Complex Care Management Protocols and Procedures

Transcription

1 Complex Care Management Protocols and Procedures December 2014 Version 3.0 1

2 Table of Contents I. Complex Care Management Program Staff Roles and Responsibilities... 4 II. Complex Care Management Program Initial Participant Identification... 5 I. Screening... 5 III. Enrollment... 5 III. Complex Care Management Practice Protocol Phase I... 6 a. Home Visit Protocol... 8 A. Overview... 8 B. Coordination of Care; After the initial visit and before the follow up call d. Involvement of PCP A. Phase 1 Closure IV. Complex Care Management Practice Protocol Phase II B. Case Closure Goal Setting and Problem Solving F. Identification of Appropriate Community based Services for Referral G. Assessment of Condition Related Signs and Symptoms (HCRN) C. Linkage to Appropriate Care for Zone Changes

3 QUICK GUIDE STEP # ACTION Tools 1 Identify patient population Review data feed Trilogy/Valence report 2 Select appropriate patients Guideline tool 3 Document patient designation Care Mgt system 4 Enrollment Visit patients who are inpatient and educate on program and enroll Script, Brochure, enrollment form Hospital privileges Document for inpatient care manager 5 Call patients Outpatients educate on program and enroll. Schedule home visit within 3 days of call or discharge Mail brochure and home visit date/time Script 6 Home Visit Complete complex case assessment Complete medication reconciliation/education Establish goals and prioritize Educates on Disease process and self management Provide, reinforce stop light tool Ensure patient and care partner have appropriate phone numbers Medication adherence and symptom monitoring Schedule follow up call Home visit check list Enrollment form if not completed Assessment tools Medication recon tool Goal/care plan template Stoplight Tool Educational materials Diaries/log Folders Pill boxes 7 Care Planning Coordination Complete care plan Care plan template 8 Contact provider to coordinate services or care as needed Send care plan to leading provider Provider contacts 9 Arrange MSW or Pharm intervention, additional services if needed Attend MD appointment if indicated 10 Follow Up Call Call patient at agreed day/time 11 Review goals, health status, appointments, questions Criteria for MSW or Pharm engagement Referral form Care plan 12 Review stop light 13 Arrange follow up home visit 14 Home Visit Assess health and social status Care plan 3

4 Reviews goals and prioritize Modify as needed Educates on disease process and self management Provide, reinforce stop light tool Schedule follow up call Goal/care plan template Stoplight Tool Educational materials 15 Care Planning Coordination Update care plan Care plan template 16 Contact provider to coordinate services or care as needed Send care plan to leading provider 17 Arrange MSW or Pharm intervention, additional services if needed 18 Attend MD appointment if indicated 19 Follow up Call Repeat from 1 st follow up call Assess degree of ongoing support needed Phase 1 Closure Contract for ongoing support Phase 2 Assessment form I. Complex Care Management Program Staff Roles and Responsibilities Complex Care Manager: A registered nurse (HCRN) who is responsible for the overall management of identified patients including coordination of services, establishing care plans, determining the need for Social Work and pharmacy intervention. Social Worker: An MSW or LCSW will be responsible for the assessment and planning for Psychosocial and mental health needs. The Social Worker will be assigned base on the HCRN assessment and will coordinate with the HCRN to mutually address barriers and work towards completing Patient goals. Pharmacist: The Licensed Pharmacist will be assigned as needed by the HCRN to address complex medication issues that may include compliance, multiple providers, complex medication regimes. Interventions may include medication reconciliation, education on medication compliance and disposal and coordination with prescribing physicians. The Pharmacist will work with the patient, and their providers in concert with the HCRN and Social Worker to mutually address barriers and work towards completing Patient goals. 4

