1. Shared Care Plans Aimee English (AF Williams) Jaclyn King (HealthTeamWorks) Kerry Salter (SFMR) 1 © 1996-2014 HealthTeamWorks Reprint with Permission Only

2. Learning Objectives By the end of this session participants will be able to: Explain the value of the shared care planning process and shared care plans as documents. Summarize the implementation of shared care plans from two residency practice examples. Improve or apply concepts of shared care plans to your practice. 2 © 1996-2014 HealthTeamWorks Reprint with Permission Only

3. Shared Care Planning A collaborative process that engages patients, families, providers, the care team and community partners to focus together on: patient centered shared decision making active patient engagement self-management support communication among and across multidisciplinary care teams A collaborative document used to structure the clinical information, goals and activities of the patient.

4. Shared care plan in context: Care Compact: a framework for standardized communication between primary care and medical neighbors to improve care transitions for patients. Care Plan: a document of how a patient can manage their day to day health, often located in the clinical notes. Shared Care Plan: A co-created document to keep track of important information and a health improvement plan for the patient that can be shared with family and other health care providers. 4 © 1996-2014 HealthTeamWorks Reprint with Permission Only

5. Value of Shared Care Plans Focuses on the whole health of the patient Is a tool for patient engagement Creates a team-based approach to providing care Provides the opportunity to integrate care, clinical information and goals across health care settings Builds relationships & improves communication between medical neighbors (smoother care transitions) Provides more efficient and high quality clinical care Other? © 1996-2014 HealthTeamWorks Reprint with Permission Only 9

6. Instead of speaking for the patient and saying…. Patient problem list Clinical recommendations or clinical care plan Patient to dos Next appointment with PCP Diagnoses such as Diabetic patient, obese patient or depressed patient Try having the patient speak for themselves by asking… What are your concerns? What are your life goals? How I will achieve your goals. Actions items for: Patient/Family, Care Team (Providers, medical assistants, health educators) & other resources. Next steps including use of patient portal for communication, patient update the care team & next appointment(s). Patient experiencing depression, person with goals of weight management or diabetes management Shared Care Plan: A Philosophy

7. Swedish Family Medicine Residency

8. Care and Medication Management Documentation (Macro(s)) -For patients with our designated clinically important conditions (Diabetes, Ischemic Vascular Disease, Depression) and complex patients (those recently hospitalized) care management documentation must be entered into the visit if the care plan changes (i.e. – if it is addressed at the visit). -This is achieved by using the Care Coordination macros. This is accessed by clicking the browse button in the assessment notes screen. -The macros will no longer be attached to the specific disease related ICD codes as was done in the past. -Instead, attach the Care Coordination macros to the diagnosis code – “Counseling and Coordination of Care.” This exact phrasing must be entered to search for the code. DO NOT search under the IDC 9 code V65.49 because there are many different titles under this number.

9. Swedish Family Medicine Residency -Enter information for diabetes/IVD/Depression and hospital follow up care management in the single Care Coordination macros. -Save this ICD9 code to the problem list in the assessment screen to ensure that the information carries forward. -This should be updated whenever addressing one of these specified conditions (i.e. – whenever you enter the ICD 9 code into a visit note).

10. Swedish Family Medicine Residency Macros defined Medications: Medication understanding (3D:3) (pt’s level of understanding) Answer: Y/N Need for medication education (3D:4) (does pt need med education? Answer: Y/N Date provided (3D:4) (if so, date) Answer: not needed if no medication education provided, date if medication education provided Barriers to medication adherence (3D:5) (does pt not understand how to take medications, etc) Answer: Y/N Care Management: Motivational interviewing (4A:5) (motivational interviewing needed?) Answer: Y/N Need for coaching/care management (4A:1) (Need for coaching/need for care management) Answer: Y/N Readiness to change (4A:4) (pt’s level of activation) Answer: precontemplative, contemplative, preparation, action, maintenance Education resources given (3C:6) (Healthwise or other education material) Answer: Y/N Self management tools (4A:5) (blood pressure diary, blood sugar diary, diet diary provided to pt) Answer: Y/N Barriers to care (3C:4) (social determinants of health, etc) Answer: list barrier(s) Goals of care (3C:3) – (weight loss, improve labs, etc) Answer: list goal(s) After defining goals of care, paste goals into the treatment section so that goals populate the after visit summary

11. Resources HealthTeamWorks Guides: Treatment Tracking Log for Depression Patient Handout: What is Type 2 Diabetes? Shared Care Plans: A Reference Guide

12. Shared Care Planning at UCH Family Medicine Residency Aimee Falardeau Practice Transformation Fellow

13. Outline Overview of 3 ways Shared Care Plans have been/are being Review template Successes/failures/lessons learned

14. 3 Areas of Shared Care Plan Use over the Years Care Team Inpatient Discharge Planning Shared Care Plan Visits

