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Bea Herbeck Belnap, Dr Biol Hum
School of MedicineUniversity of Pittsburgh
Learning Objectives
1. To understand the different functions and tools required to effectively implement the Chronic Care Model for depression management in primary care
2. To identify the core roles and qualifications of care managers, particularly as liaisons to providers and for patient self-management support
3. To understand the role and function of care manager registries and their utility in fostering provider and patient communication
Wagner Chronic Care ModelWagner Chronic Care Model
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Functional and Clinical Outcomes
DeliverySystemDesign
Decision Support
ClinicalInformation
Systems
Self-Management
Support
Health SystemCommunity Health Care Organization
Resources & Policies
CCM: Core Clinical ElementsLeadership
Practice Design
Clinical Information Systems
Vision Resources
Care managementProtocols- coordinated
care
Clinical information tracking
RegistryFeedback to clinicians
CCM: Core Clinical ElementsDecision Support
Self-managementSupport
Community Resources
GuidelinesExpert/specialist
consultation
Patient preferencesInformation on treatment
Information on and for consumers, groups, etc.
Access to non-provider sources of care
General Medical
(Chronic care, Prevention, Follow-up)
Care Manager Self-management
CM/Liaison: PCP, MHCommunity linkagesCrisis intervention
Registry
Behavioral Health (crisis
referral, complexity,
etc.)
Care Manager: Core FunctionsPatient educationRegistry trackingProvider communicationCommunity linkages
Care Manager: PatientsPatient education about depression, treatment
optionsFamiliar with commonly used antidepressant
medications, dosesSupport medication adherence and recovery
Brief interventionsTheory-based approaches (MI, PST, etc.)
Monitor treatment progressKnow when treatment is ‘not working’
Structured symptom assessment (PHQ-9)8-12 week trialProvider recommendations MHS, PCP
CM: Goals of a RegistryIdentify, manage, and track patientsFacilitate patient contacts Provide patient visit summariesProvide real-time data on tx response, etc.RemindersPerformance feedback
CM: Provider LiaisonRelay concerns/progress
Symptom monitoringRefillsSymptoms and side effectsUrgent, emergent protocolsMedical record documentation
Cue providers if no improvementSupplement, not replace providers
CM: Community LinkageCooperation with MHS
SupervisionReferral
Self-help groupsSupport for comorbidities, psychosocial
problemsFinancial resources
Care Management:Patient Support
CM: CustomizationCultural competenceRole of familiesRole of religion/spiritualityCompeting needs
CM: Self-managementEliciting concerns/barriersProblem-solvingProviding informationClarifying preferencesEncouraging informed decision-makingTeaching skillsMonitoring progressReinforcing self-managementCommunity resources
CM: Self-management ToolsWorkbooks
Medication listsAppointment remindersHealthy behaviorsPleasure activities list
PillboxesMedication informationWebsites
Care Management:Provider Communication
CM: Provider LiaisonHelp patients and providers identify
Potentially inadequate dosesIneffective treatment (e.g., persistent depression
afterAdequate duration of antidepressant trial)Side effects
Facilitate patient-provider (e.g., PCP) communication about antidepressant medications
Consult about medication questions
Care Manager: ProvidersTracks depressive sx and treatment response
(PHQ-9)Screens for co-occurring MH conditions
Alcohol use (e.g., AUDIT-C)PTSD (e.g., PC-PTSD)
Consults with team psychiatristProvides follow-up and recommendations to PCP
who prescribes antidepressantsCollaborates closely with patient’s (PCP)Facilitates referrals to specialty, community
Formal and informal connectionsPrepares for relapse prevention
Examples of CM-Provider ContactMedication toxicity, cross-reactivity
Notifying provider of patient concerns, follow-up
Fatigue, physical symptomsCM prompted provider to call pt. after
missed appt
Managing multiple medications, depression, diabetes, and HT (medication lists, pillboxes)
Alcohol use and grief managementKilbourne AM, et al. Bipolar Disorders, 2008
Kilbourne AM, et al. Psychiatric Services, 2008
CM: Provider ResourceCMs as a resource for clinic, providersDissemination of specific guidelines
Ask providers for suggestions on specific topicsHold CME, lunches, or disseminate information
ExamplesBipolar disorder in pregnancyDepression treatment in late life
Provider Communication TipsObtain preferred mode of
communicationEmphasize as a supplemental serviceFocus on providing information on
changes in treatment response, side effects, etc. to inform decisionsBaseline, Current PHQLength of time on medicationsProblematic symptoms/side effects
Adequate contact, but don’t overdo it
Care Management:Registries
Care Manager: RegistryRegistries are . . .