5 II. Complex Care Management Program Initial Participant Identification Potential candidates for complex care management will be identified primarily by a provider or through data tools. In both cases, there will be a secondary screening by a staff member for impact opportunities The process using Claims data to identify potential candidates for the Health Choice Complex Care Management Program, irrespective of site of care is detailed below: I. Screening 1. Review list of suggested patients for inclusion/exclusion a. Review daily Complex Care Management Program Eligibility Report i. Validate that case is complex using validation criteria ii. Assign a risk level of high, medium, or low, based on Valence risk level: b. Assess those previously screened and enrolled as full participants in the past 12 month period i. Compare eligibility report to the list of persons previously screened and enrolled as full participants to assess appropriateness of inclusion to include reasons goals not met, or new issues identified. Complex Care Management Validation Criteria 2+ hospital admissions OR 1 inpatient admission and 2+ prior emergency visits in the last 12 months prior to the current admission Diagnosis of at least two different chronic conditions (HTN, CHF, CAD, DM, CLD) in the last 12 months Any one diagnosis in the following areas: cancer, renal, liver disease Total charges of at least $70,000 Age > or = 18 at the current admission Exclusions are: transplants, conditions associated with pregnancy, substance abuse III. Enrollment 1. Patients in an Outpatient Setting: a. Nurse calls the patient, explains the program and the role of the HCRN. If the patient agrees to a face to face assessment, an appointment is made for a home visit. 5

6 i. Describe the benefits of the Complex Care Management Program individualized to the patient s condition and needs b. A program brochure is sent to the patient who has agreed to participate along with a confirmation of the date and time of the visit. The document will be sent via regular mail. c. Call to patient to confirm date/time and setting for visit 2. Patients in an Inpatient Setting: HCRN visits the patient in the hospital, explains the program and the role of the RN. If the patient agrees to participate, a consent is completed by the patient. a. Give patient Complex Care Management Program flyer i. Describe the benefits of the Complex Care Management Program individualized to the patient s condition and needs ii. If the patient agrees to participate, have the consent form signed iii. Verify contact information and expected place for discharge (home, facility etc.) b. If the patient agrees to participate inform the Hospital Case manager. Provide Case Manager with Notification of Enrollment Form and instruction form for follow up c. Hospital case manager to contact HCRN with discharge date. d. HCRN contacts the patient prior to discharge or within 24 hours of discharge to arrange a home visit a. HCRN confirms that the patient has received i. A patient friendly comprehensive discharge medication list ii. Stop light tool iii. Understands discharge instructions iv. Validated provider follow up appointment III. Complex Care Management Practice Protocol Phase I An overview of the process for all Complex Care Management Program outpatient interventions, including home visits, telephone follow up, coordination with primary care and specialist providers, comprehensive medication review and medication therapy management. 6

7 Upon initiation of program participation, the Complex Care Management Team will use the complex care management tool to assess each patient with regard to their level of medical and social complexity to assess participant needs for intensive social work and medication problem solving and support. Increasing Social Complexity Increasing Medical Complexity Low Low No additional medication and social support provided High Additional medication support provided High Additional social support provided Additional medication and social support provided Week Activities 1st Home Telephone Followup (and/or 2nd Home Visit 30 day Telephone Follow up Visit within 72 hours of discharge or within 7 days of initial contact accompanying patient to PCP visit) to insure PCP follow up within 14 days of initial contact Responsibility HCRN HCRN/Pharm/MSW HCRN/Pharm/MSW HCRN/Pharm/MSW After the 30 days Phase 1 of the Complex Care Management Program, monthly telephonic touch base/education outreach calls will be scheduled for a period of 6 11 months for up to 12 months, depending on the patients needs. If during this first 30 day stage, it is determined that the case should be closed, the care manager should discuss this with a supervisor and with agreement, share the decision with patient and provider and document appropriately in Care Manager. Notification letters of care closure to both patient and provider are sent. Examples of reasons to close a case early are: Lack of participation by patient Determination that the patient s condition is stable and does not require additional support Other parties are assuming responsibility for care management. 7

