care coordination process at the center for pediatric medicine - care... · •diagnosis of...

Care Coordination Process

at the

Center for Pediatric Medicine

Blakely Amati, MD

January 20, 2016

Center for Pediatric Medicine

QTIP Team

Blakely Amati, MD Katy Smathers Tammy Gladson, RN

Cindy Garnett

Jenny Kelley, RN

Kristi Caballero Susan Skytte, RN

5 practices

Predominately Medicaid

Population

Affiliated with GHS Pediatric

Residency Program

Level 3 NCQA PCMH Status

New EMR Summer 2015

Ancillary Staff Rich

Close Proximity to

Subspecialists

When to Consider Care

Coordination Referrals

•NICU discharges

•Diagnosed with systemic diseases, syndromes, chromosomal abnormalities

•Multiple subspecialists involved

•Requiring BabyNet and/or therapy services

•Prescribed multiple medications

•Recent surgery

Case Management

• Social concerns that may or may not include Department of Social Service involvement-abuse, neglect, family mental illness, domestic violence. Positive Edinburgh and SEEK screens.

•Newborn with NAS on a Methadone Wean

•Children who need to be referred to outpatient therapies, behavioral and or mental health resources

•Diagnosis of ADHD; need for behavioral modification techniques and parenting tips

Social Work

•Any child with asthma

Respiratory Therapist/Asthma Educator

•Child with a G-tube

•Diagnosis of *obesity* or failure to thrive

•Any child with a specialized diet

Dietician

Case Management Referral

Process

Physicians Social Work Chart

Review/Huddle* At Hospital Discharge

CM performs formal

assessment at next visit

Added to Caseload;

Detailed care plan +/- SMAP

Targeted Intervention;

SMAP

Family declines services

Referred to Complex Care

Center

No follow-up Routine follow-up

Morning Huddle

https://www.stepsforward.org/modules/team-huddles

Case Management Referral

Process

Physicians Social Work Chart

Review/Huddle At Hospital Discharge

CM performs formal

assessment at next visit

Added to Caseload;

Detailed care plan +/- SMAP

Targeted Intervention;

SMAP

Family declines services

Referred to Complex Care

Center

No follow-up Routine follow-up

LOC Coordination Acuity

Indicator Indicator Level I Level II Level III

Medical/Health Management

Managed by PCP and 1 subspecialist (seen 1-2x/yr) (1)

Requires periodic medical specialty consultation (seen 2-4 times/yr) (3)

Requires frequent, complex multi-specialty consultation (seen >4x/yr) (4)

Education/Training Needs Requires minimal E/T (1) Requires moderate E/T (3) Requires extensive E/T (4)

Resource Utilization Indentifies/utilizes resources appropriately (1)

Requires assistance in identification/utilization of resources (2)

Unwilling/unable to identify resources; requires accommodations (3)

Finances Requires minimal assistance with third party funding (1)

Requires moderate assistance (2)

Requires extensive assistance (3)

Problem Solving Skills Good problem identification and problem solving skills (1)

Requires assistance in identifying problems/PS skills (2)

Unwilling/unable to identify problems and solutions (3)

Support Systems Strong SS; SS utilized (1) SS present, may need encouragement in utilizing(2)

SS not present or not utilized (3)

Coping Family coping independently (1)

Able to cope with support and encouragement (2)

Able to cope with extensive support (3)

Transition Transition needs are met (1) Requires minimal assistance with transition (2)

Requires extensive assistance with transition (3)

Level I: 8-13 Level II: 14-19 Level III: 20-26

What CM does for Doctors

• Reinforces to families what was discussed during office visit

• HIGHLY encourages families to call office (or nurse line after-hours) for medical questions to determine ER need

• Follows up with provider about any additional findings from home visits, developmental screenings, etc.

• Notifies provider of observed family dynamics

What CM does for Families

• Provides written developmental information

• Attends well child checks with families; consistent presence

• Provides anticipatory guidance/ parental education

• Supports families through the challenges of raising children and addresses issues parents are facing

• Educates on safety issues

Case Management Referral

Process

Physicians Social Work Chart

Review/Huddle At Hospital Discharge

CM performs formal

assessment at next visit

Added to Caseload;

Detailed care plan +/- SMAP

Targeted Intervention;

SMAP

Family declines services

Referred to Complex Care

Center

No follow-up Routine follow-up

Case Management Referral

Process

Physicians Social Work Chart

Review/Huddle At Hospital Discharge

CM performs formal

assessment at next visit

Added to Caseload;

Detailed care plan +/- SMAP

Targeted Intervention;

SMAP

Family declines services

Referred to Complex Care

Center

No follow-up Routine follow-up

Self Management Action Plan

(SMAP)

Other SMAP Templates: •Compliance issues •Therapy referrals •Social concerns •G-tube dependent •Trach dependent •Feeding difficulties •Asthma •ED Utilization

Case Management Referral

Process

Physicians Social Work Chart

Review/Huddle At Hospital Discharge

CM performs formal

assessment at next visit

Added to Caseload;

Detailed care plan +/- SMAP

Targeted Intervention;

SMAP

Family declines services

Referred to Complex Care

Center

No follow-up Routine follow-up