Download Care Manager Registry

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
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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
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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
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Medication lists
Appointment reminders
Healthy behaviors
Pleasure activities list
 Pillboxes
 Medication information
 Websites
CM: Customization
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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
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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
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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:
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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
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Identify, manage, and track patients
Facilitate patient contacts
Provide patient visit summaries
Provide real-time data on tx response, etc.
Reminders
Performance feedback
Registries
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Other data sources (e.g., pharmacy, EMR)
should NOT replace a registry
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BUT can be used to:
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Improved patient identification (top conditions)
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Enhance performance measurement
Challenges to using electronic data
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Cumbersome to update and merge
Time lag
 Data not available on all patients
 Privacy and security issues
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Registry Functions
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Patient risk stratification
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Tracking and management
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Patient characteristics facilitating treatment
Acute phase
Continuation, maintenance
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Performance feedback
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Patient process and outcomes
Key Registry Variables
 Dates
 Patient contact information
 Best number, time to call, and leave message
 Status
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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):
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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:
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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
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Adequate staffing, who should update?
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Research vs. clinical use
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Integrating into routine care
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How identified patients are entered
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Involving PCP
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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