CARE MANAGEMENT AND HEART FAILURE Preventing Re-admissions UNIVERSITY OF OKLAHOMA SCHOOL OF COMMUNITY MEDICINE DEPARTMENT OF MEDICAL INFORMATICS© Care managers are expected to have the same level of knowledge that people with HF need to self- manage.

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 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 UNIVERSITY OF OKLAHOMA SCHOOL OF COMMUNITY MEDICINE DEPARTMENT OF MEDICAL INFORMATICS©

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©

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: Patient Identification

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© 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© Why comprehensive? Standards

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 Planning

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 Monitoring

CARE TRANSITIONS University of Oklahoma School of Community Medicine Department of Medical Informatics © Hospital With Family/ Friends Home Nursing Home Rehab Assisted Living Specialty Care Social Services Hospice Home Health DME Mental Health Personal care and chores PCP Standard: Care Transitions

TRANSITIONS POORLY EXECUTED Redundant servicesInappropriate or conflicting ordersMedication errorsEmergency room visitsHospital readmissionsPre-mature nursing home placement University of Oklahoma School of Community Medicine Department of Medical Informatics © Care Transitions

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 UNIVERSITY OF OKLAHOMA SCHOOL OF COMMUNITY MEDICINE DEPARTMENT OF MEDICAL INFORMATICS© 30 Days Post - Hospitalization Ongoing Post 30 Days Patient Panel Urgent Panel

Clinic Patient Panel Care Management Protocol Case conferences/staffings PCP visit within 30 days if not seen in last 3 months Daily or weekly telephone support for 4 weeks At least monthly telephone contact thereafter At least quarterly face-to-face visits Initial home visit within 7 days 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  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 2 nd home visit within 2 weeks of initial visit University of Oklahoma School of Community Medicine Department of Medical Informatics © Protocols

In-hospital assessment Reconcile medications Follow-up phone call within 24 hrs. Home visit within hrs. PCP visit within 5 days Daily or weekly phone contact Care Transitions 30 Day Protocol High Touch Case conferences/staffings University of Oklahoma School of Community Medicine Department of Medical Informatics © High Touch Protocols

Ongoing Post 30 Days High Touch Case conference/staffing At least monthly telephone contact At least quarterly face-to face visits At least monthly telephone contact UNIVERSITY OF OKLAHOMA SCHOOL OF COMMUNITY MEDICINE DEPARTMENT OF MEDICAL INFORMATICS© High Touch Protocols

HF CARE MANAGEMENT INTERVENTIONS Lifestyle modification and Self care Medication reconciliation Care transitions Preventive care UNIVERSITY OF OKLAHOMA SCHOOL OF COMMUNITY MEDICINE DEPARTMENT OF MEDICAL INFORMATICS© Interventions

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 UNIVERSITY OF OKLAHOMA SCHOOL OF COMMUNITY MEDICINE DEPARTMENT OF MEDICAL INFORMATICS© Lifestyle Modification/Self-Care Caregiver Support

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© Lifestyle Modification/Self-Care

IMMUNIZATIONS  Flu  Pneumococcal  Tdap  Shingles  Meningococcal  Hep A  Hep B UNIVERSITY OF OKLAHOMA SCHOOL OF COMMUNITY MEDICINE DEPARTMENT OF MEDICAL INFORMATICS© Preventive Care

RECONCILE MEDICATIONS Review medication list at every contact UNIVERSITY OF OKLAHOMA SCHOOL OF COMMUNITY MEDICINE DEPARTMENT OF MEDICAL INFORMATICS© Medication Reconciliation

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.

‘WHAT IF… UNIVERSITY OF OKLAHOMA SCHOOL OF COMMUNITY MEDICINE DEPARTMENT OF MEDICAL INFORMATICS© Mr. Gomez could not afford his medications?