Download General Medicine Clinic Care Management Program

General Medicine Clinic
Care Management Program
Fern Ebeling, RN
Lisa Tang, MEA
Lindsay Evans, LCSW
Julia Finch, BA
Elizabeth Davis, MD
Mr. P is a 49 year old man with congestive heart
failure, active methamphetamine use, depression,
severe coronary artery disease, and bilateral
pulmonary emboli. Over the year prior to enrolling in
our program he had been admitted three times (23
hospital days). He frequently missed appointments
and did not regularly take his medications.
General Medicine Clinic
San Francisco General Hospital, UCSF
SNAPSHOT OF OUR CLINIC
Complex Care
Management Team
Level 3:
Complex
healthcare needs
Level 2:
Multiple chronic conditions:
diabetes, HTN, COPD
Level 1:
Uncomplicated chronic disease or risk factors: obesity,
pre-diabetes
GMC Care Management Team Roles
Team member
Roles
RN Care Manager



Medical Assistant
Health Coach




Provider (Resident,
attending, or NP)
Initial assessment and Care Plan
Complex clinical issues and medication issues
Clinical back-up for Health Coach
Outreach to patients
Coaching toward care plan goals
Focus on self-management
Primary point of contact for patients

Refer patients
Collaborate with CM team
Titrate medications, plan diagnostic work ups
Coordinator

Manages referrals, data tracking, reporting
Social Worker

Referrals to entitlements and community-based programs
Physician CM lead

Program development and evaluation
Clinical back-up to team
Lead quality improvement




Home Assessment
• Chart Review
• Trust building
• Self Management
• Medication Reconciliation
• Function
• ADLs/IADLs
• Social Support
• Get family involved
• Behavioral Health
• Depression Screening
• Substance Use
• Safety
• IPV and Elder Abuse screen
• Home safety
GMC Care Management Program: Enrollment and Levels of Care
ASSESSMENT: The team RN and health coach
conduct a comprehensive assessment, either in
the home, in clinic, or by phone. From this
information, they develop a care plan and assign
the patient a level of care.
CRITICAL
CRITICAL
Intensive case
case mgmt
mgmt in
in
Intensive
st
nd
and 22nd wk
wk postpost11st and
discharge.
discharge.
or == 1x/wk
1x/wk check-ins
check-ins
>> or
LEVEL
LEVEL 11
Check-ins every
every 22 wks
wks
Check-ins
LEVEL
LEVEL 22
WAIT LIST
INITIAL CONTACT
AND CHART
REVIEW
ASSESSMENT
Check-ins every
every 33 wks
wks
Check-ins
LEVEL
LEVEL 33
Monthly check-ins
check-ins
Monthly
LEVEL
LEVEL 44
PT DECLINED
HAS OTHER
SERVICES
LEVELS OF CARE: The assigned level of
care determines the intensity of our care
management for each patient. Patients can
move up and down the levels of care at any
time depending on need.
Pt calls
calls team
team PRN
PRN
Pt
LEVEL
LEVEL 55
GRADUATE
Pt graduated
graduated from
from
Pt
program
program
Health Coaching
•
•
•
•
•
•
Done over the phone
• Freq depends on status
Check-in
Problem-solving
• Pharm
• DME
• Appts
Motivational Interviewing
Role modeling
Patient Education/Symptom Management
• Health-O-Meters
Health-O-Meter
Mr. P, four months later
•
•
•
Upon enrollment to our program, we focused on
building a relationship with Mr. P and with his family.
He was hesitant about working with our team, but after
three months of intensive involvement, he began to
engage. He now feels comfortable calling us with his
concerns.
Over the first four months, we had 43 conversations
with him and his family and had 6 in-person visits. We
then decreased to much less frequent contacts.
He has had no ED visits or admissions since enrolling
in our program, and he has attended almost all of his
appointments. At one of these visits, his primary care
provider said “This is the first time I have seen him
stable. He looks like a different person!”
GMC Care Management
Challenges
Challenge
Strategies
Capacity
•Assigning patients to levels
•Weekly team discussion
Engagement
•System for deciding when to stop trying to
engage
•Learning from other programs
Communication with
PCPs
•Email questions in bold
•Huddles
•Brochure
•Case conferences
GMC Care Management
Lessons Learned
•
•
•
•
•
•
•
Interprofessional teams embedded in primary care
Efficient data management
Dashboard key to ongoing improvement
Improvement in utilization and health despite
complexity
Effective care management takes time
Partnership with local partners and stakeholders
Patient Advisory Board
Resident and Provider Experience
•
•
All providers surveyed thought quality of care
improved with care management
"The largest impact that having teams at the GMC
has had on me is this feeling that I'm not on my own
advocating and caring for our patients--and that has
been a huge emotional burden lifted."
Patient Experience
•
“Another thing that makes me feel good is when
people like Lisa and Fern and Dr. Hurstak reach
goals with me. I know there’s someone on the other
side fighting for me. I’m not by myself…They
convinced me with facts that they are an asset for
the patient’s care because they are always there for
you.”
GMC Care Management
Outcomes
Year prior to
During CM
enrollment in CM
Percent reduction
Hospital days per
year per patient
9.75
4.53
53.5%
ED Visits per year
per patient
3.40
2.49
26.6%
Utilization data for all patients who have been enrolled in Care Management (n=73). One patient was excluded from this
analysis due to incomplete hospitalization data. Utilization data for patients in the program for less than one year was annualized.
Key Stakeholders and Partnerships
•
SFGH and the SF Department of Public Health
•
Training from UCSF Center for Excellence in Primary
Care
•
San Francisco Health Plan (Medicaid managed care)
•
Health at Home
•
In Home Supportive Services
Thank you!