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Bea Herbeck Belnap, Dr Biol Hum School of Medicine University of Pittsburgh Learning Objectives 1. To understand the different functions and tools required to effectively implement the Chronic Care Model for depression management in primary care 2. To identify the core roles and qualifications of care managers, particularly as liaisons to providers and for patient self-management support 3. To understand the role and function of care manager registries and their utility in fostering provider and patient communication Wagner Chronic Care Model Health System Community Resources & Policies Informed, Activated Patient Health Care Organization SelfManagement Support 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 Clinical Information Systems Clinical information tracking Protocols- coordinated care Registry Feedback to clinicians CCM: Core Clinical Elements Decision Support Guidelines Expert/specialist consultation Self-management Support Patient preferences Information on treatment Information on and for Community Resources consumers, groups, etc. Access to non-provider sources of care Care Manager Role Encompasses CCM core elements General Medical (Chronic care, Prevention, Follow-up) Care Manager Self-management CM/Liaison: PCP, MH Community linkages Crisis intervention Registry Behavioral Health (crisis referral, complexity, etc.) Care Manager: Core Functions Patient education Registry tracking Provider communication Community linkages Care Manager: Patients Patient education about depression, treatment options Familiar with commonly used antidepressant medications, doses Support medication adherence and recovery Brief interventions Theory-based approaches (MI, PST, etc.) Monitor treatment progress Know when treatment is ‘not working’ Structured symptom assessment (PHQ-9) 8-12 week trial Provider recommendations MHS, PCP CM: Goals of a Registry Identify, manage, and track patients Facilitate patient contacts Provide patient visit summaries Provide real-time data on tx response, etc. Reminders Performance feedback CM: Provider Liaison Relay concerns/progress Symptom monitoring Refills Symptoms and side effects Urgent, emergent protocols Medical record documentation Cue providers if no improvement Supplement, not replace providers CM: Community Linkage Cooperation with MHS Supervision Referral Self-help groups Support for comorbidities, psychosocial problems Financial resources Care Management: Patient Support CM: Customization Cultural competence Role of families Role of religion/spirituality Competing needs CM: Self-management 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 Workbooks Medication lists Appointment reminders Healthy behaviors Pleasure activities list Pillboxes Medication information Websites Care Management: Provider Communication CM: Provider Liaison Help patients and providers identify 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 Care Manager: Providers Tracks depressive sx and treatment response (PHQ-9) Screens for co-occurring MH conditions Alcohol use (e.g., AUDIT-C) PTSD (e.g., PC-PTSD) Consults with team psychiatrist Provides follow-up and recommendations to PCP who prescribes antidepressants Collaborates closely with patient’s (PCP) Facilitates referrals to specialty, community Formal and informal connections Prepares for relapse prevention 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, et al. Bipolar Disorders, 2008 Kilbourne AM, et al. Psychiatric Services, 2008 CM: Provider Resource CMs as a resource for clinic, providers Dissemination of specific guidelines Ask providers for suggestions on specific topics Hold CME, lunches, or disseminate information Examples Bipolar disorder in pregnancy Depression treatment in late life 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 Care Management: Registries Care Manager: Registry Registries are . . . Simple tools to track patient progress Integrated into routine clinical care Easily updated NOT EMRs NOT research-focused Best if “home-grown” Registry Functions Patient risk stratification Tracking and management Patient characteristics facilitating treatment Acute phase Continuation, maintenance Performance feedback Patient process and outcomes Registries Other data sources (e.g., pharmacy, EMR) should NOT replace a registry BUT can be used to: Improved patient identification (top conditions) Enhance performance measurement Challenges to using electronic data Cumbersome to update and merge Time lag Data not available on all patients Privacy and security issues Key Registry Variables Dates Patient contact information Best number, time to call, and leave message Status No shows Treatment stage Current medications (dose, duration) Self-management materials Depression severity score, MD assessment Referral status (MHS, community resources) Next contact, date Registry: Sample Fields General information (update at each contact): 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: 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 Care Management: Crisis Intervention CM: Suicidal Ideation If the patient articulates thoughts death/suicide: 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? CM: Crisis Intervention Suicidal ideation- coordinate with clinic Protocols On-call numbers Missed appointments Immediate follow-up Care Management: Implementation Tips Care Manager Timeline 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 Timeline Subsequent Visits Registry- ongoing tracking Reminders for upcoming appointments Regular contact with providers Implementing Registries Adequate staffing, who should update? Research vs. clinical use Integrating into routine care How identified patients are entered Involving PCP IRB issues Types of Registries Formats (pros and cons for each) Excel file Web-based Examples SMAHRT IMPACT REACH-NOLA Care Manager Toolbox 1. Manual: provider interactions Contacts, location, communication preferences Medication info Protocols to ID treatment response, side effects 2. Manual: patient interactions Brief interventions (e.g., PST, MI, others) Crisis intervention 3. Self-management materials Medication information Behavioral change information (e.g., pleasure activities) 4. Registry file Bottom Lines The CCM for depression includes key elements Self-management Care management Community linkages Registries Guidelines BUT the CCM is most effective if customized to local settings . . . . .