Simple tools to track patient progress Integrated into routine clinical careEasily updatedNOT EMRsNOT research-focusedBest if “home-grown”
Patient risk stratificationTracking and management
Patient characteristics facilitating treatmentAcute phase Continuation, maintenance
Performance feedbackPatient process and outcomes
Registry FunctionsRegistry Functions
Other data sources (e.g., pharmacy, EMR)
should NOT replace a registry BUT can be used to:
Improved patient identification (top conditions) Enhance performance measurement
Challenges to using electronic data Cumbersome to update and merge Time lag Data not available on all patients Privacy and security issues
RegistriesRegistries
Key Registry VariablesDatesPatient contact information
Best number, time to call, and leave messageStatus
No showsTreatment stage Current medications (dose, duration)Self-management materials
Depression severity score, MD assessmentReferral status (MHS, community resources)Next contact, date
Registry: Sample FieldsGeneral information (update at each contact):
Patient contact info, including emergency contactProvidersBest time to call/OK to leave message?Plan to keep then safe/calm
Contact (Encounter)-specific information:Contact or visit dateCurrent Mood, Speech, ComorbiditiesCurrent medications/OTCs, refills needed?Medications not taking and reasonSymptoms and side effectsHealth behaviors (sleeping, drug use, smoking ,exercise)Job/personal problemsEducation providedAccess/barriers, provider engagementNext appt
Care Management:Crisis Intervention
CM: Suicidal IdeationIf the patient articulates thoughts
death/suicide:Where are you now?What is your phone number at the location?Are you alone or with someone?Do you have a plan of how you would do this?Do you have these things available (guns, pills)?Have you actually rehearsed or practiced how you
would do this?Have you attempted suicide in the past?Do you have voices telling you to harm or kill
yourself?
CM: Crisis InterventionSuicidal ideation- coordinate with clinic
ProtocolsOn-call numbers
Missed appointmentsImmediate follow-up
Care Management:Implementation Tips
Care Manager TimelineInitial VisitRapport- providersPatient initial intake
Contact preferences Crisis and urgent care protocols
AssessmentDiscuss treatment options / plansCoordinate care with PCPStart initial treatment planArrange follow-up contactDocument initial visit
Care Manager TimelineSubsequent Visits
Registry- ongoing trackingReminders for upcoming appointmentsRegular contact with providers
Adequate staffing, who should update? Research vs. clinical use Integrating into routine care How identified patients are entered Involving PCP IRB issues
Implementing RegistriesImplementing Registries
Types of RegistriesFormats (pros and cons for each)
Excel fileWeb-based
ExamplesSMAHRTIMPACTREACH-NOLA
Care Manager Toolbox1. Manual: provider interactions
Contacts, location, communication preferences Medication info Protocols to ID treatment response, side effects
2. Manual: patient interactions Brief interventions (e.g., PST, MI, others) Crisis intervention
3. Self-management materials Medication information Behavioral change information (e.g., pleasure
activities)4. Registry file
Bottom LinesThe CCM for depression includes key elements
Self-management Care management Community linkages Registries Guidelines
BUT the CCM is most effective if customized to local settings . . . . .