systematic case review for multi- condition collaborative care

Systematic Case Review for Multi-Condition Collaborative Care

Paul Ciechanowski, MD, MPH Diabetes Care Center

University of Washington Seattle, WA

© 2013 University of Washington. All rights reserved.

Care of Mental, Physical, and Substance use Syndromes!The project described was supported by Grant Number 1C1CMS331048-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The analysis presented was conducted by the awardee. Findings might or might not be consistent with or confirmed by the findings of the independent evaluation contractor.

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LearningObjec-ves

•  Describecorerolesandtasksinsystema3ccasereview.•  UnderstandandapplyprinciplesofTreat-to-Target•  Gainstrategiesforadop3ngandimprovingSCRprocesses.

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Team - Collaborative Care


Core Roles and Tasks •  Identify uncontrolled disease parameters

–  e.g. A1c, BP, Lipids, PHQ-9

•  Diagnose depression cases –  e.g. major depression and dysthymia

•  Carry out collaborative care treatment –  e.g. monitoring, self-care support, care coordination

•  Establish patient-centered care plans –  e.g. behavioral change, disease outcomes

•  Regular, systemized team case review •  Treat-to-Target •  Clinical tracking


Treat-to-Target (TTT) Treatment titration

– Frequent and consistent – Relentless, incremental increases

Always: – Increase to next step – If not, document why not!

TTT Algorithm •  Simplified and uniform approaches across conditions to

achieve targets –  Riddles et al., Diabetes Care, 2003 –  Kaiser Permanente, Care Management Institute


PCPCM

CM

BehPsy


Mgr

IM

CM

CM

CM

Psy


Rx CM CM Mgr IM

CM

Sup CM CM CM Psy


Clinical Outcome Report – Access Data Base


ID Name CM PCP Baseline A1c Recent A1c/Date Baseline BP Recent BP/Date

Baseline LDL Recent LDL/Date Baseline PHQ-9 Recent PHQ-9/Date Last contact Date enrolled Contact level

Clinical Outcome Report – Access Data Base


•  New cases •  Ongoing cases that haven’t reached targeted goals

–  (e.g. PHQ-9 <5, HbA1c <7.0%, SBP <130 mmHG, LDL <100 mg/dL)

•  Difficult nurse-patient relationships •  Patients out of contact

Case Review Priorities


•  Who is this patient? –  e.g. age, psychosocial background, unique personality

features, coping strategies

•  Depression and diabetes/CHD history •  Current treatment and past treatment experience •  Treatment targets

Case Review Content


•  Succinct, clear, short case presentations •  Make data a team member: PHQ-9, HbA1c, SBP and

LDL levels, current medications, prior medications •  Accountability for making appointments, changing

treatment protocols, outcomes

Case Review Characteristics


•  Be supportive, but clear on goals and accountability •  Don’t lower self-esteem! •  Set clear goals and action plan for following week •  Be curious and problem-solve solutions •  Be available between supervision sessions via pager,

e-mail, phone

Keys for MD Case Reviewers


•  Who is running the meeting? •  Changes in role for both physician and nurse •  Accountability

Potential Tensions in Case Review


Casemanager:Date: Suggestedac-ons

Pa3entID:Nextcontact:

Medica3onchanges:•  Simplify,consolidate•  Checkformulary•  Checklowestprices•  Assessadherence•  Assesssideeffects

Behavioralac3va3on:•  Physicalac3va3on•  Socialac3va3on•  Pleasantevents

Mo3va3onalissues:•  Stagesofchange•  Decisionalbalance

Diseaseself-management:•  BPcuff,BPrecord•  Pedometer•  Glucometer(newor2nd)•  Sleephygeine•  Nutri3onist/Die3cian•  Mediset

Strategiesforhard-to-reach:•  ContactPCP•  Voicemail•  LeSer






Other tips and pointers


•  All PHQ-9 data is necessary for case review •  Multiple ways of completing a PHQ-9


•  Respectful, non-demeaning manner necessary because reporting in this setting can be unnerving at first


•  Shared roles among team where team members who are not presenting can serve as “scribes” for completing the action sheet or can “drive” the EHR


•  “Non-compliant” patients should not be disregarded – team should strategize about how to reach them


•  Use chart or EHR to determine when next engagement with system is as a way of making contact with hard-to-reach patients


•  If there are systematic resource issues, sort cases by case managers so once case managers are done they can be dismissed (only after efficiency and effective case review achieved)


•  On-the-fly education by the case reviewers (e.g. few minute recap of essential clinical principles)

•  Booster sessions


•  Decision to “graduate” a patient based on parameters is a TEAM decision


•  Review data to observe proportion of patients reaching target for each case manager

•  Only when enough cases have been enrolled for a long enough duration


Care of Mental, Physical, and Substance use Syndromes!The project described was supported by Grant Number 1C1CMS331048-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The analysis presented was conducted by the awardee. Findings might or might not be consistent with or confirmed by the findings of the independent evaluation contractor.

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Thank you.


systematic case review for multi- condition collaborative care

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