Personalized Primary Care Annual Meeting. Care Management Catherine Hamilton, BSN, MS, MBA

Transcription

1 Personalized Primary Care Annual Meeting Care Management Catherine Hamilton, BSN, MS, MBA

2 Care Manager Assessments 75% of care managers assessed Observed processes Evaluated against NCQA 2014 Medical Home Standards 2

3 Assessment Results: Strengths Care management staff Spending time with patients Facilitating team approach (strong relationships with providers) Appropriate delegation to Care Guides and Health Advocates 3

4 Assessment Results: Recommendations Staffing based on risk/acuity Clarify roles and responsibilities Define an advancement pathway for care managers (growth opportunities) Include regular skills training on leadership competencies, motivational interviewing, and community resources Develop network of social support services 4

5 How will we use these results? Integrated Care Management: Staffing, Education, and Training Development Committee Defined core competencies for care management system wide Building a strategy for talent management which includes recommendations from our assessments Optimize staffing mix and align competencies to system and clinic needs (patient acuity) 5

6 Core Competencies System-wide competencies for care management Leadership Professional proficiency Knowledge of the healthcare environment Operational knowledge and skill 6

7 Core Competencies System-Wide skills for care managers Develop evidence-based, patient-centered care plan which includes caregivers as appropriate Collaborate across professions and healthcare entities Motivational interviewing Building relationships

8 Core Competencies New orientation checklist Link to LMS/My Learning Previous training will be grandfathered in 8

9 Risk Assessment: Need for CM? Assign Longitudinal CM Population Stratification Program Eligibility ALL PATIENTS & MEMBERS YES NO Longitudinal CM Episodic CM HIGH RISK MEDIUM RISK LOW RISK HIGH RISK MEDIUM RISK LOW RISK Longitudinal Intermountain & Communitybased Interventions Episodic Intermountain & Communitybased Interventions Patient Handover Community Partners & Resources PPC or SelectHealth CM Prevention Services: PPC, Health Answers, LiVe Well

10 Implemented Planned Future Longitudinal Interventions High Med Personalized Primary Care Inpatient Palliative Care SelectHealth Disease Mngmt Specialty Clinics Outpatient Palliative Care Health Answers Expansion Community Health Workers Affiliate Contracted CM Embedded CM Services SelectHealth CM Transfer PPC- High Utilizers/ High Cost Community Care Management Rural Hotspotting CM Project Episodic Interventions High Comprehensive Care Clinic SelectHealth Pts ID s by triggers High Risk Specialty Clinics (Maternal Fetal Med, Onc) Navigation Services SR Hybrid Project Tele-ED CM Services Med Personalized Primary Care IP & ED pts ID s by screening Promatora Program Home Health Bridging Project Community Based Programs

11 Pediatric High Risk Defined criteria for Level 3 Children with Special Healthcare Needs Supports VRP and care management goals Created a report for Level 3 with date of last care plan Providers and care managers will use this report to monitor progress toward goals The report is a new tab in the PPC report 11

12 Pilot: Home Visits Outcome of the care manager assessments Pilot in one region Care manager visit for home/environment assessment (not skilled nursing) Developing criteria for home visits, safety training, and assessment documentation

13 Pilot: Behavior Change and Motivational Interviewing Helping Patients Engage in Healthy Behaviors Motivational Interviewing is a skill used in the Behavior Change Framework The first training course is December care managers from Medical Group will participate Additional training in 2016

14 Pilot: Behavior Change and Motivational Interviewing The course will be both didactic and simulation based. Participants will: Be able to explain the Behavior Change Model Use growth mindset messages when communicating with patients Listen to the patient story and verbally reflect Engage the patient in experimenting with new steps taking into consideration all of the framework variables

15 Transfer Care Management from SelectHealth to Medical Group Achieve a single care plan and one care manager Care management of chronic conditions will be transferred to Medical Group when the patient sees a Medical Group PCP Benefits management and utilization management will stay with SelectHealth

16 Transfer Care Management from SelectHealth to Medical Group New care manager workflow in icentra with more extensive documentation than HELP2 Training on the workflow will follow icentra go-live schedule

17 Chronic Pain Management Care managers will have a key role in developing a patient-centered care plan for chronic pain Controlled substances medication management agreement Training starting in 2016 Training will take place regionally 17

18 Today s Agenda Leadership Regional integration and collaboration NCQA certification for Medical Home icentra changes to support our work 18

19 You Are Leaders!

20 Questions??? 20