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