IC3 Beacon Pilot Diabetes
Care Coordination Training
Care
Sarah Woolsey, M.D.
Janet Tennison, PhD
HealthInsight, August 16, 2012
This material was prepared by HealthInsight as part of our work as the Beacon Community, under Cooperative Agreement grant #90BC00006
from the Office of the National Coordinator, Department of Health and Human Services.
Welcome
Pre-work
Today’s Objectives
• Understand Care Coordination and SelfManagement
• How to identify high risk patients with diabetes
in your system
• Assessing patients’ needs and goals
–
–
–
–
–
–
Health Literacy
Motivational Interviewing
Stages of Change
Teach Back
Planned follow-up
ProQual tool
• Starting Care Coordination in your setting
Definition: Care
Coordination
“The calculated integration of
patient care activities between two
or more participants, to facilitate
the suitable provision of health
care services”
Closing the Quality Gap: A Critical Analysis of Quality Improvement
Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7.
McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD):
Agency for Healthcare Research and Quality (US); 2007 Jun.
Coordination--Why Do
We Need It?
• Determine the patients’ goals
• Assist those “high-risk” patients who
have been unsuccessful at managing
their own care
• Engage patients to improve their selfcare
• Improve the exchange between
providers, patients, community
services
We Sometimes Get
Frustrated
Removing Barriers to
Accomplish Goals
Engaging
Patients in
Their Own
Care
Traditional
• Professionals are
experts, patients
passive
• Behavior change
externally motivated
• Non-compliance is
personal deficit
Collaborative
• Providers experts
about disease;
patients experts
about lives
• Behavior change
internally motivated
• Lack of goal
achievement requires
modifications
Bodenheimer, T., & Abramowitz, S. (2010). Helping patients help
themselves: How to implement self-management support. Oakland, CA:
California HealthCare Foundation.
Differences
Traditional Patient
Education
• Technical skills
• Problems with disease
control
• Disease-specific
knowledge
• Goal is compliance to
improve outcomes
• Health professional is
educator
Self-Management
Education
• Skills to act on problems
• Problems ID‘d by
patients
• Improving confidence
• Goal is increased selfefficacy to improve
• Health team, peers,
educators
Bodenheimer, T., & Abramowitz, S. (2010). Helping patients help
themselves: How to implement self-management support. Oakland,
CA: California HealthCare Foundation.
Organizational
Outcomes
Patient Outcomes
•Culture/climate
•Staff satisfaction
•Efficiency/cost
•Physiologic
•Satisfaction
•Functional status
Clinical
Information
Systems1
Healthcare
Organization6
Activated
Patients
Decision
Support2
o
Delivery
System
Redesign3
DSM
Clinic Care
Coordination
Community
5
Resources
SelfManagement4
Developed by Janet
Tennison, PHD,
Adapted from Kirsch et.
al., 2008
Interprofessional
Outcomes
•Team Self-efficacy
•Shared Perspectives
•Teamwork
• Attitudes towards
collaboration
Essential CC Tasks
•
•
•
•
Identify high-risk patients
Assess patient
Develop care plan
Identify care participants,
communicate needs
• Execute care plan
• Monitor and adjust care
• Evaluate health outcomes
ESSENTIAL CARE TASKS and Associated
Coordination Activity
•
IDENTIFY and ASSESS PATIENT Determine
Likely Coordination Challenges, determine
patients vulnerable to disconnected care
•
DEVELOP CARE PLAN Proactive Plan for Coordination Challenges
and Follow-up
IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES
Specify Who is Primarily Responsible for Coordination (Medical
Home)
EXECUTE CARE PLAN Implement Coordination Interventions
COMMUNICATE TO PATIENTS /Family AND ALL OTHER CARE
PARTICIPANTS Ensure Information Exchange Across Care
Interfaces
MONITOR AND ADJUST CARE Monitor For and Address
Coordination Failures
EVALUATE HEALTH OUTCOMES Identify Coordination Problems
that Impact Outcomes
•
•
•
•
•
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7:
Care Coordination).Technical Reviews, No. 9.7. McDonald KM, Sundaram V, Bravata
DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.
Case: Mr. Thomas
• Mr. Thomas is a 56 -year old patient
with DM II.
• He has private insurance through his
wife’s job.
• He is here for a cough and cold visit,
has not been in for 9 months.
• You note he has no-shows recorded
for his last 3 visits to you, both
education visits and a diabetes
check-up.
