Population Management and Using a Registry to Drive Care Session 4 - - PowerPoint PPT Presentation

Used with permission from the University of Washington AIMS Center Used with permission from the University of Washington AIMS Center

Population Management and Using a Registry to Drive Care

Session 4

Used with permission from the University of Washington AIMS Center

Learning Objectives

• Define measurement‐base care and treatment to

target and give an example of using a registry as an RN care manager

• Describe how a registry is a population‐based tool to

use with a caseload of SPMI clients in a behavioral health setting

• Practice with patient cases the actions you would

take as a RN care manager

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Used with permission from the University of Washington AIMS Center

Population Health Management

Population Health

• The health outcomes of a group of individuals,

including the distribution of such outcomes within the group

www.ihi.org

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Used with permission from the University of Washington AIMS Center

Measurement‐Based Care

“Involves the systematic use of symptom rating scales to drive clinical decision making.”

https://www.thekennedyforum.org/news/measurement‐based‐care‐ issue‐brief

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Used with permission from the University of Washington AIMS Center

Measurement‐Based Care in Practice

• Data collection integrated into clinical workflow.

Standard protocol for data collection at prescriber

• visit. Who and where recorded?

—Weight/ BMI —Blood pressure —Labs

• Outside lab results called to attention of prescriber
• r PCP, as necessary
• During course of treatment, BMI regularly tracked

and 12‐week labs obtained

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Used with permission from the University of Washington AIMS Center

What is a registry and what do you do with it?

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Used with permission from the University of Washington AIMS Center

Example Systematic Case/Data Review

• When: Weekly, 60‐90 minute sessions
• Who: Medical RN care manager, prescriber, case

managers

• How: In‐person or by phone

– Registry & EHR must be available to both

• Goal: Monitor entire caseload over time

– Review all patients on caseload in one session – Only priority patients over several sessions

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Used with permission from the University of Washington AIMS Center

Small Group Activity

Collaborative Care Lab

Instructions 1. In groups of five, assign care team roles

• A. Care Manager
• B. Primary Care Consultant
• C. Psychiatrist Consultant
• D. Case Manager

E. “Scribe,” if not one of the above 2. Review four cases and their accompanying registry in the next 15 mins. 3. Develop a treatment plan, assigning tasks to each team member.

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Used with permission from the University of Washington AIMS Center

Contact Information

• John Kern MD

jkern2@uw.edu

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Evaluations & Adjourn

The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

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