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Helping our Patients Know What to Expect: Tools from the ABC Medical Home

Helping our Patients Know What to Expect: Tools from the ABC Medical Home . Michael A. LaMantia, MD, MPH Medical Director, Aging Brain Care Medical Home Assistant Professor of Medicine Center Scientist, IU Center for Aging Research Research Scientist, Regenstrief Institute. Team:.

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Helping our Patients Know What to Expect: Tools from the ABC Medical Home

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  1. Helping our Patients Know What to Expect:Tools from the ABC Medical Home Michael A. LaMantia, MD, MPH Medical Director, Aging Brain Care Medical Home Assistant Professor of Medicine Center Scientist, IU Center for Aging Research Research Scientist, Regenstrief Institute

  2. Team: • Malaz Boustani • Mickey Vogel • Ebony Rich • Jane Brooks • Samantha Seright • Cathy Alder • Michael LaMantia

  3. Outline of Presentation • ABC Medical Home: Brief Overview • Our Problem • Questions for our Consultants • Proposed Solution to the Problem (in 3 parts) • Feedback/Comments

  4. Overview: ABC Medical Home • Grew out of Healthy Aging Brain Center • Started October 2009 • Incredible Growth: • July-December 2011: Add new medical director and SW • January-June 2012: Add 2nd NP • July 2012: Begin CMS Innovation Grantto expand our services to 2000 patients with dementia or depression across Marion County served by the Wishard Health System • Will employ 20 care coordinator assistants, 4 care coordinators (NPs), and 2 SWs in 4 teams

  5. Overview: ABC Medical Home • Focus: • Dementia/Cognitive Impairment • Depression • Acute Care Utilization • Tools: • eMR ABC • Allows case management and population health management • HABC Monitor • Assesses caregiver stress and patient behavior • PHQ-9 • Gauges patient depression • Mobile Office • Meet patients and caregivers in their homes

  6. Caregiver Counseling & Self-Management Consultants: HABC & Midtown Access, Coordinate, e-Feedback, & Deliver Community Resources ABC Med Home: Interactions Access, Coordinate, e-Feedback, & Deliver The ABC Medical Home Team Access, Coordinate, e-Feedback, & Deliver Access, Coordinate, e-Feedback, & Deliver Primary Care Physicians

  7. Our Problem • Feedback from patients: • Confusion about how our program is related to other Wishard programs • Confusion about who to call in the office for specific needs • Sense that they (patients) may not know where to turn when facing urgent medical issues • Patients medications become incredibly “mixed-up” around ER visits and hospitalizations

  8. Advice Needed • We need help with the following questions: • Are the tools we developed likely to be useful? • Are there other tools that we should develop instead or in addition? • Should these tools be presented in a different format?

  9. Our Proposed Solution • 3 products: • 2 brochures and • Vial of Life

  10. A Solution in 3 Parts • Brochure 1: • Who to Call in the Program • Provides Key Names and Numbers • Provides Overview of How to Make Appointments • Provides Outline of Program’s Role and How We Interact with Patient’s Doctors

  11. A Solution in 3 Parts • Brochure 2: • What to Do in a Crisis • Where you can get help • Who you can speak with • When you should definitely go to the ED • How to Navigate the ER/Hospital & What to Expect • Provides tips on what to bring • Outlines role of most commonly encountered providers • Points out ways patients/caregivers can advocate for themselves

  12. A Solution in 3 Parts • Vial of Life: • Critical Information for Emergencies • Med List • Allergies • Major Diagnoses • Family Names/Contacts • Doctor’s Names/Contact • Advance Directives

  13. Feedback • Are the tools we developed likely to be useful? • Are there other tools that we should develop instead or in addition to these? • Should these tools be presented in a different format?

  14. Thank You! Contact info: Michael LaMantia, MD, MPH malamant@iupui.edu

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