1. Systems Support: Care Management Protocols, Disease 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

2. SMITREC 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

3. Implementation  Care Management Guidelines  Patient Registries  Other Tools

4. Wagner Chronic Care Model Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Community Health Care OrganizationResources and Policies

5. CCM: Core Clinical Elements Leadership Practice Design Clinical Information Systems  Vision  Resources  Care management  Protocols- coordinated care  Clinical information tracking  Feedback to clinicians

6. CCM: Core Clinical Elements Decision Support Self-management Support Community Resources  Guidelines  Expert/specialist consultation  Patient preferences  Information on treatment  Information on and for consumers, groups, etc.  Access to non-provider sources of care

7. Care Manager Role General Medical (Chronic care, Prevention, Follow-up) Care Manager Self-management Liaison: PCP, MH Crisis intervention Behavioral Health (crisis referral for ICM, etc.)

8. Care Manager: Skills  Tracks depressive symptoms and treatment response (PHQ-9)  Consults with team psychiatrist  Collaborates closely with patient’s primary care provider (PCP)  Provides follow-up and recommendations to PCP who prescribes antidepressants  Facilitates referrals to specialty, community  Prepares for relapse prevention

9. Care Manager: Skills  Familiar with commonly used antidepressant medications, doses  Patient education about antidepressants  Support antidepressant medication adherence  Know when treatment is ‘not working’

10. CM: Self-management  Eliciting concerns/barriers  Problem-solving  Providing information  Clarifying preferences  Encouraging informed decision-making  Teaching skills  Monitoring progress  Reinforcing self-management  Community resources

11. CM: Self-Management Tools  Medication lists  Pillboxes  Appointment reminders  Healthy behaviors  Pleasure activities list

12. CM: Therapeutic Alliance  Cultural competence  Role of families  Role of religion/spirituality  Competing needs

13. CM: Liaison  Relay concerns/progress  Refills  Symptoms and side effects  Urgent, emergent protocols  Medical record documentation  Cue providers if no improvement  Supplement, not replace providers

14. CM: Liaison  Help patients and providers ID  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

15. 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. Bipolar disorders, in press 2008 Kilbourne AM. Psychiatric services, under review, 2008

16. 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

17. CM: Crisis Intervention  Suicidal ideation- coordinate with clinic  Protocols  On-call numbers  Missed appointments  Immediate follow-up

18. CM: Suicidal Ideation If the patient articulates thoughts death/suicide:  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?

19. Care Manager Registry  Registries are...  Simple tools to track patient progress (K.I.S.S.)  NOT EMRs  Best if “home-grown”  Facilitate structured patient contacts  Types of registries, pros and cons  Excel file  Web-based

20. Developing Registries Things to Know  Know your stakeholders and get their input (purchasers, payers)  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

21. Developing Registries 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 registry 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

22. Registry: Sample Fields General information (update at each contact):  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:  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

23. Registry Examples  SMAHRT  IMPACT

24. Care Manager Toolbox  Self-management materials  Antidepressant medication list  Registry file  Provider contact sheet  Preferences  Crisis intervention  Operations manual

25. Care Manager 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

26. Care Manager Subsequent Visit  Upcoming appointments  Registry- ongoing tracking