Medical Assistant Check-In
•
•
•
•
•
He is taking 3/5 meds
listed in the EMR by
report.
Metformin, Lisinopril
and aspirin (unsure
what kind).
He is not on insulin,
simvastatin as
recorded here.
He reports no pain or
allergies.
He has not had any
office visits
elsewhere.
• Temp=98.0
• BP 152/90, pulse 88
• Weight is 224lb , BMI
29
• O2 sat is 99%
• Hba1c = 10 (last time
was 8.9)
• Coughing
• In his PJ top
• Appears well
otherwise
What Are You Thinking
Here?
MA point of view
Beacon point of view
Doctor point of view
Care Coordination point of view
More Information
Exam :
•
•
•
Obese
Nasal
congestion
R toenail is
ingrown
(you
checked)
Labs today:
Glucose-333
Old Labs:
•
•
•
LDL=144
Microalbumin is
abnormal
A1c=8.9
Other
• He did not have
a flu shot in
2011
• He has never
had a
depression
screen
• Non-smoker
Is Mr. Thomas High Risk?
• Vulnerable to disconnected
care?
• How do you find him in your
system?
• Name 3 ways
Practice Analytics Tool
“Hot Spot” Pilot
• Diabetes Care Severity Index
• Composite score of labs,
diagnoses, and know risk of
hospitalization
• Option in the CC program
What else do you want to
know about Mr. Thomas?
Patient Point of View?
Consider…
WHAT IS his GOAL for his care?
Today? Overall?
How do you know?
ESSENTIAL CARE TASKS and Associated
Coordination Activity
•
IDENTIFY/ASSESS PATIENT Determine
Likely Coordination Challenges, determine
patients vulnerable to disconnected care
•
DEVELOP CARE PLAN Proactive Plan for Coordination Challenges
and Follow-up
IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES
Specify Who is Primarily Responsible for Coordination (Medical
Home)
EXECUTE CARE PLAN Implement Coordination Interventions
COMMUNICATE TO PATIENTS /Family AND ALL OTHER CARE
PARTICIPANTS Ensure Information Exchange Across Care
Interfaces
MONITOR AND ADJUST CARE Monitor For and Address
Coordination Failures
EVALUATE HEALTH OUTCOMES Identify Coordination Problems
that Impact Outcomes
•
•
•
•
•
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7:
Care Coordination).Technical Reviews, No. 9.7. McDonald KM, Sundaram V, Bravata
DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.
Patient Assessment
“Why is Mr. Thomas so
non-compliant?”
Three methods:
The patient is not yet
engaged!
1. Health Literacy
2. Stages of Change
3. Motivational
Interviewing (MI)
Patient and provider
both have
responsibility to
determine and address
barriers.
Health
Literacy
• tervisealase
kirjaoskuse
• अनुवाद करने के लिए यहााँ
पाठ दर्ज करें
•
•
•
•
‫בריאות אוריינות‬
alfabetizasyon sante
Gesundheitskompetenz
y tế biết đọc biết viết
Definition
Health Literacy
Functional Health
Literacy
The capacity to obtain,
process, and understand
basic health information
and services needed to
make appropriate health
decisions.
The ability to read and
comprehend prescription
bottles, appointment slips,
other essential healthrelated materials required
to successfully function
as a patient.
Healthy People. (2010). Cited in What is Health
Literacy? Retrieved from www.chcs.org
Health Literacy
• Only 12% of adults have
proficient health literacy
• 9/10 patients lack skills to
manage their health/prevent
disease
• Ask Me 3
Advocate for Health Literacy in your organization (n. d.). Quick
Guide to Health Literacy. Retrieved from http://HHS.com
Determine then Support
Health Literacy
• Verify understanding by “teach
back”
• “Tell me in your own words what
we just talked about”
• “Why do you take this
medication?”
• Provide instructions like you’re
speaking with a friend
MOST IMPORTANT!
Create a shame-free environment
where low-literacy patients can
seek help without embarrassment
or being stigmatized
Don’t Forget Culture
• Ethnic/racial/population/religious
differences affect perceptions,
trust, access to medical care
• Poverty, language and
communication barriers, other
demographics
• Personal bias, prejudices, lack of
understanding
Mr. Thomas and Health
Literacy
• Visit Summary Example
The
Stages of
Change
Inappropriate Assumptions
About Behavior Change
•
•
•
•
•
•
•
•
This person ought to change, and wants to change.
