Discussion Board in Learning Community Site

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1 Discussion Board in Learning Community Site The Discussion Board feature allows you to start discussion threads, share resources, and ask questions or seek input from the Care Partners community. Make sure to set up your notifications (under Settings ) such that you are notified when a discussion topic or response is posted.

2 Starting a Discussion Topic 1. Select Discussions from the left hand menu. 2. Click the button in the top right corner of the Discussions page.

3 Starting a Discussion Topic 3. Enter a topic title. 4. Enter your question or discussion topic.

4 Starting a Discussion Topic 5. Attach files, if applicable. 6. Choose whether or not to allow threaded replies. a) If you are simply asking a question or sharing resources, you can leave all of the check boxes blank. b) If you are starting a discussion, you should check the box for Allow threaded replies. c) When in doubt, choose to allow threaded replies. 5. Click the button

5 Sonoma Care Collaborative Patient Recruitment Algorithm First Steps March 23, 2016

6 Recruitment: Algorithm Overview Primary Care Provider Buy In & Roll Out Marketing Plan Sonoma County Adult & Aging Services Data and PCP entry points Clinic Care Manager (CCM) Assessment Inclusion/exclusion Referral to services Home Visiting Care Manager (HVCM) Action Assessment Motivational Interviewing Referral to services Psychiatry MDT Participants review the case and trajectory Treatment planning Referral to services Relapse prevention Decrease Depression 6

7 Roll Out PHC establishes a Collaborative Care Model of Elder Depression Care PHC hired Social Worker Case Manager (CCM) Psychiatric Consultant appointed Physician Champion selected MDT and program management team established Sonoma County Adult and Aging (SCAA) SCAA hired Home Visiting Care Manager (HVCM) Weekly PHC/SCAA admin/innovation meetings occurred 7

8 Primary Care Provider Buy In Primary Care Provider Training Roll out of program at Primary Care All Provider meeting Description of empirical evidence, goals, referral process and work flow Provider panels reviewed inclusion/exclusion/depression in general Patients who might have depression and meet criteria were flagged Referral Process Developed Referral process established through ecw Care Managers and Operations attend on an ongoing basis Team meetings QI meetings Operations Meetings Team Huddles Warm hand offs and scheduled Consults referred by PCPs 8

9 Marketing Plan Developed Flow/Recruitment Algorithm chart to share with PHC s collaborative team Communications plan regarding patient s care How patients will be engaged in care if there are multiple points of entry How and when family members will be engaged Developed Post Card summarizing the Sonoma Care Collaborative program Literature available on each team and at the front desk Press Releases: Sonoma County Gazette Radio Spot Univision TV spot Plan May mental health month video for our website 9

10 Sonoma County Adult & Aging Services The Human Services Department Adult and Aging Services Division provides assessment and support in home, coordinated with treatment in primary care to older adults with depressive symptoms. Utilizing the evidence based Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors) intervention strategy, PHC patients receive support and greater access to care through in home services and referral to community resources. Sonoma County has provided leadership and program management to facilitate a social worker (HVCM) and supervisor to be embedded in the PHC clinical teams and MDT, leading to innovation, improved care and better outcomes. 10

11 Sonoma Care Collaborative Elder Depression Care Team: Treatment Algorithm ACO/EHR Data Regular Patient appointment scheduled with PCP CCM or Operations schedules appointment with PCP Flagged for warm hand off Primary Care Visit Screening/Introduction to Program PCP will contact CCM for warm hand off If CCM is not available a referral will be made through ecw CCM schedules patient appointment In If program criteria is met, patient signs consent and is enrolled in Elder Depression Care Program. TE is sent to the PCP informing them the patient will be part of the Elder Depression Care Program HVCM is notified of new patient. Home visit is scheduled and assessment completed HVCM & CCM collaborate to develop an initial care plan and LCM identified CCM screens patient using PHQ 9, GAD 7, and rules out Dementia/ Bipolar/Psychosis Out Patient does not meet criteria: PCP notified via TE Referred to other Services Available Services: Follow up visits with PCP Psychiatry Patient Navigator Assistance Referral to Community Resources Psychotherapy Education regarding depression management Behavioral Activation through Healthy IDEAS Psych Consult/med review occurs with CCM and HVCM weekly LCM Coordinates care and tracks progress MDT Depression Continues CCM: Clinic Care Manager HVCM: Home Visiting Care Manager LCM: Lead Care Manager TE: Secured messaging MDT Participants: Clinic Care Manager Home Visiting Care Manager PCP Champion HVCM Supervisor Director of MH/BH Services Clinical Geropsychologist MH/BH Team Manager Project Manager Patient improves PHQ 9 < 10 Relapse Prevention 11

