NURSE CASE MANAGEMENT REDESIGN PROJECT: LOS ANGELES COUNTY CALIFORNIA CHILDREN’S SERVICES (CCS) P RESEN TER: M A RY D O YLE, M D , FA A P SEP TEM BER 1 0 , 2 0 1 4 FA M ILY V O IC ES W EBIN A R: N UTS A N D BO LTS O F C C S 1
BACKGROUND am : CCS Pr ogr Co ve rs a dive rse se t o f me dic a l c o nditio ns CCS Patie nts/ F amilie s: Ne e d c a re c o o rdina tio n o n a c a re c o ntinuum spe c trum dination Mode l : CCS Car e Coor T ra ditio na lly, the sa me fo r e ve ryo ne Pr oble m: T he mo st ne e dy a re unde rse rve d 2
LA COUNTY CCS EXPERIENCE ving: 45,000 c lie nts in the g e ne ra l pro g ra m; 5,000 in the MT P • Se r oc e ssing: 2500 ne w re fe rra ls a mo nth • Pr • Case load/ mix: a ve ra g e o f 650 c a se s/ nurse ; ra ndo m a sso rtme nt • Analysis of a sample of 2000 patie nts in Apr il 2013: ~60% - a c ute a nd like ly to re so lve in 1 ye a r o r le ss o r c hro nic b ut stra ig htfo rwa rd to ma na g e ~40% - c hro nic a nd c o mplic a te d • Conc lusion: o ne c a se ma na g e me nt mo de l do e s NOT fit a ll! 3
THE IDEA • Sort by c omple xity of the CCS c ondition • Assign c omple x c ase s to one group of nurse s and non-c omple x one s to anothe r • Adjust the c ase loads: nurse s with the c o mple x c a se s wo uld c a rry le ss; nurse s with the no n-c o mple x c a se s wo uld c a rry mo re • Assign e ac h c ase a he alth status group: ta ke s into a c c o unt a ll o f ne e ds o f the pa tie nt a nd his o r he r fa mily • Matc h le ve l of c are c oordination to c omple xity of ne e d • T rac k me aningful data 4
EXPECTED OUTCOMES Ove r all and In Ge ne r al: I mpro ve d c a se ma na g e me nt fo r a ll pa tie nts in the CCS pro g ra m m and Spe c ific ally : L ong te r Answe rs to the se q ue stio ns 1. Whic h inte rve ntio ns he lp? Whic h do n’ t? 2. Whe re a re the ine ffic ie nc ie s in o ur syste ms? 3. I s CCS me e ting the ne e ds o f o ur pa tie nts, fa milie s, pro vide rs a nd sta ff? 5
THE PILOT • L aunc he d: F e b rua ry 10, 2014 • T ar ge t gr oup: 4000 CCS pa tie nts – mix o f ne w & e xisting c a se s • Sor te d by c omple xity: no n-c o mple x ve rsus c o mple x • Assigne d to one of 8 nur se s: 4 nurse s with 250 c o mple x c a se s e a c h 4 nurse s with 750 no n-c o mple x c a se s • Assigne d a he alth status gr oup: ra ng e s fro m 2 to 9 • Inte r ve ne d: c a se ma na g e me nt a c tivitie s diffe re d de pe nding o n c o mple xity a nd he a lth sta tus g ro up 6
THE PILOT ACTIVITIES • Case Manage me nt Ac tivitie s: Non- c omple x Case s 1. I ntro duc to ry le tte r 2. Autho riza tio ns 3. Re spo nse s to inq uirie s 4. Ca se c lo sure a fte r o ne ye a r if the c o nditio n re so lve s 7
THE PILOT ACTIVITIES • Case Manage me nt Ac tivitie s: Comple x Case s 1. I ntro duc to ry c a ll with a de ta ile d ne e ds a sse ssme nt 2. Autho riza tio ns a nd re fe rra ls, inc luding c a re o f the who le c hild 3. Ong o ing inte rve ntio ns a c c o rding to ne e d 4. Qua rte rly re vie w 5. Annua l re vie w with a n o b je c tive a na lysis o f the suc c e ss o f the inte rve ntio ns a nd o ve ra ll he a lth o f the pa tie nt 8
