Disclosures Case Management for Socially We have nothing to - - PowerPoint PPT Presentation

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Case Management for Socially and Medically Complex Patients

Devora Keller, MD Medical Director, Emergency Department Case Management Program Assistant Clinical Professor, UCSF Elizabeth Davis, MD Medical Director of Care Coordination, San Francisco Health Network Primary Care Assistant Clinical Professor, UCSF

Disclosures

We have nothing to disclose

Objectives

• Describe interdisciplinary models of care for

complex patients

• Review the characteristics of successful case

management programs

• Review the skills necessary to partner with case

managers in the care of complex patients

Case

• Mr. W is a 62 year old man with CHF, CAD,

homelessness, and cocaine use disorder with frequent ED visits and admissions for chest pain and shortness

• f breath in the setting of cocaine use and difficulty

managing his medications. He infrequently engages with care and and is difficult to find between hospitalizations. He does not go to shelters or have a functioning cell phone.

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Problem

• Five percent of patients account for 50% of health-

care costs.

• Often these pts are poor and have high rates of

chronic disease, mental illness, and/or addiction.

• Multiple barriers to effective care: homelessness,

low literacy, social isolation, language barriers, addiction, and mental illness.

• Barriers to health care result in high rates of ED

visits and hospitalizations, driving high costs

Challenges: System

• Poorly integrated medical, psychiatric, addiction

and social services.

• Insufficient self management coaching leaves

patients unable to manage their chronic conditions

• Inadequate support with complicated medication

regimens leads to medication errors and non- adherence

• Lack of caregiver support and/or transportation

support limits patients’ ability to follow-up.

Challenges for providers

• Providers are overwhelmed by the patient’s

complex social situation

• Providers do not feel competent to address

complex care issues such as homelessness

• Providers lack the skills to recognize and leverage

patient strengths and resiliency factors

• Overcoming language differences can feel

impossible

• Real or perceived cultural biases may impede

effective alliances between patients and providers.

Challenges for patients

• Competing personal priorities (the search for food,

housing, and safety) interfere with accessing medical care.

• Mental illness and/or substance use interfere with

patients’ follow up

• Lack of social support makes self-management

challenging

• Other issues –lack of trust, language, costs- are

barriers to seeking care.

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A Brief History of Case Management

1970s 1970s

Case management for patients with severe mental illness

1980 1980

Medicare demonstration projects

1990s 1990s

HMO-based nurse case management Homelessness focused case management

2010s 2010s

Primary care- based complex care management Health Homes

Craig, C; Eby, D; Whittington, J. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. Institute for Healthcare Improvement, 2011. BerryMillett R, Bodenheimer TS. Care management of patients with complex health care

• needs. Synth Proj Res Synth Rep. 2009 Dec;(19)

Shared Characteristics of Effective Care Management Programs

• Systematic process for identifying high risk patients
• Comprehensive patient assessment on enrollment
• Interdisciplinary care plans
• Tracking progress of care plan goals
• Reduce barriers to care at the system, provider,

and patient level

• Include face to face visits

BerryMillett R, Bodenheimer TS. Care management of patients with complex health care needs. Synth Proj Res Synth Rep. 2009 Dec;(19)

12

Learn to Operate Sustainably at Full Scale: 5 to 25 to 125 to ….

Steps of Program Design

From: Institute for Healthcare Improvement, Better Health at Lower Cost Collaborative Choose your population and learn about its assets and needs Choose your population and learn about its assets and needs Develop and test out your enhanced care design Develop and test out your enhanced care design Revolutionize patient engagement Revolutionize patient engagement Iteratively improve your enhanced care model to fit the assets and needs of your population Iteratively improve your enhanced care model to fit the assets and needs of your population Strengthen partnerships within and

• utside of

your

• rganization

Strengthen partnerships within and

• utside of

your

• rganization

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Variability in Program Design

• Duration of services
• Intensity of services
• Focus of services
• Availability
• Length and approach to engagement period
• Location of services

Clinic based Free standing Outreach/home-based

Successful Program Models: Primary care based – Ambulatory ICU

• Intensive primary care
• Efficient utilization of specialty services
• Employer based: Boeing, Stanford, Atlantic City

