Enhancing Care of Indigent Populations Implementation of a Care Manager Core Competency Training Program November 2007 Marshfield Clinic: Eva Scheppa, RN, BSN Mary Dorsch Theodore Praxel, MD Pfizer Health Solutions: Keiko Higuchi, MPH Mary Curry, RN, MN, Consultant ©2007 Pfizer Health Solutions Inc All Rights Reserved

Objectives Introduce Marshfield Clinic and its Community Health Access (CHA) program Describe the Core Competency Training Program (CCTP) and its implementation for the CHA program Demonstrate impact of the CCTP through baseline and follow-up outcomes Identify the potential impact of a CCTP on nurse care manager skill development in preventive health

Marshfield Clinic Over 40 centers throughout northern, central and western Wisconsin 750+ physicians in 80 medical specialties and subspecialties 361,436 patients served per year Patients seen from every county in WI, every state in the nation, as well as 25 foreign countries Located in over 40 centers throughout northern, central and western Wisconsin, Marshfield Clinic has about 751 physicians in 80 medical specialties and subspecialties. Although Marshfield Clinic has become synonymous with the city of Marshfield , the Clinic's "community" goes well beyond the immediate area, embracing nearly all of Wisconsin and much of Michigan's Upper Peninsula.

Community Care and Community Health Access Program (CHA) Helps under- and uninsured patients receive preventive and primary healthcare services on a regular basis Administrative costs supported by state and federal grant funds Patients approved for 6 months of Community Care are referred for CHA Case Management, helping them to: Navigate the health care system more effectively Understand the importance of preventive health care Self-manage chronic conditions

CHA and Case Management Case Managers are trained nurses who promote patient empowerment by providing: As Case Managers help patients become effective self-managers, they carry out many roles: Information Support Tools Care Coordinator Health Educator Coach & Motivator Change Agent NEW SLIDE: Sample Speaker Notes TBD

Care Manager Core Competencies The Core Competency Training Program (CCTP) Helps assess the needs of the Nurse Case Managers in order to build their skills Provides a quantitative way to assess and enhance quality on an individual and team basis 1 Professionalism and teamwork 2 Clinical competency 3 Problem solving skills 4 Communication skills 5 Technical abilities Not only has Marshfield Clinic implemented an innovative strategy that provides disease management to an unlikely population, but it has also began implementing a care manager Core Competency Training (CMCCT) Program. This program provided Marshfield a quantitative means by which the quality of Care Management services could be assessed and enhanced on an individual and team basis and focused on five domains. Five core competencies domains are: (1) professionalism and teamwork (2) clinical competency (3) problem solving skills (4) communication skills, and (5) technical skills This care manager competency framework was built upon a set of flexible tools that was adapted for the CHA program to identify, track and coach or strengthen key competencies. Specifically, the CHA program supervisor used CMCCT tools to conduct a pre-assessment for baseline competency, monitor calls, audit charts, set educational plans, and a follow up with post-assessment activities for individual care manager development over time. The five core competency domains

Knowledge & Skills Inventory Staff Development Planning Tool CCTP Assessment Tools Knowledge & Skills Inventory Examples of the specific knowledge and skills associated with each of the core competency domains for new and experienced Case Managers Sup & CM Assessment Interviewing Guide Guidelines for conducting interviews to help assess competencies of the candidate Chart Audit Tool Format for assessing the completeness and quality of documentation Call Monitoring Tool Guidance on how to assess the quality of a Case Manager’s telephonic interactions with a patient Staff Development Planning Tool Documentation and guidance to establish a plan for individual and team development

Developing Staff Competencies Training & Additional Staff Development Principles of Motivational Interviewing 10 Strategies of Change Talk Helpful Responses Readiness Ruler Three in a Row Batting Practice Feb Mar Apr May Jun Jul The purpose of the CMCCT Program was intended to provide the organization with specific, practical ways to assess and enhance the quality of care management services. In Feb 2007 Marshfield Clinic implemented the CMCCT program to assess the needs of the nurses and to build the skills of the nurses caring for patients. The 5 Competency Domains provided the structure for assessing care management competencies and to ensure a consistent context. Each competency domain contains specific skills and attributes corresponding to that area, utilizing a 5 point Likert Scale, although some skills do overlap. For example, “good communication skills” may be needed within more than one domain. Performance Management Call Monitoring Chart Auditing Individual Development Planning Baseline Self & Supervisor Assessment Follow-Up Self & Supervisor Assessment Resource: www.motivationalinterview.org