8 Additional social or medication support provided to selected participants may include: Telephone outreach and follow up by MSW and/or Pharmacist Participation in home visits by MSW and/or Pharmacist Assistance with and linkage to appropriate community based services by MSW and/or Pharmacist a. Home Visit Protocol The process for all Complex Care Management Program activities occurring in the home at initial and follow up home visits including assessment of condition related signs and symptoms, documentation of current medication use and side effects, drug disposal, teach back of condition educational materials, goal setting and problem solving, and identification of appropriate community based services is detailed below: A. Overview The assigned HCRN will conduct all home visits. After the initial enrollment, the first home visit will occur within three five business days. The second home visit will occur approximately two weeks after the initial visit. Any additional home visits will be at the discretion of the supervising Manager. The HCRN and or MSW will be responsible for phone follow ups. Assessment a. Complete Complex Care Management Assessment Form (using Valence template) Medication reconciliation i. Include the patient advocate in the initial assessment process ii. Prefill as many items as possible using valence tool iii. Identify additional resources needed 1. Medical equipment 2. MSW or Pharmacist support 3. Financial resources 8

9 1. Ask patient/caregiver to bring all medications to the nurse during the visit including all over the counter medications and supplements 2. Ask the patients to show which of the medications they are currently taking 3. Compare medications the patient/caregiver indicates they are currently taking to the current discharge medication list to determine Is the patient taking any prescription medications that are not on the medication list? If yes, contact managing provider to determine preferred prescription and facilitate obtaining medications as needed Are there medications on the discharge medication list that the patient is not taking? If yes, contact managing provider to determine preferred prescription and facilitate obtaining medications as needed. Goal Setting and Problem Solving 1. Based on the results of the assessment, the HCRN will engage the patient in the patient s own personal goal setting and problem solving setting priorities from the problem list created from the assessment process. 2. Include outcomes from the medication reconciliation 3. Work with the patient to establish an action plan 4. The HCRN may negotiate and assist the patient in setting goals based on the postdischarge care plan in consideration of risk factors identified during screening as well as prior patient experience of symptom exacerbations leading to hospitalization; however, the ultimate decision is the patient s choice. 5. It is advised that the patient choose one or two goals initially. 6. If the patient does not choose a goal, efforts to raise awareness of problem areas and impact on condition management should be taken. [NEED TO UNDERSTAND HOW VALENCE SYSTEM WORKS ON ACTION PLANNING] Condition specific education 1. Complete the disease specific assessment as available [NEED TO UNDERSTAND HOW VALENCE SYSTEM WORKS ON ACTION PLANNING] 2. Based on assessment determine patient understanding of disease process and the appropriate self management goals 9

10 i. Ask patient to state as many self management goals for their driving diagnoses, as they can ii. Ask patient to state basic information about their disease process Good Fair Poor The patient/caregiver can state the majority of self management goals for their disease process they are able to state a majority (more than 4 items) of the basic information about their disease process upon prompting The patient/caregiver can state a couple of the selfmanagement goals for their disease process they are able to state a moderate amount (3 to 4 items) of basic information about their disease process upon prompting The patient/caregiver cannot state more than one selfmanagement goal for their disease process cannot state more than one piece of basic information about their disease process upon prompting 1. Spend additional time reviewing the materials for any assessment deemed fair or poor and allow the patient/caregiver to ask questions 2. Provide patient with patient friendly stop light tool or reinforce how it is to be used 3. Determine additional risk for mental health issues (use the X depression tool if appropriate) 4. Outline all needs for referrals Medication Support a. Medication education a. Based on disease specific and initial assessments determine need for education on current medications b. Assess need for additional support from Pharmacist i. Use the following criteria for determination: 10

11 2. Review patient friendly comprehensive medication list with patient/family member/caregiver using teach back method b. Drug Disposal 1. Review each medication, what they are for and how to take them 2. State the directions for the first medication and ask them when during the day they would take it (like 7am, or 7am and 7pm) a. Repeat for all medications 3. Review medications and provide side effect/warning information on meds where appropriate 4. Provide general storage and missed dose information 5. Confirm that each Complex Care Management Program participant has access to all prescribed drugs a. Check for formulary and cost issues ii. Patient Pillbox Education Review patient friendly medication list with patient/family member/caregiver in conjunction with the pillbox supplied to the patient and demonstrate how to fill the pillbox properly. i. Complete the Record of In Home Medication Disposal document (Appendix) a. The CHPT should use the counting tray provided to obtain an accurate number of each pill form medication to be disposed. b. The CPT should document the approximate amount of liquid medication disposed of based on the container holding the medication. Tools Self Management tools are available to assist the patient and care givers optimize their own health. These may include the following Health folder Symptom log Daily weight, intake and exercise logs Pillboxes Zone tool Contact sheet 11