This patient’s health is the prime motivating factor
for him/her.
If he or she does not decide to change, the
consultation has failed.
Patients are either motivated to change, or not.
Now is the right time to consider change.
A tough approach is always best.
I’m the expert. He or she must follow my advice.
A negotiation-based approach is best.
Emmons, K. M. , & Rollnick, S. (2001). Motivational Interviewing in
health care settings: Opportunities and limitations. American Journal
of Preventive Medicine, 20(1)
How To Suppress Change
• Tell patients what to do (give advice)
• Misjudge sense of importance regarding
behavior change
• Use scare tactics, argue, blame them for no
willpower and self-concern
• Overestimate readiness to change and
degree of confidence
• Take control away and generate resistance
Is Patient Ready to
Change?
Readiness to change: Stages of Change. (2005). Retrieved July 10, 2011, from Well-Fit
Bodies Website: http://www.well-fitbodies.com/readiness_for_change
Patient Assessments
How ready are you (to improve a behavior)?
0
1
2
3
4
5
6
7
8
9
Not ready
10
Ready
How confident are you (that you can)?
0
1
2
Not at all confident
3
4
5
6
7
8
9
10
Very Confident
True Change Takes Time
• Some may remain in one phase a long
time or forever
• Pre-contemplation—cons of quitting
outweigh the pros
• Relapse is expected, should be
integrated to normalize it
• Most don’t go from pre-contemplation
to action
• Goal—try to move through stages
Success = Positive
Relationships & Support
Provider-patient relationship
most important determinant of
diabetes self-management
Craig, C., Eby, D., & Whittington, J. (2011). Care Coordination Model: Better
care at lower cost for people with multiple health and social needs. IHI
Innovation Series white paper. Cambridge, Massachusetts: Institute for
Healthcare Improvement.
Where is Mr. Thomas?
•
•
•
•
•
Contemplation
Pre-contemplation
Preparation
Action
Maintenance
BREAK
Motivational
Interviewing
Motivational Interviewing
“A collaborative, patientcentered form of guiding to
elicit and strengthen
motivation for change”
Miller, W.R. & Rollnick, S. (2009). Ten things that Motivational Interviewing
is not. Behavioural and Cognitive Psychotherapy, 37, 129-40.
Motivational Interviewing
•
•
•
•
•
•
Non-coercive
Non-judgmental
Non-confrontational
Non-adversarial
Explore and resolve inconsistency
Help patients envision a better future,
and become increasingly motivated
to achieve it
Why Do We Need MI?
No matter what reasons we might offer
to convince individuals of the need to
change their behavior,
or how much we want them to do so,
lasting change is more likely to occur
when they discover their own reasons
and determination to change.
Four Principles of MI
1. Express empathy
2. Explore differences
3. Roll with resistance
4. Support of self-efficacy
OARS
•Open-ended questions
•Affirmations
•Reflections
•Summaries
Patient Assessment
Mr. Thomas
Role play referral for insulin use,
why was it unsuccessful before?
What would you say and do?
What is his goal?
LUNCH 12:00-12:30
Pro Qual Tool–Patient Experience of
Health Assessment and Barriers
• http://informatics.mayo.edu/proqol (test)
IC3 Beacon Pilot Diabetes
Care Coordination Training Part 2
Care
Sarah Woolsey, M.D.
Janet Tennison, PhD
Michelle Carlson, S.S.W.
HealthInsight, 2012
This material was prepared by HealthInsight as part of our work as the Beacon Community, under Cooperative Agreement grant #90BC00006
from the Office of the National Coordinator, Department of Health and Human Services.
Motivational Interview #2
• Mrs. Smith is a 48 y/o, she has had
DM 2 for 5 years, since her last child
was born.
• She is on your list as a patient that
has not come in for >12 months.
• Her last A1c was 7.5, and she was up
to date on DM care.
• Today’s A1c=9.
• You notice she has had no shows a
few times for follow-up for Diabetes.
WHAT MIGHT BE HAPPENING?
