Working as an Integrated Multi-Disciplinary Care Team: Developing - PowerPoint PPT Presentation

Working as an Integrated Multi-Disciplinary Care Team: Developing and Using Shared Plans of Care Jeanne W. McAllister, BSN, MS, MHA VT: Integrated Communities Care Management Learning Collaborative May 19 , 20 15

 Why? (What we know)  Engaged patients and families T he Why, How  better - access, information, enhanced navigation, improved health outcomes, & and What of a more Share d  How? Plan of Care 10 Step Approach  Preparation and planning  Assessment, goal setting, implementation and oversight  Relational care coordination  What? Shared Plan of Care  Medical Summary , Negotiated Actions & Attachments (e.g. emergency plan, legal needs) Source: TED.com Simon Sinek, The Golden Circle

Care Plans & Care Planning – A function of care coordination In few (1-3) words • Care Coordination

Care Plans Care Planning – A function of care coordination In few (1-3) words • Care Coordination -

Care Coordination A patient & fam ily-centered, assessm ent driven, continuous, team -based activity designed to: • m eet the bio-psychosocial needs of children youth, and adults while • enhancing person & fam ily care-giving skills and capabilities. Reference: Commonwealth Fund 2009, LPFCH 2014, AAP 2014

Why Shared Care-Planning? • Care is fragm ented across m ultiple providers / system s • Coordination of care is lacking • Inform ation sharing across providers often falls to patient/ fam ily

Why Shared Care-Planning? • Patients and Fam ilies ask for: • Help in system & resource navigation • Team-based care • With access to a clear contact person • Goals and strategies used consistently across providers (aka standards of care)

Why Shared Care-Planning? • Clinicians/ team s seek a better approach: • Partnership relationships with patients/ families • Succinct, at-a-glance Medical Summaries • Clarity of next-steps, responsibilities and accountabilities

A Little Backstory

DEER in the HEADLIGHTS! 2003-2004 50 Primary Care Teams with newly identified family partners and Sponsoring Title V Leadership – "You want us to do what?"

Medical Hom e Transform ation What Drives Change? Mixed Methods: Medical Hom e In dex, Adaptive Reserve, Q – In terview s 4 Essential Elem ents: 1) Quality Im provem ent 3) Team based care 2) Fam ily Centered Care 4 ) Care Coordination/ Plans of Care ( ★ Ph y sicia n a n d sta ff sa tisfa ction w a s str on g / h ig h ) McAllister, J.W., et al., M ed ica l hom e t ra nsform a t ion in p ed ia t ric p rim a ry ca re-- w ha t d riv es cha ng e? An n als of Fam ily Medicin e, 20 13. 11 Suppl 1: p. S9 0 -8 .

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Medical Home and Care Plans – they go together, you can't have one without the other! Family -

Care coordination “elevator speech”?

Care coordination “elevator speech”? “With care coordination…you have to take the stairs!

Objectives: Shared Plan of Care as a Function of Ca re Coord ina tion Tools, How this is Supports & accomplished Strategies Description: Why, How & Resources Shared What Plan of Care (10 Steps)

The Purpose of Shared Care-Planning 1. Improve care and reduce fragmentation for children/ families -subsequently for an identified population 2. Guide a family-centered, multi-disciplinary team process - joint development / use of a plan of care 3. Enable the patient, child/ family and their “care neighborhood” to communicate, collaborate, and operate from the “ sam e page ” SPoC 4. Deliver oversight with developed timelines ensuring responsibilities and accountabilities

1. Identify Needs & Strengths of the Patient and Family 2 . Build Essential 4 . Implement/Improve Partnerships the Plan of Care (Identify personal/clinical goals) 3. Create, Use, Renew the Plan of Care Mo del o f Shared Care-Planning Achieved in Partnership with Fam ilies LPFCH

10 Step Approach to a Shared Plan of Care 1. Identify who will benefit from a plan of care 2. Discuss with families and colleagues the value of developing and using a comprehensive and integrated plan of care. 3. Select, use and review a multi-faceted assessment with a child, youth and family 4. Set shared personal and clinical goals 5. Identify other needed partners (e.g. subspecialists, and community providers) and link them into the shared care- planning process