12 B. Coordination of Care; After the initial visit and before the follow up call Referrals/Coordination a. Use the Community Resource Information Guide to Identify Resources to Meet Patient Needs i. A large amount of community resource information has been compiled as a guide to be used during home visits. This resource guide includes information about home health agencies and skilled nursing facilities. Also included in the community guide is information for free or reduced meal assistance and food banks, low cost prescription services and local pharmacy lists, support groups for stroke, CHF, diabetes, and COPD, and non emergent transportation assistance. ii. Determine need for social work and or pharmacy consultation using the established guidelines iii. If it is determined that Home Care is needed, contact Methodist Affiliated Services. iv. If Home Care is currently in place with Affiliated and it is determined that a change in care or coordination is needed, contact the Affiliated Clinical Director who will connect the Care Manager to the right person Provider Coordination Coordinate care with outpatient PCP and/or specialty care providers i. If multiple specialists/providers help identify Quarterback provider to coordinate care ii. Communicate with providers as needed a. Communicate any identified medication issues b. Assist as needed in the scheduling of provider appointment for patient within 72 business hours of either discharge of identification of significant issues/barriers i. Confirm plans for provider appointment by telephone within 48 hours of scheduled visit(s). Ensure a transportation plan is in place for appointment(s) c. Obtain orders for services and equipment 1. Share documents 12

13 a. Provide providers, with Complex Care Management Discharge Note/Continuity of Care Document, and the Discharge Summary and other discharge materials (e.g. Depart Summary) if available. b. Share provider notes to all parties as needed 2. Update Providers a. Communicate changes in medication regimen and self management needs b. Through direct telephone conversation as needed, on the post discharge care plan (including any medication management changes) at least within 72 hours of either discharge or major post discharge plan or management need changes or recommendations c. Review/discuss the post discharge care plan or changes i. i. The Complex Care Management Discharge Note will summarize the post discharge care plan, including medication changes, within 72 hours of either discharge or major post discharge plan changes d. Involvement of PCP i. For patients with PCP 1. Notify PCP office that patient is in Complex Care Management Program and coordinate as above ii. For patients without PCP 1. When the patient s condition is stable, provide patient with list of PCPs in area and ask for their top three preferences Behavioral health and/or substance abuse services if needed (inform primary care of referrals) (MSW) v. Assess patient for behavioral health concerns and needs. Use the depression assessment tools vi. Identify triggers, and signs and symptoms list 1. Patient currently on psychotropic meds with alterations and mental status changes 2. Patient discusses depression, and other mood changes 13

14 3. Patient not taking meds or following Complex Care Management procedures vii. Notify PCP viii. Request Behavioral Health consult Coordination with other Services Due to the complex nature of the patient s medical and psychosocial circumstances, multiple services may be in place for the individual including home healthcare, hospice, social services, telephonic case management, the HealthChoice Care Manager will work with the patient and service providers to reduce redundancies and confusion. The goals is to be sure all services are provided as efficiently as possible, taking into account the interest and wishes of the patient. As part of the care planning process, the HC Care Manager will include the coordination of services as part of the care plan and will build in ongoing monitoring as needed Follow up Phone Contacts b. HCRN contacts patient by phone 7 days of the home visit at agreed date/time i. Reviews/modifies goals ii. Assesses status and progress against goals iii. Identifies any changes in barriers and side effects of medication iv. Assess for barriers to self care v. Review patient s diary weekly to assess for symptoms associated with condition exacerbations vi. Confirms any tasks the HCRN was to take vii. Confirms any tasks patient or advocate agreed to take viii. Determines next provider appointments ix. Care plan adjusted as needed x. Follow up home visit scheduled C. Second Home Visit c. A follow up assessment will be performed to i. Assess status of condition and progress in goals ii. Determine barriers to self management d. Perform medication and condition education as needed e. Identify additional resources needed D. Follow up Coordination (use tools/steps in section B (p.12) above as needed) E. Final Phase 1 phone call i. Reviews/modifies goals 14

