This material was prepared by HealthInsight as part of our work as the Beacon Community, under Cooperative Agreement grant #90BC00006 from the Office of the

National Coordinator, Department of Health and Human Services.

IC3 Beacon Pilot Diabetes Care Coordination

TrainingCare

Sarah Woolsey, M.D.Janet Tennison, PhDHealthInsight, August 16, 2012

Welcome

Pre-work

Today’s Objectives

• Understand Care Coordination and Self-Management • How to identify high risk patients with diabetes in

your system• Assessing patients’ needs and goals

– Health Literacy– Motivational Interviewing– Stages of Change– Teach Back– Planned follow-up– ProQual tool

• Starting Care Coordination in your setting

Definition: Care Coordination

“The calculated integration of patient care activities between

two or more participants, to facilitate the suitable provision of

health care services”

Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7. McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.

Coordination--Why Do We Need It?

• Determine the patients’ goals • Assist those “high-risk” patients who

have been unsuccessful at managing their own care

• Engage patients to improve their self-care

• Improve the exchange between providers, patients, community services

We Sometimes Get Frustrated

Removing Barriers to Accomplish Goals

Engaging Patients in Their Own Care

Traditional Collaborative

• Professionals are experts, patients passive

• Behavior change externally motivated

• Non-compliance is personal deficit

• Providers experts about disease; patients experts about lives

• Behavior change internally motivated

• Lack of goal achievement requires modifications

Bodenheimer, T., & Abramowitz, S. (2010). Helping patients help themselves: How to implement self-management support. Oakland, CA: California HealthCare Foundation.

Differences

Traditional Patient Education

• Technical skills• Problems with disease

control• Disease-specific

knowledge• Goal is compliance to

improve outcomes• Health professional is

educator

Self-Management Education

• Skills to act on problems• Problems ID‘d by

patients • Improving confidence

• Goal is increased self-efficacy to improve

• Health team, peers, educators

Bodenheimer, T., & Abramowitz, S. (2010). Helping patients help themselves: How to implement self-management support. Oakland,

CA: California HealthCare Foundation.

DSM

o

Interprofessional Outcomes •Team Self-efficacy •Shared Perspectives •Teamwork • Attitudes towards collaboration

Patient Outcomes •Physiologic •Satisfaction •Functional status

Organizational Outcomes •Culture/climate •Staff satisfaction •Efficiency/cost

Clinical Information Systems1

Decision Support2

Delivery System

Redesign3

Self-Management4

Community Resources5

Clinic Care Coordination

Activated Patients

Healthcare Organization6

Developed by Janet Tennison, PHD,Adapted from Kirsch et. al., 2008

Essential CC Tasks

• Identify high-risk patients• Assess patient• Develop care plan• Identify care participants,

communicate needs• Execute care plan • Monitor and adjust care• Evaluate health outcomes

ESSENTIAL CARE TASKS and Associated Coordination Activity

• IDENTIFY and ASSESS PATIENT Determine Likely Coordination Challenges, determine patients vulnerable to disconnected care

• DEVELOP CARE PLAN Proactive Plan for Coordination Challenges and Follow-up

• IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES Specify Who is Primarily Responsible for Coordination (Medical Home)

• EXECUTE CARE PLAN Implement Coordination Interventions• COMMUNICATE TO PATIENTS /Family AND ALL OTHER CARE

PARTICIPANTS Ensure Information Exchange Across Care Interfaces

• MONITOR AND ADJUST CARE Monitor For and Address Coordination Failures

• EVALUATE HEALTH OUTCOMES Identify Coordination Problems that Impact Outcomes

Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7. McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.

Case: Mr. Thomas

• Mr. Thomas is a 56 -year old patient with DM II.

• He has private insurance through his wife’s job.

• He is here for a cough and cold visit, has not been in for 9 months.

• You note he has no-shows recorded for his last 3 visits to you, both education visits and a diabetes check-up.

Medical Assistant Check-In

• He is taking 3/5 meds listed in the EMR by report.

• Metformin, Lisinopril and aspirin (unsure what kind).

• He is not on insulin, simvastatin as recorded here.

• He reports no pain or allergies.

• He has not had any office visits elsewhere.

• Temp=98.0• BP 152/90, pulse 88• Weight is 224lb , BMI

29 • O2 sat is 99%• Hba1c = 10 (last time

was 8.9)• Coughing• In his PJ top• Appears well

otherwise

What Are You Thinking Here?

MA point of view

Beacon point of view

Doctor point of view

Care Coordination point of view

More InformationExam :

• Obese• Nasal

congestion• R toenail is

ingrown (you checked)

Labs today:Glucose-333

Old Labs:

• LDL=144• Microalbumin is

abnormal• A1c=8.9

Other• He did not have a

flu shot in 2011• He has never had

a depression screen

• Non-smoker

Is Mr. Thomas High Risk?

