Download Care management and Heart Failure

CARE MANAGEMENT
AND HEART FAILURE
Preventing Re-admissions
Care managers are expected to
have the same level of knowledge
that people with HF need to selfmanage.
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
PREVIEW
 Evidence
 Definition
 Standard care management process/tools
 Standard care management protocols
 HF care management interventions/tools
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
EVIDENCE BASE
CM Standards
• National
Committee for
Quality Assurance
(NCQA)
• Institute for
Healthcare
Improvement
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Protocols
• Mary Naylor
• Chad Bolt
• Eric Coleman
HF/CM Interventions
• Heart Failure
Society of America
(HFSA)
• American College
of Cardiology
(ACC)
• American Heart
Association (AHA)
• Physician
Consortium for
Performance
Improvement Heart
Failure Core
Physician
Performance
Measurement Set
CARE/CASE MANAGEMENT
DEFINITION
Case management is a collaborative process of assessment, planning,
facilitation, care coordination, evaluation and advocacy for options and
services to meet the comprehensive medical, behavioral health and
psychosocial needs of an individual and family, while promoting quality and
cost-effective outcomes.
National Committee for Quality Assurance (NCQA)
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
CARE MANAGEMENT PROCESS
 Population identification
 Comprehensive assessment
 Shared plan
 Monitoring/revisions
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Standard: Patient Identification
PATIENT IDENTIFICATION
 Renal insufficiency
 Low output state
 Diabetes
 Chronic obstructive pulmonary disease
 Persistent New York Heart Association (NYHA) class III or IV symptoms
 Frequent hospitalization for any cause
 Multiple active comorbidities
 History of depression or cognitive impairment
 Inadequate social support, poor health literacy, or persistent nonadherence
to therapeutic regimens
HFSA
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Standard: Assessment
COMPREHENSIVE ASSESSMENT
 Provide comprehensive member assessment

Healthcare Utilization

Community Resource Utilization

Health Status

Medications

Mental Health

ADL/IADLs

Falls Risk

Social Supports

Housing

Transportation

Income

Personal Safety

Legal Issues

Life Care Planning

Caregiver stability
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Standards
COMPREHENSIVE ASSESSMENT
 Provide comprehensive member assessment

Healthcare Utilization

Community Resource Utilization

Health Status

Medications

Mental Health

ADL/IADLs

Falls Risk

Social Supports

Housing

Transportation

Income

Personal Safety

Legal Issues

Life Care Planning

Caregiver stability
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Why comprehensive?
Standard: Care Planning
CARE PLANNING
 Initiate shared plan
 Personal goals
 Health
 Function
 Social
 Behavioral
 Safety
 Life care planning
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Standard: Care Planning
CARE PLANNING
 Facilitate development of the individual’s personal plan
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Standard: Care Monitoring
CARE MONITORING
 Monitor and evaluate the individual’s health status, progress and response to his/her
personal plan