SO FAR, HERE’S WHAT WE’VE FOUND • Pr e - pilot satisfac tion sur ve ys of familie s : N=331 ► Ove ra ll: 89-97% ne e d to c o nne c t with a t le a st 1 pe rso n a t CCS 56-60% re po rte d e ithe r ne ve r o r ra re ly spe a king with the ir nurse ► Ove ra ll g re a te st se rvic e ne e ds fro m CCS: me dic a tio ns; tra nspo rta tio n; me dic a l a ppo intme nts ► F o r fa milie s with c o mple x c a se s: ne e ds • Mo re e duc a tio n o n se rvic e s fo r the m/ the ir c hild • Unde rsta nding the ir/ the ir c hild’ s insura nc e • Unde rsta nding the ir/ the ir c hild’ s me dic a l c o nditio n • Autho rizing CCS spe c ia lty do c to rs to c a re fo r the m/ the ir c hild 9
SO FAR, HERE’S WHAT WE’VE FOUND ve ys of staff: N=67 • Pr e - pilot satisfac tion sur ► 75% we re no t sa tisfie d with the ir c a se lo a ds ► T he mo st sa tisfie d o ve ra ll we re o n spe c ia lty te a ms • Pr e - pilot he alth status of our c omple x patie nts: Pa re nta l re po rt in the ye a r prio r to the pilo t fo r c o mple x c a se s 1. Da ys o f sc ho o l misse d: 1248 2. Da ys o f ho spita liza tio n: 154 3. E R visits: 208 4. I llne ss visits: 183 10
SO FAR, HERE’S WHAT WE’VE FOUND • Dur ing the pilot: initial data thr ough June ► T o ta l c a se s ha ndle d: 1060 – c o mple x; 2247 – no n-c o mple x ► Ca se lo a ds: 205 – c o mple x; 472 – no n-c o mple x ► T o ta l numb e r o f c o mpla ints/ inq uirie s: 6 - no n-c o mple x 0 – c o mple x 11
SO FAR, HERE’S WHAT WE’VE FOUND • Dur ing the pilot: initial data thr ough June ► Pilo t te a m nurse s: • Spe nding 60% o f the ir da y c o lle c ting a nd e nte ring da ta • All ve ry sa tisfie d with the mo de l • Qua lity o f c a re c o o rdina tio n is impro ving 12
SO FAR, HERE’S WHAT WE’VE FOUND • Dur ing the pilot: initial data thr ough June “I L o ve the Pilo t Case Manag e me nt Mo de l b e c ause it allo ws me to b e mo re c o mfo rtab le , mo re satisfie d b e c ause I have mo re time with my patie nts.” “A po sitive e ffe c t o f the mo de l is that e ve ry thre e mo nths the familie s are e xpe c ting a pho ne c all, whic h e nab le s the familie s to fe e l mo re c o mfo rtab le g e tting a ho ld o f us to pre ve nt mino r issue s fro m e sc alating .” “I am satisfie d b e c ause I am ab le to spe nd mo re time with the m, I am ab le to le arn mo re ab o ut the m and the ir ne e ds and the y c o ntac t me whe n the y have a c halle ng e .” 13
A LOT MORE TO DO! • Now: study the c a re c o o rdina tio n inte rve ntio ns -Who ne e ds the m -Ho w o fte n -Whic h o ne s wo rk y 2015: da ta c o lle c tio n a nd a na lysis • F e br uar -Surve ys: pa tie nts, fa milie s a nd sta ff -He a lth sta tus -E ffe c tive ne ss o f c a re c o o rdina tio n inte rve ntio ns • Ongoing: sha re da ta a nd o ur e xpe rie nc e -With who : a ll wo rking to wa rd impro ving the CCS pro g ra m -Why: to b e tte r se rve all c hildre n a nd fa milie s with spe c ia l he a lth c a re ne e ds 14
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