• Vulnerable to disconnected care?

• How do you find him in your system?• Name 3 ways

Practice Analytics Tool“Hot Spot” Pilot

• Diabetes Care Severity Index• Composite score of labs,

diagnoses, and know risk of hospitalization

• Option in the CC program

What else do you want to know about Mr. Thomas?

Patient Point of View?

Consider…

WHAT IS his GOAL for his care?

Today? Overall?

How do you know?

ESSENTIAL CARE TASKS and Associated Coordination Activity

• IDENTIFY/ASSESS PATIENT Determine Likely Coordination Challenges, determine patients vulnerable to disconnected care

• DEVELOP CARE PLAN Proactive Plan for Coordination Challenges and Follow-up

• IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES Specify Who is Primarily Responsible for Coordination (Medical Home)

• EXECUTE CARE PLAN Implement Coordination Interventions• COMMUNICATE TO PATIENTS /Family AND ALL OTHER CARE

PARTICIPANTS Ensure Information Exchange Across Care Interfaces

• MONITOR AND ADJUST CARE Monitor For and Address Coordination Failures

• EVALUATE HEALTH OUTCOMES Identify Coordination Problems that Impact Outcomes

Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7. McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.

Patient Assessment

“Why is Mr. Thomas so non-compliant?”

The patient is not yet engaged!

Patient and provider both have responsibility to determine and address barriers.

Three methods:

1. Health Literacy

2. Stages of Change

3. Motivational Interviewing (MI)

Health Literacy

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DefinitionHealth Literacy

The capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Functional Health Literacy

The ability to read and comprehend prescription bottles, appointment slips, other essential health-related materials required to successfully function as a patient.

Healthy People. (2010). Cited in What is Health

Literacy? Retrieved from www.chcs.org

Health Literacy

• Only 12% of adults have proficient health literacy

• 9/10 patients lack skills to manage their health/prevent disease

• Ask Me 3

Advocate for Health Literacy in your organization (n. d.). Quick

Guide to Health Literacy. Retrieved from http://HHS.com

Determine then Support Health Literacy

• Verify understanding by “teach back”

• “Tell me in your own words what we just talked about”

• “Why do you take this medication?”

• Provide instructions like you’re speaking with a friend

MOST IMPORTANT!

Create a shame-free environment where low-literacy patients can seek help without embarrassment or being stigmatized

Don’t Forget Culture

• Ethnic/racial/population/religious differences affect perceptions, trust, access to medical care

• Poverty, language and communication barriers, other demographics

• Personal bias, prejudices, lack of understanding

Mr. Thomas and Health Literacy

• Visit Summary Example

The Stages of Change

Inappropriate Assumptions About Behavior Change

• This person ought to change, and wants to change.

• This patient’s health is the prime motivating factor for him/her.

• If he or she does not decide to change, the consultation has

failed.

• Patients are either motivated to change, or not.

• Now is the right time to consider change.

• A tough approach is always best.

• I’m the expert. He or she must follow my advice.

• A negotiation-based approach is best.

Emmons, K. M. , & Rollnick, S. (2001). Motivational Interviewing in

health care settings: Opportunities and limitations. American Journal

of Preventive Medicine, 20(1)

How To Suppress Change

• Tell patients what to do (give advice)• Misjudge sense of importance regarding

behavior change• Use scare tactics, argue, blame them for no

willpower and self-concern• Overestimate readiness to change and

degree of confidence • Take control away and generate resistance

Is Patient Ready to Change?

Readiness to change: Stages of Change. (2005). Retrieved July 10, 2011, from Well-Fit Bodies Website: http://www.well-fitbodies.com/readiness_for_change

Patient AssessmentsHow ready are you (to improve a behavior)?

0 1 2 3 4 5 6 7 8 9 10

Not ready Ready

How confident are you (that you can)?

0 1 2 3 4 5 6 7 8 9 10

Not at all confident Very Confident

True Change Takes Time

• Some may remain in one phase a long time or forever

• Pre-contemplation—cons of quitting outweigh the pros

• Relapse is expected, should be integrated to normalize it

• Most don’t go from pre-contemplation to action

• Goal—try to move through stages

Success = Positive Relationships & Support

Provider-patient relationship most important determinant of diabetes self-management

Craig, C., Eby, D., & Whittington, J. (2011). Care Coordination Model: Better care at lower cost for people with multiple health and social needs. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement.

Where is Mr. Thomas?

• Contemplation• Pre-contemplation• Preparation• Action• Maintenance

BREAK

Motivational Interviewing

Motivational Interviewing

“A collaborative, patient-centered form of guiding to elicit and strengthen motivation for change”

Miller, W.R. & Rollnick, S. (2009). Ten things that Motivational Interviewing

is not. Behavioural and Cognitive Psychotherapy, 37, 129-40.

