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Systems Support: Care Management Protocols, 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 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 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 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 Registry 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 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 Community linkages Provider communication Registry tracking Care Manager: Patients Familiar with commonly used antidepressant medications, doses Patient education about antidepressants Support medication adherence and recovery Brief interventions Theory-based approaches (MI, PST, etc.) Know when treatment is ‘not working’ Structured symptom assessment (PHQ-9) 8-12 week trial Provider recommendations MHS, PCP Care Manager: Support Several treatment modalities available Examples used with CCM Psychoeducation Problem-solving therapy Cognitive-behavioral therapy Motivational Interviewing Phone, group session formats available Move beyond “adherence” to whole person Care Manager Resources Guidelines medications Self-management materials Common barriers to antidepressant treatment Expected side effects Materials widely available REACH-NOLA IMPACT 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 CM: Customization Cultural competence Role of families Role of religion/spirituality Competing needs 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 CM: Provider 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: 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 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 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: 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 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: 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.) Integrated into routine clinical care Easily updated NOT EMRs NOT research-focused Best if “home-grown” 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 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 Registry Functions Patient risk stratification Tracking and management Patient characteristics facilitating treatment Acute phase Continuation, maintenance Performance feedback Patient process and outcomes 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 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 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 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 . . . . . Customizing the CCM Things to Know Know your stakeholders and get their input (payers, consumers) 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 Customizing the CCM 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 tools and protocols on a day-to-day 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 Access Quality Outcomes