15 ii. Assesses status and progress against goals iii. Identifies any barriers and side effects of meds iv. Assess for barriers to self care v. assess for medication problems and medication changes vi. review patient s diary weekly vii. to assess for symptoms associated with condition exacerbations viii. Confirms any tasks the HCRN was to take ix. Confirms any tasks patient or advocate agreed to take x. Assess for extended care management needs xi. Enroll patient in extended care management plan A. Phase 1 Closure After completing the phase 1 protocol, a minimum of 2 phone calls and 2 home visits, the HCRN will assess the patient s status to determine the need for additional medical/psychosocial support which may include: Accompanying patient to PCP and/or specialist visits Assisting patients in arranging transportation to PCP visits Calling PCP and/or specialist provider to coordinate care Providing Complex Care Management outpatient visits to provide patients with additional focused training in disease self management (APN) Providing additional CMR/MTM visits to assist patients in resolving medication related problems Additional social support provided to selected participants may include: Telephone outreach and follow up by MSW Participation in home visits by MSW Assistance with and linkage to appropriate community based services IV. Complex Care Management Practice Protocol Phase II 1. Phase II phone calls will occur once monthly for the agreed upon time frame, usually 6 11 months. 2. Phase II calls will include the following elements a. Assessments for medication problems and medication changes 15

16 Discuss with patient any barriers and side effects of meds Education on medication use and symptoms associated with condition exacerbations b. Assessments for symptoms associated with condition exacerbations Review patient s diary weekly Monitor patient s progress in the program Discuss with patient any barriers to self care Provide disease and self management education as needed based on assessments c. Identify additional services needed d. Provide PCP an electronic update of patient s progress 3. Additional phone follow ups may occur between monthly follow ups depending on patient needs. a. Refer to Section IV 2. a h above 4. Additional medical/psychosocial support may be appropriate which may include: I. Accompanying patient to PCP and/or specialist visits II. Assisting patients in arranging transportation to PCP visits III. Calling PCP and/or specialist provider to coordinate care IV. Providing Complex Care Management outpatient visits to provide patients with additional focused training in disease self management V. Providing additional MSW and or Pharmacist visits to assist patients in resolving medication related problems VI. Assistance with and linkage to appropriate community based services B. Case Closure I. Complete closure summary a. Goals set b. Goals met c. Goals not met d. Remaining barriers e. Suggestions for overcoming barriers II. Share summary with providers 16

17 APPENDIX II Case Management Strategies 1. Goal Setting and Problem Solving 7. The HCRN will engage the patient in the patient s own personal goal setting and problem solving for high priority self management needs through completion of the Action Plan. 8. Using the Self Care Recommendations in the disease toolkit associated with the driving diagnosis, the patient will choose the goal(s) they would like to focus on initially. 9. Note behaviors encouraged in previous portions of the home visit (i.e., keeping medicines in a pillbox, recording daily weight) should not be the focus of patient goal setting. 10. The HCRN may negotiate and assist the patient in setting goals based on the post discharge care plan developed by the APN and CHP in consideration of risk factors identified during screening as well as prior patient experience of symptom exacerbations leading to hospitalization; however, the ultimate decision is the patient s choice. 11. It is advised that the patient choose one or two goals initially. 12. If the patient does not choose a goal, efforts to raise awareness of problem areas and impact on condition management should be taken. 13. The HCRN will document the category of the goal area in the Complex Care Management database (see Patient Goal Setting Checklist below). 17