Motivational Interviewing

• Non-coercive• Non-judgmental• Non-confrontational • Non-adversarial• Explore and resolve inconsistency• Help patients envision a better future,

and become increasingly motivated to achieve it

Why Do We Need MI?

No matter what reasons we might offer to convince individuals of the need to change their behavior,

or how much we want them to do so,

lasting change is more likely to occur when they discover their own reasons and determination to change.

Four Principles of MI

1. Express empathy

2. Explore differences

3. Roll with resistance

4. Support of self-efficacy

OARS

•Open-ended questions•Affirmations•Reflections•Summaries

Patient Assessment

Mr. Thomas

Role play referral for insulin use, why was it unsuccessful before?

What would you say and do?

What is his goal?

LUNCH 12:00-12:30

Pro Qual Tool–Patient Experience of Health

Assessment and Barriers

• http://informatics.mayo.edu/proqol (test)

This material was prepared by HealthInsight as part of our work as the Beacon Community, under Cooperative Agreement grant #90BC00006 from the Office of the

National Coordinator, Department of Health and Human Services.

IC3 Beacon Pilot Diabetes Care Coordination Training

Part 2Care

Sarah Woolsey, M.D.Janet Tennison, PhDMichelle Carlson, S.S.W.HealthInsight, 2012

Motivational Interview #2 • Mrs. Smith is a 48 y/o, she has had

DM 2 for 5 years, since her last child was born.

• She is on your list as a patient that has not come in for >12 months.

• Her last A1c was 7.5, and she was up to date on DM care.

• Today’s A1c=9.• You notice she has had no shows a

few times for follow-up for Diabetes.

WHAT MIGHT BE HAPPENING?

Part 2 Learning Objectives

• Developing a Care Plan• Identify roles• Communicating (information

exchange)• Monitor and Adjust • Data collection• Resources

ESSENTIAL CARE TASKS and Associated Coordination Activity

• IDENTIFY/ASSESS PATIENT Determine Likely Coordination Challenges, determine patients vulnerable to disconnected care

• DEVELOP CARE PLAN Proactive Plan for Coordination Challenges and Follow-up

• IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES Specify Who is Primarily Responsible for Coordination (Medical Home)

• EXECUTE CARE PLAN Implement Coordination Interventions• COMMUNICATE TO PATIENTS /Family AND ALL OTHER CARE

PARTICIPANTS Ensure Information Exchange Across Care Interfaces

• MONITOR AND ADJUST CARE Monitor For and Address Coordination Failures

• EVALUATE HEALTH OUTCOMES Identify Coordination Problems that Impact Outcomes

Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7.McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.

The Mr. Thomas Care Plan

Provider wants to re-start Insulin that patient agreed to start prior

What is the current workflow at your site?

How do we succeed?

Care PlanBasic Clinic Example of a Working Care Plan

For next visit: (To be completed by Physician /Care Coordinator and Patient) Patient Name__________________ Chart ID____________ Patient Goal:Medical Plan:• Care Coordination Needs/Referrals: __________________________________________ • Labs Needed: ___________________________________________________________ • New Meds/ Education Needed: ______________________________________________ • Ref letters/Contact needs for patient: ________________________________________ • Follow Up Needed: Call (Who/date/subject) ______________________________________________ Next Visit (Schedule period/date) _______________________________________ Next Visit agenda ___________________________________________________ Care Plan: Patient will: ____________________________________________________ By:(Date)_____________ Care Coordinator/Clinical Team will: ____________________________________________________ By:(Date)_____________ Reviewed Date __________ Care Team or Physician Signature Patient signature- plan

Adapted from the Utah Medical Home Portal www.medicalhomeportal.org, 2009

Care Plan Brainstorm

ESSENTIAL CARE TASKS and Associated Coordination Activity

• IDENTIFY/ASSESS PATIENT Determine Likely Coordination Challenges, determine patients vulnerable to disconnected care

• DEVELOP CARE PLAN Proactive Plan for Coordination Challenges and Follow-up

• IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES Specify Who is Primarily Responsible for Coordination (Medical Home)

• EXECUTE CARE PLAN Implement Coordination Interventions• COMMUNICATE TO PATIENTS /Family AND ALL OTHER CARE

PARTICIPANTS Ensure Information Exchange Across Care Interfaces

• MONITOR AND ADJUST CARE Monitor For and Address Coordination Failures

• EVALUATE HEALTH OUTCOMES Identify Coordination Problems that Impact Outcomes

Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7.McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.

Roles at Your Clinic

Who is going to coordinate the patients?

When will the work get done?

Initiation? Follow-up?

Who is responsible for X patient?

