Complex Care Management What is it, and how do we begin? Emily Brandenfels, MD February 16, 2016

Goals Gain an understanding for basics of complex care management (CCM) Spend time with teams working through some of the elements of CCM Learn about broader context of CCM

Complex Care Management Brief description: A model which provides infrastructure that allows us to effectively care for individuals who are physically, behaviorally and socially complex

Multiple Steps Required for Success Engage Leadership Engage Employees Adopt a quality improvement methodology/tools Use data and measurement to guide systems Define, stratify and identify the population Build a multi-disciplinary complex care team Offer integrated, complex care management Engage individuals and supports in whole health Develop sustainability plan There are many steps required to build a successful CCM program. We are going to focus on three of them this afternoon.

Case Study Ms. Cruz is 55 years old woman with known DM and HTN who comes in complaining of knee pain since last year. She has not been seen in over a year. On examination, BP is 188/90 (dangerously high) and you smell EtOH. Blood sugar is 280 (dangerously high), and PHQ-9 is 19 (moderate to severe). She has a black eye and though married, is currently staying with her sister. She tells you that “I react strongly to medications and I don’t like to rely on chemicals for treatment. I had a bad experience in the past with my previous heart doctor and I don’t want to go back.” We are going to start by considering some clinical scenarios. It’s important to continue to remind ourselves what this work is all about. It also makes it far easier to visualize, when using some concrete examples. Take 15 minutes to discuss amongst your teams

Table Top Discussion Questions In your current environment, what are the gaps in care for Ms. Cruz? What tasks/activities need to occur to better address Ms. Cruz’ needs?

Definition of Complex Care Management A practice of providing integrated, coordinated, team based clinical care, Which is patient centered and ensures each patient has his or her own coordinated plan of care. When care is coordinated the patient's needs and preferences are known ahead of time, Communicated at the right time to the right people, This information is used to provide safe, appropriate, and effective care to the patient. Care management includes addressing social determinants of health, Transitions of care, Population health management, Measurement-based treatment. Example 1: her main complaint was knee pain, what WAS Mr. Han’s main complaint? Example 2: If it is known that Mr. Han is fearful of doctors and has trouble in waiting rooms, what might be done? Perhaps a home visit, or accompanying him? For Ms. Cruz, knowing about her reluctance to take medications might be helpful for providers to know ahead of time, so they don’t bombard her with a list of new prescriptions.