Casino Workers Union

• Safety net: Hennepin County Medical Center,

Denver Health

Bodenheimer, T. Strategies to reduce cost and improve care for high utilizing Medicaid patients: Reflections on pioneering programs. Center for Health Care Strategies, October 2013. Redesigning Primary Care For Breakthrough in Health Insurance Affordability Model I: The Ambulatory Intensive Caring Unit. August 2005, California Health Care Foundation

Successful Program Models: Primary care based – Wrap around

• Patients keep their PCP
• Interdisciplinary, usually nurse-led, team provides

supportive services

• San Francisco Health Network

Nurse-health coach dyad with MD and SW support 50% fewer hospital days after enrollment

• Cambridge Health Alliance

Nurse-SW dyad with MD support 40% fewer hosp days; 30% lower cost

Successful Program Models: Health Plan Based

• Community Care of North Carolina

Face to face visits in hospital, home, primary care

• ffice

Focus on safe transitions in care, self management,

medications

Nurse led with strong pharmacy component Hospitalizations state-wide decreased 10.5% Readmissions state-wide decreased 10.2%

DuBard CA, Cockerham J, Jackson C. Collaborative accountability for care transitions: the community care of North Carolina transitions program. N C Med J. 2012 JanFeb;73(1):3440

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Successful Program Models: Community Based and Street Outreach Emergency Department Case Management Program

• MSW based intensive case management program
• Wrap around medical services
• Linkage to housing, entitlements, primary care,

mental health, substance abuse services

• Direct mental health and SUD counseling

Outcomes:

• Decrease in ED usage
• Decrease in hospitalizations (not statistically sig)
• Decrease in homelessness
• Decrease in problem drinking.

Shumway M, Boccellari A, O’Brien K, Okin RL. Costeffectiveness of clinical case management for ED frequent users: results of a randomized trial. Am J Emerg Med. 2008 Feb; 26 (2): 15564

Successful Program Models: Community Based and Street Outreach Case Continued

After extensive street outreach efforts, Mr. W engaged with a case manager with the Emergency Department Case Management Program

• Engaged and learned self-management skills
• Started taking medications
• Though motivational interviewing by CM decided to

enroll in residential treatment program

• On graduation from residential program linked to

long-term housing

Successful Program Models: Homeless Focused Chicago

• Post hospitalization transitional housing with

linkage to long term housing

• Housing-based MSW led case management
• Randomized controlled trial

Outcomes:

• 24% decrease in hospital days
• 29% decrease in emergency department visit

Sadowski LS, Kee RA, VanderWeele TJ, Buchanan D. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA. 2009 May 6;301(17):17718.

Best Practices for Collaborating with Members of the Case Management Team

• Understand the role/ scope of practice of various

members of the team – ask for clarification if needed!

• Maintain active communication and collaboration
• Support each other and avoid opportunities for

client splitting

• Recognize differences in language and approach

between different disciplines on the team

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Case Continued

While in residential housing, Mr W relapsed. He had a strong relationship with his case manager and asked for help.

Case manager re-linked with residential treatment

program

He continued to use self-management skills He remained out of the ED and hospital despite

relapse

Recently graduated from residential treatment,

reconnected with his family, is doing well in the community

Which of the following is a core component of all case management programs for highrisk patients?

A.

Track patients’ hemoglobin A1cs

B.

Perform home visits

C.

Formulate interdisciplinary care plans

• D. Link to

psychiatric care

Track patients’ hemoglob.. Perform home visits Formulate interdisciplin... Link to psychiatric care

2% 0% 96% 2%

Summary

• High users of care tend to have high rates of

poverty, chronic disease, mental illness, and addiction.

• Interdisciplinary teams provide perspectives from

multiple professions and reduce barriers to adequate care at the system, provider, and patient level.

• There is no one-size-fits-all approach; each

program must be tailored to the local population.

Thank you!

Kathy O’Brien and the EDCM team SFHN Complex Care Management team Debra.keller@ucsf.edu Elizabeth.davis@ucsf.edu