St Mark’s Pilot Success

ESSENTIAL CARE TASKS and Associated Coordination Activity

• IDENTIFY/ASSESS PATIENT Determine Likely Coordination Challenges, determine patients vulnerable to disconnected care

• DEVELOP CARE PLAN Proactive Plan for Coordination Challenges and Follow-up

• IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES Specify Who is Primarily Responsible for Coordination (Medical Home)

• EXECUTE CARE PLAN Implement Coordination Interventions

• COMMUNICATE TO PATIENTS/FAMILY AND ALL OTHER CARE PARTICIPANTS Ensure Information Exchange Across Care Interfaces

• MONITOR AND ADJUST CARE Monitor For and Address Coordination Failures

• EVALUATE HEALTH OUTCOMES Identify Coordination Problems that Impact Outcomes

Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7.McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.

Communication

• TEMPLATE DEVELOPMENT• How will you share this

information with all team members?

• Where Does the Care Plan Go in the Chart?

• How is a patient flagged?

Communication

• When should I call you or have you come in (to check on progress)?

• Reinforce Change Plan at every visit/opportunity

• Share plan with all team members• Assist with problem solving as

needed

ESSENTIAL CARE TASKS and Associated Coordination Activity

• IDENTIFY/ASSESS PATIENT Determine Likely Coordination Challenges, determine patients vulnerable to disconnected care

• DEVELOP CARE PLAN Proactive Plan for Coordination Challenges and Follow-up

• IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES Specify Who is Primarily Responsible for Coordination (Medical Home)

• EXECUTE CARE PLAN Implement Coordination Interventions• COMMUNICATE TO PATIENTS/FAMILY AND ALL OTHER CARE

PARTICIPANTS Ensure Information Exchange Across Care Interfaces

• MONITOR AND ADJUST CARE Monitor For and Address Coordination Failures

• EVALUATE HEALTH OUTCOMES Identify Coordination Problems that Impact Outcomes

Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7.McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.

Monitor and Adjust

• Set strong boundaries with patients: role/purpose, time constraints

• Discuss “problem patients” with care team: decide if appropriate for care coordination

• Discuss other potential failure reasons with team

• Reassess patients, as needed

ESSENTIAL CARE TASKS and Associated Coordination Activity

• IDENTIFY/ASSESS PATIENT Determine Likely Coordination Challenges, determine patients vulnerable to disconnected care

• DEVELOP CARE PLAN Proactive Plan for Coordination Challenges and Follow-up

• IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES Specify Who is Primarily Responsible for Coordination (Medical Home)

• EXECUTE CARE PLAN Implement Coordination Interventions• COMMUNICATE TO PATIENTS /Family AND ALL OTHER CARE

PARTICIPANTS Ensure Information Exchange Across Care Interfaces

• MONITOR AND ADJUST CARE Monitor For and Address Coordination Failures

• EVALUATE HEALTH OUTCOMES Identify Coordination Problems that Impact Outcomes

Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7.McDonald KM, Sundaram V, Bravata DM, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.

Health Outcomes Data Collection

• Excel Database • Document your

success• Assist us in

program evaluation• Learn to measure

what you do• Develop your

capacity to show the quality you deliver

Knowing Your Community

Resources and Referrals

Beacon Website Resources

Beacon Clinic Resources

Public Benefit Programs

• SSI (Social Security Income)• SSDI (Social Security Disability

Income)• Medicare (Over 65 years-old,

and disabled)• Medicaid and CHIP (Low

income)

Support Groups

• Disease-based (Cancer, Mental Health)

• On-line groups (Women’s, Grief, Addictions)

• Agency-based (Red Cross, United Way)

• 2-1-1

Community Resources

• Religion affiliated (LDS, Catholic Community)

• Aging and elder care• Pharmacy Assistance Programs• Homeless services• Donated dental

Home Health

• Home health referrals and criteria (Skilled need, homebound status)

• Pre-authorizing services through insurers

• DME (FWW’s, potty-chairs, electric WC’s)

Long-Term Care

• Skilled Nursing Facility (SNF)

- Skilled needs vs. “custodial”• Extended Care Facility (ECF)• Independent/Assisted Living• Medicare versus private pay• Referral processes/paperwork

How to Succeed

• ID the right patients reliably• Track patients• Care Plan in place for patients with a

patient goal in place• Follow-up in place for care plan items• Resources list available, if needed• Improving DM measures in patients and

meeting their goals for care• Patient Satisfaction, experience of health

and support

Wrap-Up and Next Steps

• HealthInsight Assistance• Feedback on self-assessments • Data collection tool assistance• Monthly visit with team (if

desired)• Proqual assistance

Wrap-Up and Next Steps

• Action Plan• What can you do by next

Tuesday? (ideas)

-- Finish assessments

-- Team meeting

-- Begin using ProQual tool on

patients

Wrap-Up and Next Steps

• Evaluations