Community Health TeamCare Management Process

PinnacleHealth Systems

Don DeArmitt, M.D.

Becky E. Zook RN, BSN, MS, CCP

Community Health Team Members

• Physician Champion

• Nurse Care Manager

• Chronic Care Initiative Nurse

• Medical Social Worker

• Behavioral Health Counselor

• Information Technologies Specialist

Referral Process

• Patient identification– Manually- encounter with office staff

• Provider

• MA

• CHT member

• Self

– Automatically- high risk stratification report• Quarterly on DM, HTN, CHF, CVD, COPD, Depression,

Frail Elderly

• Daily- transitional care report

Identify Patients with DM in Panel

Determine

Low Risk 0-2 BP<130/80A1c<6.5LDL<100

Medium Risk 3-5 pBP>130/80<140/90A1c 6.6-8.0LDL>100<130BMI 30-35

MedicationMonitoringTitration up

Labs q6 months

Determine Priority Patient

Need

Labs q3 months

Advanced Self CareDM EducationSM SupportMonitoringFunctional AbilityTransition Care

Delivery Mechanism

Pt F/U with Provider

Phone F/U

Q6 months

Care ManagementMonitoring (BG, BP, BMI, SM goals, etc)Titration of medsHome visit &/or phone F/U

Q3 months

Class with ADE

Social Worker

Behavioral Health

prn

prn

Social IssuesTransportation$$ for MedsAbuseInsurance, etc

High Risk >5 BP>140/90A1c>8.0LDL>130BMI >35Seen in ER/ Hospital

*Having two or more of the concomitant factors (tobacco use, LDL>130 or HDL<40) moves patient up in risk stratification

Stage A:Asymptomatic

CHF Stage B:Structural heart diseasew/o symptoms

Stage C:Structural heart disease with prior/ current symptomsMild activity intolerance, fatiguePalpitationsDyspnea/angina with activityComfort at rest

Stage D:Refractory CHF requiring specialized interventionsSevere activity intolerance, fatigueDyspneaAngina FatiguePalpitations at rest

Refer to Care Manager

Low Risk*Pre-HTNSystolic <120-139Diastolic 80-89

Moderate Risk*Stage 1Systolic 149-159Diastolic 90-99

High Risk*Stage 2BP> 160/90

Identifying and Managing High Risk Patients

HTN

COPDHigh Risk patients will have additional diagnosis and:OV for acute bronchitisOV for acute sinusitis>4 OV in 1 year for COPDER or hospitalization for COPD in last 1 year2 or more other chronic diagnosis

Refer to Care Manager

Frail ElderlyHigh Risk patients will have metrics and / or diagnosis of:Age > 65 yearsBMI < 15Dementia or dementia related diseasePersonal history of falls

Acute CareHigh Risk patients include:In-patient FacilityHome Health CareTransitional CareDiagnosis of Sepsis

CVDHigh Risk patients will have additional diagnosis of:DVTPECVACAD or MI or PVDStage 1 or 2 Hypertension2 or more other chronic diagnosis

Depression, Mental HealthHigh Risk patients will have additional diagnosis of:Substance AbuseDrug and/or Alcohol abuseTobacco useMDI 10 score of severe or major depression2 or more other chronic diagnosis

Referral Process

• Triage and Assignment– Per task status- STAT or Routine– Manually by CM- based upon risk

stratifications and qualifying diagnosis, transitional and STAT referrals priority

– Initial outreach• 1-2 days for STAT referrals• 10 days for routine referrals• 1-2 days from notification of discharge of

transitional referrals

Referral Process

• Successful contact– Documented in the telephone template

section of the EMR, task sent back to provider with documentation attached

• Unsuccessful contact– 3 Attempts documented in the EMR– CHT Unable to Contact letter– Close if no response in 10 days to letter– Task provider

Initial Patient Screening

• Patient identified as appropriate for contact from CM– Introduce CHT, scope and practice, role of

CM and self management skills– Discuss trigger diagnosis– Assess prior knowledge of diagnosis– Assess use of hospital or ED in last 4 weeks

Initial Patient Screening

• Patient identified as appropriate for contact from CM– Assess PHQ2 from G.O. intake assessment– Identify needed behavior / lifestyle changes

and blockers to change– Identification of care driver- PCP vs specialist– Set initial goals, time to next contact, plan for

intake assessment

Intake Assessment

• Initial assessment completed

• Pt in agreement with services from CHT

• Documented in the EMR under the appropriate disease management template for guided assessments

Follow-up Encounters

• Telephone

• Office visits with CM

• Home visits– Review of previous encounter for status of

POC– Cumulative review of goals and update of

goals– Establish next expected contact

Follow-up Encounters

• Review of self management progress

• Self management support and teaching

• Identify any new care gaps, needed coordination or safety issues

• Medication or treatment updates

CHT Outcomes

• Since April 2010 inception- served nearly 700 patients in 2 Family Care practices

• 48% increase in patients with an A1C of less than 7.0

• Since June 2010, 12% decrease in total number of patients utilizing hospital based services

• Addition of Behavioral Health Services