10 Step Approach to a Shared Plan of Care 6. Develop the plan of care – “Medical Summary 7. Establish the plan of care “Negotiated Actions” 8. Ensure that the plan of care is available, accessible, and retrievable (for all permissible partners) 9. Provide tracking, monitoring and oversight for the plan of care 10.Systematically use the shared care-planning model process with a group of patients and families 5/4/2016 22

THE HOW 10 STEPS • Patient Fam ily Request standard of care • Criteria – multiple needs, Step 1 providers, plan, barriers Identify • Who? who will • Com plexity – Examples • HOMES benefit • Bobs from a • Co-m anagem ent - p la n of • Psych and primary care ca r e • Neuro and developmental peds

Selecting Assigning & Using a Complexity Score

Step 2 • Invite in , reach out; build rapport Discuss with • *Explanatory / descriptive materials families & • (Can family partners help with?) colleagues the • Workflow – your design (see guide) value of • Prepare – Pre Work & team and family developing “think time” and using a • Patient / Fam ily feedback (PDSA) comprehensi ve This is practice of team work / integrated to achieve together “plan of care”.

Workflow Visit & Shared Pre Visit Plan of Care Care Recruit/Pre Team Pre Coordina- pare Huddles tion 3 mos

• Examples: “*Pediatric CC pre- visit STEP 3 Assessment”, Bright Futures, Select, review and Guided visit use a multi- • Use to frame health care “not as faceted usual, this is something different” assessment with • Prepare to address gaps with plan each patient and of care/visit, patient directed goal family setting

Pre Visit Assessment Form (handout)

• What Matters to you? • vs. What is the Matter with you? • Support patients and families to frame personal *goals STEP 4 • Short term clinical/personal Set shared • Long term goals “parking lot” personal and (life-course) clinical goals • Examples: behavior, preschool, enjoy a family event, prepare & go to college, find jobs, etc.

STEP 5 • Gather data supportive of a Identify other planned visit (e.g.) needed • Build Registry – CC, PCP, partners (e.g. subspecialists, • “Care Neighborhood” community • Eco Maps providers); link • Example: IN tap the “bench” – e.g. them into shared neurology, psychiatry, developmental care-planning pediatrics, child development, etc. process

REGISTRY Name Patient DOB Diagnosis ETC. Demographics Date care coordination begins Plan of care in place? Date Condition Primary Care Provider Multiple Providers/Neighborhood School/other Complexity Score Monthly Measures (see step 9) Shared Plan of Care Goals/progress against Care Coordination Activity & Time: - Prevent - Promote

The Neighborhood Primary Care Medical Home Many Specialty Other Care Partners Child/Family- Centered Care All Payers Coordination Friends/F – state, amily insurers, School Spiritual Services Supports 33

• Shared Plan of Care -Template • Clinical section, CC section, Family section STEP 6 • Workflow Develop the • CC initiates assembly plan of care • Interacts with team • Shares/reviews w/family – • Reiterates *“Medical • Outcome of visit or care conference Summary” • {(IN) Special team develops/shares back to PCP with support to help them continue}

• Framed goals are addressed • Develop strategies, timeline, STEP 7 responsibilities and accountabilities – this is Establish the different plan of care • “Teach backs” and “reflect backs” *“Negotiated • Timely follow-up and duration Actions” • {Example - IN team finalize plan, get back to family within 10 days, use for 3 months, transfer to “locus of care coordination” in community}

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DREAMS • Assemble into e-health record STEP 8 • E-Health Record prompts  Has Plan of Care Ensure that  Needs Plan of Care? the plan of  Touch points in system care is • Family access/print through portal available, • Message to other providers accessible, – “a common document is available” WORKAROUNDS and • Electronic, paper, scanned, cloud, jump retrievable drive, what ever it takes! SHAREPOINT • Families are encouraged to advocate for use of plan of care across systems