managing client care models of care delivery decision making care allocation communication...
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Managing Client Care
Models of Care Delivery
Decision making Care allocation Communication Management
Traditional Models of Care Delivery
Total Care-Percursor of Primary Care– Home Health– Private Duty– Intensive Care– Nursing Students
Advantage of being client focused-yet, not the most efficient use of staff
Functional Models of Care Delivery
Grew in the 1950’s Manager assigns a medication nurse, treatment
nurse Communication is clearly defined
Efficient model in getting the work done. Also economical
Negative factor is “care is fragmented” and emotional needs of staff an clients are overlooked in the interest of time management and task completion
Contemporary Models of Care Delivery
Restructuring and Redesigning appeared Case Management
– Describes a variety of healthcare delivery systems in acute, long-term and community settings
– This is not new…Public Health has used this since the early 1900’s and Mental Health since 1960’s
Chronic Care Management Design
Pioneered by Edward H. Wagner, MD, MPH and colleagues at MacColl Institute for Healthcare Innovation at Group Health Cooperative of Puget Sound, Seattle Washington*
Supported by Robert Wood Johnson Foundation**
*Wagner, E.H. (1998). Chronic disease management. What will it take to improve care for chronic illness? Effective Clinical Practice, 1, 2-4.
**Improving Chronic illness Care (ICIC) is a national program supported by Robert Wood Johnson Foundation with direction and technical assistance by Group Health Cooperative’s MacColl Institute for Healthcare Innovation.
Chronic Care Management Premise
Right Thing
Right Patient
Right Time
Chronic Care Management Model
3. Self-Management Support
4. Delivery 5. Decision 6. Clinical System Support Information Design Systems
2. Health SystemHealth Care Organization
1. CommunityResources and Policies
Informed,ActivatedPatient
Prepared, ProactivePractice Team
Productive Interactions
ImprovedOutcomes
Wagner, E.H. Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness? Effective Clinical Practice 1998; 1:2-4. Permission to reproduce model image granted from American College of Physicians (ACP), July 7, 2006.
Mobilize Community Resources
Patients participate in effective community programs
Form partnerships to fill gaps in needed services and avoid duplicating efforts
Advocate for policies to improve patient care
Health System – Organization of Care
Improvement at all levels of the organization
Promote effective strategies Open and systematic
handling of errors and quality issues to improve care
Provide incentives based on quality of care
Facilitate care coordination within and across organizations
Self-Management Support
Patient has a central role in managing health
Self-management support strategies
– Assessment, goal-setting, action planning, problem solving, and follow-up
Community resources to support self-management
Delivery System Design
Define roles and distribute task
Planned interactions for evidence-based care
Clinical case management services for complex patients
Regular provider initiated follow-up
Cultural sensitive care
Decision Support
Daily practice of evidence-based care
Share clinical guidelines and information with patients*
Provide professional education
Integrate specialty and primary care
*Agency for Healthcare Research and Quality – National Guideline Clearinghousehttp://www.guideline.gov
Clinical Information Systems
Timely reminders for providers and patients
Identify subpopulations for proactive care
Facilitate individual patient care planning
Share information Monitor outcomes
Continuous Quality Improvement
Registry
tracks
individuals and populations
Chronic Care Management Programs
Comprehensive system change
Targeting
Case management
Primary Care Delivery System
Traditional Provide acute care Diagnostic and laboratory
services Treatment of signs and
symptoms Prescriptions Brief education Short appointments Patient-initiated follow-up
Delivery System Redesign
Traditional Provide acute care Diagnostic and
laboratory Services Treatment of signs and
symptoms Prescriptions Brief education Short appointments Patient-initiated follow-
up
Reconfigured Developed processes for CD Incentives for making
changes Extensive patient education
to increase patient’s confidence and skills
Provider-initiated appointments and follow-up
