1. Community Health Team Care Management Process PinnacleHealth Systems Becky E. Zook RN, BSN, MS, CCP Grace Eaton, LPN

2. Community Health Team Members Physician Champion Nurse Care Manager LPN Disease Manager Medical Social Worker Behavioral Health Counselor Information Technologies Specialist

3. Care Manager Qualifications

4. Referral Process Patient identification –Manually- encounter with office staff Provider MA CHT member Self –Automatically- high risk stratification report Quarterly on DM, HTN, CHF, CVD, COPD, Depression, Frail Elderly Daily- transitional care report

5. Identify Patients with DM in Panel Determine Low Risk 0-2 pts BP<130/80 A1c<8.0 LDL<100 Medium Risk 3-5 pts BP>130/80<140/90 A1c 8.0-9.0 LDL>100<130 BMI 30-35 Medication  Monitoring  Titration up Labs q6 months Determine Priority Patient Need Labs q3 months Advanced Self Care  DM Education  SM Support  Monitoring  Functional Ability  Transition Care Delivery Mechanism s Pt F/U with Provider Phone F/U Q6 months Care Management  Monitoring (BG, BP, BMI, SM goals, etc)  Titration of meds  Home visit &/or phone F/U Q3 months Class with ADE Social Worker Behavioral Health prn Social Issues  Transportation  $$ for Meds  Abuse  Insurance, etc High Risk >5 pts BP>140/90 A1c > 9.0 LDL>130 BMI >35 Seen in ER/Hosp

6. *Having two or more of the concomitant factors (tobacco use, LDL>130 or HDL<40) moves patient up in risk stratification Stage A: Asymptomatic CHF Stage B: Structural heart disease w/o symptoms Stage C: Structural heart disease with prior/ current symptoms Mild activity intolerance, fatigue Palpitations Dyspnea/angina with activity Comfort at rest Stage D: Refractory CHF requiring specialized interventions Severe activity intolerance, fatigue Dyspnea Angina Fatigue Palpitations at rest Refer to Care Manager Low Risk* Pre-HTN Systolic <120-139 Diastolic 80-89 Moderate Risk* Stage 1 Systolic 140-159 Diastolic 90-99 High Risk* Stage 2 BP> 160/90 Identifying and Managing High Risk Patients HTN

7. COPD High Risk patients will have additional diagnosis and:  OV for acute bronchitis  OV for acute sinusitis  >4 OV in 1 year for COPD  ER or hospitalization for COPD in last 1 year  2 or more other chronic diagnosis Refer to Care Manager Frail Elderly High Risk patients will have metrics and / or diagnosis of:  Age > 65 years  BMI < 15  Dementia or dementia related disease  Personal history of falls Acute Care High Risk patients include:  In-patient Facility  Home Health Care  Transitional Care  Diagnosis of Sepsis CVD High Risk patients will have additional diagnosis of:  DVT  PE  CVA  CAD or MI or PVD  Stage 1 or 2 Hypertension  2 or more other chronic diagnosis Depression, Mental Health High Risk patients will have additional diagnosis of:  Substance Abuse  Drug and/or Alcohol abuse  Tobacco use  MDI 10 score of severe or major depression  2 or more other chronic diagnosis

8. Referral Process Triage and Assignment –Per task status- STAT or Routine –Manually by CM- based upon risk stratifications and qualifying diagnosis, transitional and STAT referrals priority –Initial outreach 1-2 days for STAT referrals 10 days for routine referrals 1-2 days from notification of discharge of transitional referrals

11. Referral Process Successful contact –Documented in EMR following intake or follow up process Unsuccessful contact –3 Attempts documented in the EMR –CHT Unable to Contact letter –Close if no response in 10 days to letter –Task provider

13. Initial Patient Screening Patient identified as appropriate for contact from CM –Introduce CHT, scope and practice, role of CM and self management skills –Discuss trigger diagnosis –Assess prior knowledge of diagnosis –Assess use of hospital or ED in last 4 weeks

14. Initial Patient Screening Patient identified as appropriate for contact from CM –Assess PHQ2 from G.O. intake assessment –Identify needed behavior / lifestyle changes and blockers to change –Identification of care driver- PCP vs specialist –Set initial goals, time to next contact, plan for intake assessment

15. Intake Assessment Initial assessment completed Pt in agreement with services from CHT Documented in the EMR under the appropriate templates for guided assessment Plan for continued Disease Management

34. Care Management Registry Excel file Demographics, Dx, dates of referral, contacts, open/closure of case, interventions, f/u appts, surveys, declination or exclusion criteria LPN- all Disease Management RN- all Hospital and Transitional care Schedule managed in OutLook

35.  Admission information received daily through BI (Business Intelligence) reports  List reviewed for qualifying admissions  Transitional care completed and documented Re-Admission Tracking

36.  Exclusion Criteria  Younger than 18 or older than 75  Inactive patient  Patient receiving skilled services in facility or from agency (SNF, rehab, HH)  Planned procedures/hospitalizations  Active ESRD, St 3 or 4 CHF, Chemotherapy  Hospice/palliative services  Refused services or received from provider alone  NOTE- All excluded patients are eligible for CM services but are not counted in re-admission rates

39. Transitional Care Management Documented using intake process Access hospital and ER records through PHS Connect (HIE) or Soarian in- patient documentation system. Scan to EMR Review hospitalization or ER visit Review safety Schedule PCP follow up appts ID of gaps Care Coordination Self-management skills POC and follow up schedule

40. Transitional Care Management Simple transitional care, completed in 1 contact and case closed Moderate to Complex transitional care, CM with RN for 30 days, then pass to LPN for disease management

44. Monthly Provider Meetings Review of Spread Report Brainstorm regarding areas not at goal Discuss difficult cases Review of new processes or reportables Review of Hospitalizations BI Registry review CHT feedback

45. Outcomes

46. Diabetes PopulationComparative data Measures for Adult DM PatientsPractice Goal April 2010 Data (%) Last Month’s Data Aug 2011(%) Current Data Sept 2011(%) A1C>9<5%175.56.5 A1c<7>70%4463.5<8 =85.4 BP<130/80>70%5282.784.8 BP<140/90>90%6597.497.7 LDL<100>70%4659.260.3 LDL<130>90%637778.9 Smoking cessation counseling>90%92100

47. Outcomes

48. Future Goals Expansion to 2 more FPs by early 2012 Hire 2 additional staff by early 2012 (RN, LPN) Involve MAs for administrative support Fine tune reportables and report processes Complete P/P manual

49. Final Results