Progress toward goals

Health status

Functional abilities

Mental health

Social issues

Caregiver stability

Self-management skills
 Revise plan
 Coordinate providers
 Facilitate communication
 Access community resources
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Standard: Care Transitions
CARE TRANSITIONS
Hospice
Home
Specialty
Care
Hospital
DME
Mental
Health
Assisted
Living
With
Family/
Friends
Rehab
Social
Services
Nursing
Home
PCP
University of Oklahoma School of Community Medicine Department of Medical Informatics ©
Personal
care and
chores
Home
Health
Care Transitions
TRANSITIONS
POORLY EXECUTED
Redundant services
Inappropriate or conflicting orders
Medication errors
Emergency room visits
Hospital readmissions
Pre-mature nursing home placement
University of Oklahoma School of Community Medicine Department of Medical Informatics ©
Standard: Care Transitions
 Follow across all care settings
 Assess
 Plan
 Monitor
 Collaborate
 Coordinate
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
PROTOCOLS
Urgent Panel
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Protocols
Patient Panel Care Management Protocol
Initial home visit within 7 days
PCP visit within 30 days if not seen in last 3 months
Daily or weekly telephone support for 4 weeks
Clinic
At least monthly telephone contact thereafter
At least quarterly face-to-face visits
Case conferences/staffings
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Protocols
URGENT PANEL PROTOCOL
 Criteria
 Hospitalization within last 30 days related to chronic condition OR
 Any active health condition with an Severity Rating (SR) of 2 or more
Health Conditions Severity Rating (SR)
0 - Asymptomatic, no treatment needed
1 - Symptoms well controlled with current therapy
2 - Symptoms controlled with difficulty, affecting daily functioning, requires ongoing monitoring
3 - Symptoms poorly controlled, person needs frequent adjustment in treatment and monitoring
4 - Symptoms poorly controlled, history of emergent care and re-hospitalizations
 Accelerated time lines
 Schedule and accompany patient to next PCP visit within 10 days if patient has not been
seen in last three months
 Provide 2nd home visit within 2 weeks of initial visit
University of Oklahoma School of Community Medicine Department of Medical Informatics ©
High Touch Protocols
Care Transitions 30 Day Protocol
High Touch
In-hospital assessment
Reconcile medications
Follow-up phone call within 24 hrs.
Home visit within 24-72 hrs.
PCP visit within 5 days
Daily or weekly phone contact
Case conferences/staffings
University of Oklahoma School of Community Medicine Department of Medical Informatics ©
High Touch Protocols
Ongoing Post 30 Days
High Touch
At least monthly telephone contact
At least quarterly face-to face visits
Case conference/staffing
At least monthly telephone contact
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Interventions
HF CARE MANAGEMENT INTERVENTIONS
Preventive
care
Lifestyle
modification
and
Self care
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Medication
reconciliation
Care
transitions
Lifestyle Modification/Self-Care
LIFESTYLE MODIFICATIONS/SELF-CARE
 Provide CHF self-management education and coaching
 Disease process
 Medication purpose, administration, side effects and adverse reactions
 Daily weights
 Activity
 Nutrition
 Alcohol consumption
 Smoking cessation
 Coping with chronic illness
 Life transition planning
 Individualized actions steps
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Lifestyle Modification/Self-Care
DISEASE PROCESS
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Lifestyle Modification/Self-Care
MEDICATIONS
Angiotensin Converting Enzyme
(ACE) Inhibitor
Angiotensin Receptor Blocker
(ARB3.
Diuretic
Beta-blocker
Digoxin
Vasodilator
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Lifestyle Modification/Self-Care
DAILY WEIGHTS
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Lifestyle Modification/Self-Care
ACTIVITY
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Lifestyle Modification/Self-Care
NUTRITION
 Heart healthy
 BMI within normal limits
 Salt limitations?
 Fluid limitations?
 Normal serum albumin
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Lifestyle Modification/Self-Care
COPING SKILLS
Mental health treatment
Physical activity
Relaxation
Favorite activities
Caregiver Support
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Lifestyle Modification/Self-Care
LIFE CARE PLANNING
Health care
Long term care
Life goals
Advanced directives
Will
Power of attorney
Palliative care
End-of-life care
Funeral arrangements
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Lifestyle Modification/Self-Care
ALCOHOL CONSUMPTION
 Women: No more than one drink per day
 Men: No more than two drinks per day
 No alcohol if HF related to alcohol consumption
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Lifestyle Modification/Self-Care
SMOKING CESSATION
Assess for tobacco use
Offer assistance with cessation
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Lifestyle Modification/Self-Care
INDIVIDUALIZED ACTION STEPS
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Preventive Care
IMMUNIZATIONS
 Flu
 Pneumococcal
 Tdap
 Shingles
 Meningococcal
 Hep A
 Hep B
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Medication Reconciliation
RECONCILE MEDICATIONS
Review medication list at every contact
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
Mr. Gomez is a 73 year old who lives with his 71 year old wife a Senior Housing
apartment complex. He was diagnosed with CHF 2 years ago. Since that time, he has
had multiple hospitalizations related to CHF. Prior to each hospitalization he reports
he, “just couldn’t catch my breath” and felt dizzy. He is 5’8” tall and weighs 240 lbs. He
doesn’t smoke or drink alcohol. His doctor gave him a “diet sheet” but he is not using it
because it didn’t include many of the foods he is accustomed to eating everyday. He
says he tries not to use as much salt as he used to and doesn’t drink as much sweet tea
but doesn’t know how much of either is taking in. He tried walking several times a
week but the arthritis in his knees flared up so he stopped. He and his wife used to
“get out a lot” but now all he feels like doing is staying home and watching television.
He has gained 35 lbs. in the last year.
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©
‘WHAT IF…
Mr. Gomez could not afford his medications?
UNIVERSITY OF OKLAHOMA SCHOOL OF
COMMUNITY MEDICINE DEPARTMENT OF
MEDICAL INFORMATICS©