Evidence-based guidelines and provider interaction
Information Systems
Targeting Approach
Correctly assumes a small percent of the population accounts for most health care costs
Possible to reduce cost based on this method
However, health status changes occur frequently
“Targeting” misses a substantial portion of the population at risk
Case Management Approach
Many programs include: Brief hospitalization Low intensity follow-up
care Conduct utilization
review
Chronic Care Management advocates for:
Access to services that are
proven to improve outcomes
Examples: Missouri’s Chronic Health Care Indicators, BRFSS, 2004
69.1% of seniors (age 65+) received a flu shot in past 12 months
65.2% of adults with diabetes test their blood sugar at least once daily
55.6% of adults with diabetes have participated in a course or class to manage their diabetes
52.8% of adults (age 50+) have ever had a lower endoscopy exam
39.9% of adults with arthritis have received a suggestion from their health care provider to exercise or engage in physical activity to help their joint symptoms (2003)
Example: Medicaid
A web-based system to help fee-for-service Medicaid patients manage chronic conditions
Integrate APS Healthcare’s CareConnection application with a chronic care improvement program
Product – “collaborative medical record”
Accessible to patients, providers and health care coaches
The Advisory Board Company. (2006) Missouri creates web-based chronic care system. iHealth Beat. Retrieved June 20, 2006 from http://www.ihealthbeat.org
Incentives
Vary across provider organization
May reduce patient expenses
May also reduce profitable inpatient care
Poorly reimbursed preventive services
Performance related to defined quality goals
Providers - / +
Provider groups with full-capitation +
Health Plans (deliver returns within 6-12 mo) ++
Purchasers / Employers +++
Governmental entities ++++
+ greater incentive to engage in disease management
Primary Care Physician Use of Electronic Medical Records
Country Percent Using EMR
Sweden 90%
Netherlands 88%
Britain 58%
Finland 56%
Austria 55%
Germany 48%
Belgium 42%
Italy 37%
Ireland 28%
Greece 17%
U.S. 17%
Spain 9%
France 6%
Portugal 5%
Source: Harris Interactive Inc. (2002, August 8). European physicians especially in Sweden, Netherlands and Denmark, lead U.S. in use of electronic medical records. HealthCare News, 2(16), 1-3.
European Union Barometer June, July 2001 (numbers repercentaged by Harris Interactive) and Harris Interactive Surveys for U.S.A. in June 2001 and January / February 2001.
EuroBarometer survey (N = 3,504)
U.S.A. survey (N = 377)
Care Management Processes in Physician Organizations (N = 1,040)
Process Diabetes Asthma CHF
1. Case management 39.7 39.7 43.4
2. Feedback to physicians
24.1 24.1 30.5
3. Disease registries 31.2 31.2 34.8
4. Clinical guidelines with reminders
33.9 33.9 27.7
Mean 33.2 32.2 34.1
Practices using all 4 12.7 7.6% 8.6
Casalino, L. et al. (2003). External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. Journal of the American Medical Association.
Chronic Care Management
Regular visits with health providers
Focus on function Prevent exacerbations and
complications Emphasizes self-management Ensures access to services
proven to improve outcomes Establishes links through time
with information systems Follow-up initiated by medical
provider
Improved Health StatusOverarching Goal
In Summary
Chronic care management offers improved health status for many with chronic diseases
Chronic illness care should be based on the best available evidence
Need consistent quality measures and additional research in the various models
Nursing Management involves
coordination of monitoring of patient care– A system for delivering nursing care that is based
on the philosophy of case management– Designed to decrease fragmentation of care,
decrease hospital days and cost– Nursing care management is a system for
delivering nursing care
Goals of Nursing Care Management
– Outcomes based on standards of care– Well-coordinated continuity of care through
collaborative practice– Efficient use of resources to reduce wasted time,
energy an materials– Timely discharge with prospective payment
guidelines– Professional development and satisfaction
Risk Management
A process of identifying, analyzing, treating, and evaluating real and potential hazards
Risk events categorized according to severity– Service occurrence– Serious incident– Sentinel event