Systems Support:
Care Management Protocols, Disease
Registries, and Other Tools
Amy M. Kilbourne, PhD, MPH
VA Ann Arbor Serious Mental Illness Treatment
Research and Evaluation Center
Department of Psychiatry, University of Michigan
SMITREC
Mental Health Services Research Group
 Chronic Care Model- chronic mental illness
 Quality improvement interventions to improve
medication adherence
 Mental health performance measures
 Primary Care – Mental Health Integration
Program
 Substance abuse in primary care
 Predictors of suicide
 Aging and preventable mortality
 National VA Psychosis Registry
 National VA Registry for Depression
Implementation
 Care Management Guidelines
 Patient Registries
 Other Tools
Wagner Chronic Care Model
Community
Resources and
Policies
Health System
Health Care Organization
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Functional and Clinical
Outcomes
CCM: Core Clinical Elements
Leadership
 Vision
 Resources
Practice
Design
 Care management
 Protocols- coordinated care
Clinical
Information
Systems
 Clinical information tracking
 Feedback to clinicians
CCM: Core Clinical Elements
Decision
Support
 Guidelines
 Expert/specialist
consultation
Self-management  Patient preferences
 Information on treatment
Support
Community
Resources
 Information on and for
consumers, groups, etc.
 Access to non-provider
sources of care
Care Manager Role
General
Medical
(Chronic care,
Prevention,
Follow-up)
Care Manager
Self-management
Liaison: PCP, MH
Crisis intervention
Behavioral
Health (crisis
referral for
ICM, etc.)
Care Manager: Skills
 Tracks depressive symptoms and treatment
response (PHQ-9)
 Consults with team psychiatrist
 Collaborates closely with patient’s primary care
provider (PCP)
 Provides follow-up and recommendations to PCP
who prescribes antidepressants
 Facilitates referrals to specialty, community
 Prepares for relapse prevention
Care Manager: Skills
 Familiar with commonly used
antidepressant medications, doses
 Patient education about antidepressants
 Support antidepressant medication
adherence
 Know when treatment is ‘not working’
CM: Self-management
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Eliciting concerns/barriers
Problem-solving
Providing information
Clarifying preferences
Encouraging informed decision-making
Teaching skills
Monitoring progress
Reinforcing self-management
Community resources
CM: Self-Management Tools
 Medication lists
 Pillboxes
 Appointment reminders
 Healthy behaviors
 Pleasure activities list
CM: Therapeutic Alliance
 Cultural competence
 Role of families
 Role of religion/spirituality
 Competing needs
CM: Liaison
 Relay concerns/progress
 Refills
 Symptoms and side effects
 Urgent, emergent protocols
 Medical record documentation
 Cue providers if no improvement
 Supplement, not replace providers
CM: Liaison
 Help patients and providers ID
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Potentially inadequate doses
Ineffective treatment (e.g., persistent depression after
Adequate duration of antidepressant trial)
Side effects
 Facilitate patient-provider (e.g., PCP)
communication about antidepressant medications
 Consult about medication questions
Examples of CM-Provider Contact
 Medication toxicity, cross-reactivity
 Notifying provider of patient concerns, follow-up
 Fatigue, physical symptoms
 CM prompted provider to call pt. after missed appt
 Managing multiple medications, depression,
diabetes, and HT (medication lists, pillboxes)
 Alcohol use and grief management
Kilbourne AM. Bipolar disorders, in press 2008
Kilbourne AM. Psychiatric services, under review, 2008
Provider Communication Tips
 Obtain preferred mode of communication
 Emphasize as a supplemental service
 Focus on providing information on changes in
treatment response, side effects, etc to inform
decisions
 Baseline, Current PHQ
 Length of time on medications
 Problematic symptoms/side effects
 Adequate contact, but don’t overdo it
CM: Crisis Intervention
 Suicidal ideation- coordinate with clinic
 Protocols
 On-call numbers
 Missed appointments
 Immediate follow-up
CM: Suicidal Ideation
If the patient articulates thoughts death/suicide:
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Where are you now?
What is your phone number at the location?
Are you alone or with someone?
Do you have a plan of how you would do this?
Do you have these things available (guns, pills)?
Have you actually rehearsed or practiced how you would
do this?
 Have you attempted suicide in the past?
 Do you have voices telling you to harm or kill yourself?
Care Manager Registry
 Registries are . . .
 Simple tools to track patient progress (K.I.S.S.)
 NOT EMRs
 Best if “home-grown”
 Facilitate structured patient contacts
 Types of registries, pros and cons
 Excel file
 Web-based
Developing Registries
Things to Know
 Know your stakeholders and get their input
(purchasers, payers)
 Know your population- case mix, location
 Know your key data sources
 What is in the administrative datasets?
 Do they capture utilization?
 Know what information technologies are available
and whether they can be tailored
 Web-based patient health risk assessments
Developing Registries
Things to Know (cont.)
 Know your end users (e.g., care managers, clinic
staff, providers), including their work flow, and
ensure they can work with the registry on a day-today basis
 Know what stakeholders want in terms of
outcomes: What quality and cost measures are
they interested in, and use registry to enhance
performance measures
Registry: Sample Fields
General information (update at each contact):
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Patient contact info, including emergency contact
Providers
Best time to call/OK to leave message?
Plan to keep then safe/calm
Contact (Encounter)-specific information:
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Contact or visit date
Current Mood, Speech, Comorbidities
Current medications/OTCs, refills needed?
Medications not taking and reason
Symptoms and side effects
Health behaviors (sleeping, drug use, smoking ,exercise)
Job/personal problems
Education provided
Access/barriers, provider engagement
Next appt
Registry Examples
 SMAHRT
 IMPACT
Care Manager Toolbox
 Self-management materials
 Antidepressant medication list
 Registry file
 Provider contact sheet
 Preferences
 Crisis intervention
 Operations manual
Care Manager Initial Visit
 Rapport- providers
 Patient initial intake
 Contact preferences
 Crisis and urgent care protocols
 Assessment
 Discuss treatment options / plans
 Coordinate care with PCP
 Start initial treatment plan
 Arrange follow-up contact
 Document initial visit
Care Manager Subsequent Visit
 Upcoming appointments
 Registry- ongoing tracking