15. 3 Areas of Shared Care Plan Use over the Years Care Team Meeting 1 hour long twice monthly multidisciplinary meeting attended by 3 rd year residents on outpatient months, pharmacy residents and/or faculty, psychology interns, fellows, and/or faculty, care manager Meeting process: -- resident reviews a complex patient’s case -- team solicits unanswered information regarding case -- team offers advice within their given field -- resident decides on next steps of action to be taken in this patient’s care Shared Care Plan document is generated for this patient Care Team Meeting 1 hour long twice monthly multidisciplinary meeting attended by 3 rd year residents on outpatient months, pharmacy residents and/or faculty, psychology interns, fellows, and/or faculty, care manager Meeting process: -- resident reviews a complex patient’s case -- team solicits unanswered information regarding case -- team offers advice within their given field -- resident decides on next steps of action to be taken in this patient’s care Shared Care Plan document is generated for this patient

16. - shows up in top of snapshot -uses an epic dot phrase as template -dates when it was created and updated -seen by anyone who opens the chart -linked with an FYI, so that a BPA pops up

17. SCP Template Components One-liner on patient Approach to patient care by triage nurse Approach to patient care by ED Care Team members (with contact info if outside system) including: PCP, care manager, living facility, social worker, specialists, MD-POA, etc. Active Issues/Problem List (for chronic issues) with long-term plan “Essential Care Issues” (i.e. advance directives, social/family support, spiritual beliefs, transportation needs, housing, language, cognitive limitations) Self Management Goals

20. 3 Areas of Shared Care Plan Use over the Years Inpatient Discharge Planning Same template used, except top part changed to include: - Date of recent admission/discharge - contact info for discharging resident and attending - reason for hospitalization - immediate action items for follow up visit Shared Care Plan document is generated for this patient Target population – complex patients being discharged from our inpatient service with follow up in our clinic; occasionally high utilizers following up in other clinics Inpatient Discharge Planning Same template used, except top part changed to include: - Date of recent admission/discharge - contact info for discharging resident and attending - reason for hospitalization - immediate action items for follow up visit Shared Care Plan document is generated for this patient Target population – complex patients being discharged from our inpatient service with follow up in our clinic; occasionally high utilizers following up in other clinics

21. 3 Areas of Shared Care Plan Use over the Years Shared Care Plan Visits Same concept as Care Team except in the form of a 1 hour multidisciplinary office visit - Occurs in the exam room - Coded as a 99215 - uses a collaborative agenda setting form to guide discussion - scheduled by Care manager Shared Care Plan document (and clinic visit note) is generated for this patient Target population – complex patients as determined by internal complexity scoring system Shared Care Plan Visits Same concept as Care Team except in the form of a 1 hour multidisciplinary office visit - Occurs in the exam room - Coded as a 99215 - uses a collaborative agenda setting form to guide discussion - scheduled by Care manager Shared Care Plan document (and clinic visit note) is generated for this patient Target population – complex patients as determined by internal complexity scoring system

22. Pros/Cons of the 3 SCP Uses Care Team: Pros: Way to involve multi-disciplinary learners Gets lots of input in a 1 hour session from multiple areas of expertise SCP easily viewable in Epic by anyone in patient’s chart FYI alerts ED providers who may not look at pt snapshot Forces provider to do a deep dive into patient’s chart Cons: Time consuming for resident to review chart, document entire SCP Up to provider to make SCP a living document Patient is not directly involved Other unrepresented voices exist: family, outside social worker, specialists, outside case managers, etc. Difficult to upscale (only 2 done per month)

23. Pros/Cons of the 3 SCP Uses Discharge Planning: Pros: Centralized a “to do” list for provider seeing pt in hospital follow up (if they looked at both the snapshot and the d/c summary) Cons: Extremely time consuming for residents to double document d/c summary and SCP.

24. Pros/Cons of the 3 SCP Uses Shared Care Visits: Pros: Patient was involved Worked well for patients poised for immediate benefit from those involved Required advanced collaborative agenda setting and facilitation skills on the part of the provider Helped arrange consistent follow up before patient left Benefited when it linked those without continuity of care to their care team and when it served as a jumping off point with the most needed care Cons: Sometimes had unneeded cooks at the table (i.e. right care, wrong time) Scheduling NIGHTMARE Potentially difficult format for anxious patients

25. What’s Being Done Now Care Team Rare Shared Care Visits (hoping to get back off the ground with hiring of care manager) Immediate action items for hospital follow up visit as part of discharge summary

26. What ideas can you share for keeping Shared Care Plans a living, updated document?

27. Discussion & Questions

28. Resources https://www.sharedcareplan.org

29. Thank You 29 © 1996-2014 HealthTeamWorks Reprint with Permission Only