Competency Assessment Results Self Assessment Competency Preliminary Data – Baseline Promotoras Control Group Follow-Up % Change Demographics* (N=48) (N=59) Professionalism and Teamwork 4.3 4.7 9% % Female 69% 67% Clinical Competence Mean age (yrs) 57.8 3.9 60.0 4.2 7% Problem Solving Skills Mostly or only Spanish spoken at home (%) 94% 3.8 97% 4.3 12% Communication Skills % with annual income < $10,000** 65% 4.2 4.4 67% 4% Technical Abilities % with < HS education 91% 3.4 4.4 93% 23% Supervisor Assessment Competency Preliminary Data – Baseline Promotoras Follow-Up Control Group % Change In July 2007 a post assessment was conducted to compare to the initial baseline analysis. Here progress is demonstrated in the teams overall post self assessed improvement. There was marked improvement in each domain with Technical Skills being impacted the most. Technical Skills are more tangible and easier to rate but also very important because technical skills began at a lower rating in the original ratings and supported through training. The Supervisor post assessment also demonstrated marked improvement with technical being the most improved. Demographics* (N=48) (N=59) Professionalism and Teamwork 4.0 4.3 7% % Female 69% 67% Clinical Competence 3.9 4.2 7% Mean age (yrs) 57.8 60.0 Problem Solving Skills 3.6 4.0 10% Mostly or only Spanish spoken at home (%) 94% 97% Communication Skills 3.0 3.7 19% % with annual income < $10,000** 65% 67% Technical Abilities DATA ON FILE % with < HS education 91% 4.1 4.5 93% 9%

Key Benefits The Core Competency Training Program: Provided quantitative and qualitative means for staff selection Provided a practical and consistent process to assess the quality of case management services Helped identify areas for further individual/team development Contributed to continuous quality improvement (CQI) Contributed to overall program success Some of the Key Benefits identified by during the CMCCT Program was it: Provided quantitative and qualitative means for staff selection Provided a practical and consistent process to assess the quality of care management services Helped identify areas for further individual/team development Contributed to continuous quality improvement (CQI) Contributed to overall program success

Conclusion A Core Competency Training Program is needed to: Meet the challenges of disease management settings Create a standardized method of assessing practice Provide a framework for development of Case Manager core competencies 1 Professionalism and teamwork 2 Clinical competency 3 Problem solving skills 4 Communication skills 5 Technical abilities The shift in health issues from acute to chronic diseases has profoundly changed the delivery of health care services in the U.S.. Disease management programs are becoming venues to address the challenges of an ever-growing chronically-ill population. Care managers, in particular have been charged with meeting these challenges within disease management settings. As in any healthcare environment it is important to create a standardized method of assessing practice in order to ensure the appropriate delivery of care. The care manager competency program provided the framework for identifying core competencies among care mangers within disease management settings.

Effectiveness Next Steps― Performance management Case Manager satisfaction Skill development Improved outcomes This framework offers a promising quality improvement approach for reducing operational ineffectiveness, and also provides the structure for identifying the individual educational needs of the Care Manager. Training focused on improving global issues, affecting the greatest number of Care Managers and patients, can lead to reduction of operational ineffectiveness and program-wide improvements. Training also focused on the needs of individual Care Managers will ensure individual growth and success. Through skill development, improved outcomes follow all leading to CM satisfaction. This will continue as part of the Care Managers annual goal setting of Marshfield Clinic to ensure management support of CM skill development. The extent to which core competencies influence care manager practice largely depends on the adoption by health care organizations; however we believe that the care manager competency program is essential for not only identifying the “key areas of knowledge, skill, and behavior” that are important for care management practice, but for also enhancing the quality of care management services and operational effectiveness but also satisfaction thus impacting retention. Quality improvement

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