Part 2 Learning Objectives
• Developing a Care Plan
• Identify roles
• Communicating (information
exchange)
• Monitor and Adjust
• Data collection
• Resources
ESSENTIAL CARE TASKS and Associated
Coordination Activity
•
IDENTIFY/ASSESS PATIENT Determine Likely Coordination
Challenges, determine patients vulnerable to disconnected care
•
DEVELOP CARE PLAN Proactive Plan for
Coordination Challenges and Follow-up
•
IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES
Specify Who is Primarily Responsible for Coordination (Medical
Home)
EXECUTE CARE PLAN Implement Coordination Interventions
COMMUNICATE TO PATIENTS /Family AND ALL OTHER CARE
PARTICIPANTS Ensure Information Exchange Across Care
Interfaces
MONITOR AND ADJUST CARE Monitor For and Address
Coordination Failures
EVALUATE HEALTH OUTCOMES Identify Coordination Problems
that Impact Outcomes
•
•
•
•
Closing the Quality Gap: A Critical Analysis of Quality Improvement
Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7.
McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD):
Agency for Healthcare Research and Quality (US); 2007 Jun.
The Mr. Thomas Care Plan
Provider wants to re-start Insulin
that patient agreed to start prior
What is the current workflow at
your site?
How do we succeed?
Care Plan
Basic Clinic Example of a Working Care Plan
For next visit: (To be completed by Physician /Care Coordinator and Patient)
Patient Name__________________ Chart ID____________
Patient Goal:
Medical Plan:
• Care Coordination Needs/Referrals:
__________________________________________
• Labs Needed:
___________________________________________________________
• New Meds/ Education Needed:
______________________________________________
• Ref letters/Contact needs for patient:
________________________________________
• Follow Up Needed:
Call (Who/date/subject) ______________________________________________
Next Visit (Schedule period/date) _______________________________________
Next Visit agenda ___________________________________________________
Care Plan:
Patient will:
____________________________________________________
By:(Date)_____________
Care Coordinator/Clinical Team will:
____________________________________________________
By:(Date)_____________
Reviewed Date __________
Care Team or Physician Signature
Patient signature- plan
Adapted from the Utah Medical Home Portal www.medicalhomeportal.org, 2009
Care Plan Brainstorm
ESSENTIAL CARE TASKS and Associated
Coordination Activity
•
•
IDENTIFY/ASSESS PATIENT Determine Likely Coordination
Challenges, determine patients vulnerable to disconnected care
DEVELOP CARE PLAN Proactive Plan for Coordination Challenges
and Follow-up
•
IDENTIFY PARTICIPANTS IN CARE AND SPECIFY
ROLES Specify Who is Primarily Responsible for
Coordination (Medical Home)
•
•
EXECUTE CARE PLAN Implement Coordination Interventions
COMMUNICATE TO PATIENTS /Family AND ALL OTHER CARE
PARTICIPANTS Ensure Information Exchange Across Care
Interfaces
MONITOR AND ADJUST CARE Monitor For and Address
Coordination Failures
EVALUATE HEALTH OUTCOMES Identify Coordination Problems
that Impact Outcomes
•
•
Closing the Quality Gap: A Critical Analysis of Quality Improvement
Strategies (Vol. 7: Care Coordination).Technical Reviews, No.
9.7.McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD):
Agency for Healthcare Research and Quality (US); 2007 Jun.
Roles at Your Clinic
Who is going to coordinate the
patients?
When will the work get done?
Initiation? Follow-up?
Who is responsible for X patient?
St Mark’s Pilot Success
ESSENTIAL CARE TASKS and Associated
Coordination Activity
•
•
•
•
IDENTIFY/ASSESS PATIENT Determine Likely Coordination
Challenges, determine patients vulnerable to disconnected care
DEVELOP CARE PLAN Proactive Plan for Coordination Challenges
and Follow-up
IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES
Specify Who is Primarily Responsible for Coordination (Medical
Home)
EXECUTE CARE PLAN Implement Coordination Interventions
•
COMMUNICATE TO PATIENTS/FAMILY AND ALL
OTHER CARE PARTICIPANTS Ensure Information
Exchange Across Care Interfaces
•
MONITOR AND ADJUST CARE Monitor For and Address
Coordination Failures
EVALUATE HEALTH OUTCOMES Identify Coordination Problems
that Impact Outcomes
•
Closing the Quality Gap: A Critical Analysis of Quality Improvement
Strategies (Vol. 7: Care Coordination).Technical Reviews, No.
9.7.McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD):
Agency for Healthcare Research and Quality (US); 2007 Jun.
Communication
• TEMPLATE DEVELOPMENT
• How will you share this
information with all team
members?
• Where Does the Care Plan Go in
the Chart?
• How is a patient flagged?