18 Patient Goal Setting Checklist 1. The patient has chosen a goal area related to self management of driving diagnosis. Yes No If yes, identify category of goal: [ADD OTHER CATEGORIES FROM ALL CONDITIONS] Doctor follow up Diet Alcohol Fluid intake Smoking Activity Medicines Self monitoring Prevention (primary/secondary) Environmental Irritants (COPD/asthma) Treatments (COPD/asthma) Other, specify: 2. The patient has identified barriers to recommended self management behaviors. Yes No If yes, identify barrier type and one primary example: (check all that apply) Environmental (i.e., access, home conditions), specify: Social (i.e., what other people do or say), specify: Psychological (i.e., feelings, thoughts), specify: Other, specify: 3. The patient/caregiver/staff have brainstormed possible solutions to barriers. Yes No If no, why 4. The patient has developed an action plan based on chosen solution. Yes No If no, why If yes, staff should use Ipad camera function to capture action plan for future monitoring. 5. Staff will follow up by (home visit, phone) to assess progress in (one, two) weeks. 14. Following the identification of the goal area, the HCRN/CHPT and patient will discuss what makes it difficult for the patient to achieve listed behaviors related to the goal focusing on environmental, social, and psychological barriers. 15. For example, if a patient with a driving diagnosis of CHF chooses to focus on reducing sodium intake, the discussion might include what types of food the patient eats, food preferences, knowledge of sodium content, meal preparation in the household (who), food sources, and availability. 16. The HCRN should document any significant barriers to self management behaviors discussed or reported by the patient. 17. The HCRN/CHPT will assist the patient/caregiver in brainstorming possible solutions to identified barriers. Program staff should avoid temptations to jump in and solve the patient s problem. 18. If no solutions can be generated to address a barrier, additional COMPLEX CARE MANAGEMENT PROGRAM team members or advisors 18

19 should be consulted either during the home visit or following the visit to discuss. 19. The HCRN/CHPT should assist the patient/caregiver in establishing personal goals for change that are based on at least one barrier and is acceptable to the patient. 20. The HCRN/CHPT should also establish follow up contact for monitoring goal progress F. Identification of Appropriate Community based Services for Referral b. Document All Referrals Made in Complex Care Management Database a. All referrals must be documented in the Complex Care Management database under the REFERRAL tab (not HOMEVISIT). c. Use Complex Care Management Home Visit Closing Script (Appendix) to guide home visit communication iii. c. Ask if the patient has any questions about the program d. Schedule follow up phone call setting expectations of patient and HCRN i.e. scheduling appointments, medication refills, testing etc G. Assessment of Condition Related Signs and Symptoms (HCRN) 1. Conduct a brief condition specific assessment of signs and symptoms for deterioration of diagnosis specific health (HCRN with APN back up) a. Conduct the Brief HCRN Home Visit Assessment for Symptoms and Signs (Appendix) to determine whether patient exhibits signs and symptoms in the red or yellow referral zones and follow the protocol for notification of the APN b. Document findings from above assessment using the Cerner Home Visit Note Template (Appendix) 19

20 1. Triage Patients with Potentially Life Threatening RED ZONE Signs or Symptoms a. If the patient exhibits signs or symptoms of life threatening illness (i.e., severe chest pain or difficulty breathing), according to the toolkit protocol, the HCRN will contact 911 for transport to the Methodist ED followed by an alert call to the APN b. The HCRN, with assistance from the CHPT, will continue to monitor the patient s vital signs and perform CPR measures, if needed c. Following resolution of the emergency, the HCRN will complete the documentation of home visit termination d. Termination of the home visit will be indicated by clicking the yes box to questions #1 (see below). The check box heading Assessment of conditionrelated signs and symptoms is on the Complex Care Management database Home Visit tab. Click the checkbox next to the heading 2. Triage Patients with Non Life Threatening RED ZONE Signs or Symptoms a. the HCRN will contact the APN using the phone or SKYPE technology on the Ipad b. The HCRN should document the APN recommendations in the Plan [ P ] section of the CERNER system s home visit note c. The HCRN should complete remaining questions under Question 1: Assessment of condition related signs and symptoms upon completion of assessment and documentation. 3. Triage Patients with YELLOW ZONE Signs or Symptoms a. Same as triage protocol for #3 above 4. Complete the Assessment of Condition Related Signs And Symptoms Checklist in Complex Care Management database (below) 20