12 Acronyms Clinic Care Manager CCM Home Visiting Care Manager HVCM Lead Care Manager LCM Secured Messaging TE Chief Medical Informatics Officer CMIO eclinical Works ecw Electronic Medical Record 12

13 Actuarial Data Mining and PCP visits for Depression Our Data Miner and CMIO created a list of all patients over 65 These were sorted by medical provider panel Each medical provider reviewed their list and reflected on who might be appropriate for the program Separately, the original data set was cross referenced with diagnoses of depression This was not used as the sole method due to the under diagnosis of depression in the elderly The Clinic Care Manager in a coordinated effort with operations, schedules targeted visits with the PCP to review depression The visits are scheduled at a time when the CCM can be available for a warm hand off 13

14 Primary Care Visit In the course of a normal primary care visit The PCP suspects or diagnoses depression 1. PCP introduces the program to the patient 2. Alerts medical assistant/flow coordinator and MH operations to contact CCM for warm hand off If CCM is not available then a referral is made and TE sent to CCM to schedule an intake with patient. 14

15 Clinic Care Manager (Vicki) Meets with Patient Screens for Exclusion Criteria Bi polar Dementia Psychosis Screens for Inclusion Criteria Depression (PHQ 9>10) Notifies the PCP 15

16 Services Include And others that become apparent as the need arises 16

17 IN/OUT Clinical Care Manager determines if the patient meets inclusion criteria IN Patient meets criteria: Patient signs consent Is enrolled in Elder Depression Care Program! TE is sent to the PCP informing them the patient will be part of the Elder Depression Care Program Referred to appropriate services OUT Patient does not meet criteria: PCP notified via TE Referred to other services 17

18 Home Visiting Care Manager (Diane) Notified of newly enrolled patient Home visit is scheduled In Home assessment is completed including: Psychosocial assessment Functional assessment Environmental safety Social support Legal financial assessment Initiates Healthy IDEAS Referral to services 18

19 Initial Care Plan CCM and HVCM (Vicki and Diane) Meet in person or virtually/telemedicine Discuss patient s needs Make appropriate referrals Update ecw Update CMTS Send TE to psychiatrist Send TEs to any appropriate member of the team Lead Care Manager is identified to coordinate care and track compliance. Referral to services 19

20 Psych Psychiatric Consultant Receives TE Reviews chart Makes medication recommendations Contacts PCP Referral to services CCM, HVCM and psychiatrist meet weekly as separate MDT Appropriate actions are taken (see above) Referral to services 20

21 Lead Care Manager Tracks Progress Reviews chart Looks at recent encounters Contacts patient on a regular basis Sends TEs to any appropriate entity Tracks PHQ 9 scores Tracks inclusion criteria Tracks overall wellbeing Refers to services Preps case for MDT 21

22 Positive Feedback Care Cycle MDT members Meet weekly Review each patient Think together about treatment plan Adjust, advance and evolve plan Refer to services Lead Care Manager continues to track progress If depression continues: The patient continues to be tracked and reviewed on a weekly basis to: Optimize care coordination Treatment planning Access to services 22

23 MDT Participants: Clinic Care Manager Home Visiting Care Manager PCP Champion HVCM Supervisor Director of MH/BH Services Clinical Geropsychologist MH/BH Team Manager Operations Project Manager 23

24 Access to Services At every point in the flow of treatment the patient has the opportunity to be referred for services that are assessed to be appropriate by: Any individual member of the team The MDT Communication optimizes: Treatment planning and Referral to services 24

25 Graduation When the patient improves: PHQ 9 < 10 Behavioral observations show decrease in symptoms Lead Care Manager identifies patient for Relapse Prevention MDT reviews Relapse Prevention Patient is informed and engaged in Relapse Prevention 25

26 Questions? Thanks! 26