Complex Care Management and Care Plans. Evan Saulino, MD, PhD Clinical Advisor Oregon Health Authority PCPCH Program

Transcription

1 Complex Care Management and Care Plans Evan Saulino, MD, PhD Clinical Advisor Oregon Health Authority PCPCH Program

2 Oregon s PCPCH Model is defined by six core abributes, each with specific standards and measures: Access to Care Be there when we need you Accountability Take responsibility for us to receive the best possible health care Comprehensive Whole Person Care provide/help us get the health care and informa>on we need ConFnuity Be our partner over >me in caring for us CoordinaFon and IntegraFon Help us navigate the system to get the care we need safely and >mely manner Person and Family Centered Care recognize we are the most important part of the care team, and we our responsible for our overall health and wellness

3 2011 model Standard 5.C. - Care Coordina9on Measures: 5.C.1 PCPCH assigns individual responsibility for care coordina9on and tells each pa9ent or family the name of the team member responsible for coordina9ng his or her care. (Tier 1-5 points) 5.C.2 PCPCH describes and demonstrates its process for iden9fying and coordina9ng the care of pa9ents with complex care needs. (Tier 2 10 points)

4 2011 model Standard 5.F. Comprehensive Care Planning Measure 5.F.2: PCPCH demonstrates the ability to iden9fy pa9ents with high- risk environmental or medical factors, including pa9ents with special health care needs, who will benefit from addi9onal care planning. PCPCH demonstrates it can provide these pa9ents and families with a wrinen care plan that includes the following: self management goals; goals of preven9ve and chronic illness care; ac9on plan for exacerba9ons of chronic illness (when appropriate); end of life care plans (when appropriate). (Tier 2 10 points)

5 2013 PCPCH Standards Advisory CommiNee Report Standard 5.C. - Complex Care CoordinaFon 5.C.1 PCPCH anests to a process for iden9fying pa9ents with complex care needs and enrolling them in services for care coordina9on 5.C.2 PCPCH demonstrates that members of the health care team ac9ng as care coordinators for pa9ents with complex care needs have received specific training in care coordina9on func9ons 5.C.3 PCPCH develops individualized wrinen care plans for pa9ents and families with complex medical or social concerns. This care plan should include the following goals: self management; preven9ve and chronic illness care; and an ac9on plan for exacerba9ons of chronic illness

6 PCPCH Standards Advisory CommiNee iden9fied the following tasks as examples of care coordina9on: - coordina9on of care received outside the PCPCH and in specialized care setngs - tracking of indicated care and tests - self management support and educa9on - mo9va9onal interviewing and coaching on behavior change

7 Peikes, et al, JAMA 2009

8 From AAFP website - CPCI Risk stra9fica9on

9 PaFent- Centered Care Planning Care Plans have shown benefits for pa9ents of all ages: Pediatric e.g. congenital/developmental condi9ons, ADHD, asthma Adult e.g. mental health condi9ons, COPD, diabetes, cancer, pallia9ve care Evidence suggests pa9ent engagement and goal- setng is important to empowerment/outcomes. Key to engage mul9- disciplinary frontline staff in planning/use to make care plan a living document

10 Medicaid ACA- qualified Payment Program Requirements work with each pa9ent to develop a person- centered plan within six months of ini9al par9cipa9on and revise as needed. The care plan must include: self- management preven9ve and chronic illness care goals ac9on plans for exacerba9ons of chronic illness end- of- life plans when appropriate

11

12

13

14

15

16 Goal setng guide: Work collabora9vely with pa9ent and family/caregivers Iden9fy goals that are SMART (specific, measureable, ac9onable, realis9c, 9mely) Start small and build on success Provide regular feedback/ touches follow up by phone/ /face- to- face Use relevant and frequent external rewards Goal setng discussions and follow up can be done by allied health staff Iden9fy external supports as needed Use the PDSA (Plan- Do- Study- Act) strategy to improve

17 Developing and Implemen9ng Care Plans in Clinic Process will differ in each clinic depending on popula9on needs and EHR Involve diverse staff members during development and discussion of how care plan will be used. Involve pa9ents/families in the design. Test changes with small pilots to make small discoveries instead of big mistakes Review by external en99es will be valuable Prac9ces use EHR technologies different ways most have moved to using EHR but important to develop template FIRST before considering integra9on into EHR

18

19 Person Centered Care Plan Risk Level: High Last updated by: Linda A Carrico 3/6/ :30 Original Author: Linda A Carrico 3/6/ :30 Medical Summary: Mr. X has struggled with agoraphobia/anxiety, and obesity. He has improved with venlafaxine, and gradually increased his comfort leaving the house - e.g. Once a day for a walk. He was diagnosed with diabetes in He was admibed to Providence Portland Medical Center with likely asthma exacerbafon in 3/2013. PaFent Care Team: Team C PaFent Care Team: Evan Theodore Saulino, MD as PCP - General Personal Support Team: Lives with Mother XXXXXXXX 503- XXX- XXXX PaFent s care goals (chronic and prevenfve) 1. Walk every day at least 8 blocks and try to increase the amount of walking if not short of breath 2. Eat more plants. 3. Avoid "regular" soda, and instead limit to 1 diet soda per day. PaFent s self management tools: Offered appts with Behaviorist, declined PaFent s barriers to care/goals: Agoraphobia/anxiety Team Goals: (chronic and prevenfve) 1. Ensure follow through with pulmonary workup 2. Work with Mr. X to improve his diet/increase exercise. 3. More op9mally manage his psychiatric issues so he can do more ADLS/engage in ac9vity outside the home - he has not been open to accessing more formal MH services in past. PaFent has an acfon plan in chart for: Asthma acfon plan

20 THANK YOU! For more informafon visit: PRIMARYCAREHOME.OREGON.GOV PCPCI.ORG