Communication
• When should I call you or have
you come in (to check on
progress)?
• Reinforce Change Plan at every
visit/opportunity
• Share plan with all team members
• Assist with problem solving as
needed
ESSENTIAL CARE TASKS and Associated
Coordination Activity
•
•
•
•
•
IDENTIFY/ASSESS PATIENT Determine Likely Coordination
Challenges, determine patients vulnerable to disconnected care
DEVELOP CARE PLAN Proactive Plan for Coordination Challenges
and Follow-up
IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES
Specify Who is Primarily Responsible for Coordination (Medical
Home)
EXECUTE CARE PLAN Implement Coordination Interventions
COMMUNICATE TO PATIENTS/FAMILY AND ALL OTHER CARE
PARTICIPANTS Ensure Information Exchange Across Care
Interfaces
•
MONITOR AND ADJUST CARE Monitor For and
Address Coordination Failures
•
EVALUATE HEALTH OUTCOMES Identify Coordination Problems
that Impact Outcomes
Closing the Quality Gap: A Critical Analysis of Quality Improvement
Strategies (Vol. 7: Care Coordination).Technical Reviews, No.
9.7.McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD):
Agency for Healthcare Research and Quality (US); 2007 Jun.
Monitor and Adjust
• Set strong boundaries with patients:
role/purpose, time constraints
• Discuss “problem patients” with
care team: decide if appropriate for
care coordination
• Discuss other potential failure
reasons with team
• Reassess patients, as needed
ESSENTIAL CARE TASKS and Associated
Coordination Activity
•
•
•
•
•
•
•
IDENTIFY/ASSESS PATIENT Determine Likely Coordination
Challenges, determine patients vulnerable to disconnected care
DEVELOP CARE PLAN Proactive Plan for Coordination
Challenges and Follow-up
IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES
Specify Who is Primarily Responsible for Coordination (Medical
Home)
EXECUTE CARE PLAN Implement Coordination Interventions
COMMUNICATE TO PATIENTS /Family AND ALL OTHER CARE
PARTICIPANTS Ensure Information Exchange Across Care
Interfaces
MONITOR AND ADJUST CARE Monitor For and Address
Coordination Failures
EVALUATE HEALTH OUTCOMES Identify
Coordination Problems that Impact Outcomes
Closing the Quality Gap: A Critical Analysis of Quality Improvement
Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7.
McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD): Agency
for Healthcare Research and Quality (US); 2007 Jun.
Health Outcomes Data
Collection
• Excel Database
• Document your
success
• Assist us in
program evaluation
• Learn to measure
what you do
• Develop your
capacity to show the
quality you deliver
Knowing
Your
Community
Resources
and Referrals
Beacon Website Resources
Beacon Clinic Resources
Public Benefit Programs
• SSI (Social Security Income)
• SSDI (Social Security Disability
Income)
• Medicare (Over 65 years-old,
and disabled)
• Medicaid and CHIP (Low
income)
Support Groups
• Disease-based (Cancer, Mental
Health)
• On-line groups (Women’s,
Grief, Addictions)
• Agency-based (Red Cross,
United Way)
• 2-1-1
Community Resources
• Religion affiliated (LDS,
Catholic Community)
• Aging and elder care
• Pharmacy Assistance Programs
• Homeless services
• Donated dental
Home Health
• Home health referrals and
criteria (Skilled need,
homebound status)
• Pre-authorizing services
through insurers
• DME (FWW’s, potty-chairs,
electric WC’s)
Long-Term Care
• Skilled Nursing Facility (SNF)
- Skilled needs vs. “custodial”
• Extended Care Facility (ECF)
• Independent/Assisted Living
• Medicare versus private pay
• Referral processes/paperwork
How to Succeed
•
•
•
•
•
•
•
ID the right patients reliably
Track patients
Care Plan in place for patients with a
patient goal in place
Follow-up in place for care plan items
Resources list available, if needed
Improving DM measures in patients
and meeting their goals for care
Patient Satisfaction, experience of
health and support
Wrap-Up and Next Steps
• HealthInsight Assistance
• Feedback on self-assessments
• Data collection tool assistance
• Monthly visit with team (if
desired)
• Proqual assistance
Wrap-Up and Next Steps
• Action Plan
• What can you do by next
Tuesday? (ideas)
-- Finish assessments
-- Team meeting
-- Begin using ProQual tool on
patients
Wrap-Up and Next Steps
• Evaluations