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