Standard of Care • Risk Stratification of the Population • Team-based patient engagement • Includes RN Care Management coaching sessions for sub-set of patients • Uses EHR tools to support the process

7. Medical Standard of Care (SOC) • Provider champion developed new standards with leadership support • Changed from diabetes “guideline” to SOC • Providers held accountable for adherence to new standards, except when medically necessary • Clinic leaders review patient charts for adherence

8. Risk Stratification Risk Stratification is the process for grouping patients • By clinical indicators • By social needs • By team discretion

9. Complex Care Care Management Routine Care Risk Stratification: Process and Categories Process: • Teams reviewed patient data together • Assigned appropriate flag to patient • Able to change at any time Categories: • Usual Care • Care Management • Complex Care/Care Elsewhere

10. Risk Stratification Criteria

11. Risk Stratification: Care Management Who fits this approach? Patients who want to engage in their care Patients who can engage Patients who are making progress clinically but need extra support Newly diagnosed patients who need education

12. Risk Stratification Criteria

13. Team Based Patient Engagement • Panel Manager outreach: Calls patient to schedule appointment for gaps in care • Daily huddle: Provider, Medical Assistant (MA) and Nurse review patient needs and care management status • Shared-agenda setting: MA initiates, Provider addresses, Nurse continues (for care managed only)

14. Role of the Nurse: Before Care Mgmt • Triage and walk-in visits • Immunizations, injections, procedures • Medication refills, faxing, phone coverage/team coverage • Protocol-driven nurse visits for blood pressure, INRs, one-time diabetes teaching Juggling many tasks…. …but not at the top of their license

15. Nurse Care Management • Formal referral: • From the Provider; includes care plan • Warm Hand-offs whenever possible • Standard assessments: • Initial assessment, follow-up, and maintenance planning • Promotes adherence to standard of care • Flexibility: • In person or via phone • Frequency of coaching sessions per patient preference

16. Care Management Process Patient self-management = Core Focus • Limit teaching topics • Use shared agenda setting • Maintain the spirit of Motivational Interviewing

17. EHR Tools • Standard SmartPhrases for Nurse/Patient encounters • Formal internal referral to care management • FYI Flags for risk stratification and tracking • Reports: • Caseload report (for Nurses) • Monthly Leadership Report (for review of process) • Dashboards (for review of clinic outcomes)

18. Implementation Barriers and Strategies: “We’ve been down this path before. It didn’t work.” Strategies: • Pilot team developed and tested process • Pilot team members helped with trainings • Pre-trained clinic leadership to support clinic teams

19. Process and Outcome Measures (Diabetes) Process Measures • Percent of diabetes panel risk stratified • Percent of patients with HbA1c every 6 months • Percent of patients with coaching session every 45 days Outcomes Measures • Percent of patients with D3 Bundle under control (A1c, BP, LDL)

20. Disease Management Outcomes

22. What lies ahead? • Continued improvement on the current workflows • Continued build on team care: • Care coordination, local process improvement

23. Key Take-Aways Build around team roles and strengths, and the clinic vision Involve team members in design and development of new processes Support clinic leadership team in sustaining the new process Plan for continued revision

24. Thank You! stadtlanderm@careoregon.org casey.b.grabenstein@multco.us What questions do you have?