21 Assessment of Condition Related Signs And Symptoms Checklist 1. The patient shows signs/symptoms of a life threatening condition during today s visit. Yes No If yes, contact 911, APN. (If no, continue to question #2 ) 2. The patient shows evidence of signs/symptoms in the red zone during today s visit. Yes No If yes, contact APN for RED on site consult. (If no, continue to question #3) If yes, did the APN provide on site consult? Yes No Not available 3. The patient shows evidence of signs/symptoms in the yellow zone during today s visit. Yes No If yes, assist patient with urgent PCP appointment. (If no, continue to question #3) If yes, did patient get appt with PCP in the next 24 to 48 hours? Yes No If no, contact APN for YELLOW on site consult. 4. The patient shows no signs that indicate condition deterioration (green zone) during today s visit. Yes No 5. Does the patient have any questions about signs or symptoms that require APN follow up at a later time? Yes No If yes, alert APN via text/ . C. Linkage to Appropriate Care for Zone Changes 1. Encourage patients to make appointments for early signs of condition exacerbation (e.g. yellow stop light) a. Care will be coordinated for patients seen by PCP or ED for yellow zone symptoms 1.Patients will be outreached by telephone by APN/CHP and/or HCRN/CHPT within 72 hours of a yellow zone PCP or ED evaluation, to assess for improvement 2.Any necessary changes to medications or management plan per PCP or ED, and actions taken, will be noted in the outpatient record and Outcomes System by Complex Care Management Program staff 3. Encourage patient self referral to ED and/or PCP for late signs of condition exacerbation (e.g. red stop light) 21

22 d. Patients will be instructed to call 911, go to the ED, or contact their PCP immediately for all red zone complaints b. Care will be coordinated for patients seen by ED or PCP for red zone symptoms i. HCRN will establish telephone outreach to patients within 72 hours of a red zone evaluation, to assess for improvement ii. Any necessary changes to medications or care plan per ED or PCP will be noted in the outpatient record and outcomes System by Complex Care Management Program staff, and any further actions taken documented iii. Any medication or care plan changes per ED, and noted by Complex Care Management Program staff, will be communicated to PCP iv. Any patient seen in the ED for red zone complaints will be referred to their PCP for follow up within 1 weeklv. CHP/CHPTs will provide ongoing communications as needed with any prescriber who alters medication regimen, to obtain MATCH a. APN/CHP will communicate with prescriber who altered medication b. Documentation will be made of any changes to medication regimen ii. Review Readmission Alert Notification for any subsequent admissions or ED visits after enrollment a. HCRN will alert PCP, and specialty care provider if necessary, within 24 hours of ED visit b. APN will provide a discharge continuity of care document (CCD) summarizing the post discharge care plan (including any medication changes) within 14 days of readmission to the PCP, and specialty care provider, if necessary. c. APN/CHP/MSW will review the revised post discharge plan to discuss changes within 1 week of readmission discharge iv. Provide a data collection (wt, BP, peak flow, glucometer, etc) log and symptom diary tool for use (see Appendix) v. Ensure that the patient/caregiver can accurately use all condition specific monitoring equipment by having the patient demonstrate proper use. The HCRN will also make sure the patient knows how to complete the log and symptom diary. vi. Give patient a folder/binder to keep the log/diary in vii. Encourage the patient/caregiver to bring the log/diary to all follow up visits with the patient s regular doctor(s) viii. Encourage the patient to have the symptom diary on hand to review during the next home visit and/or phone follow up calls with COMPLEX CARE MANAGEMENT PROGRAM staff. ix. If the patient experiences any difficulty in self monitoring (i.e., can t see numbers on scale) or recording information and the caregiver is not present during the home visit, the HCRN should follow up with the caregiver to assess ability and willingness to assist the patient. 22

23 x. If the caregiver is unable or unwilling, outreach worker should find alternates (i.e., home health, Congregational Health Network volunteer, Senior Companion, homemaker services) to assist the patient. xi. If the patient does not have the proper equipment (i.e., scales, matching glucometer/strips, etc.), the referral guide and/or case management should be contacted to secure resources for the patient. WHEN DOES THE SOCIAL WORKER GET DEPLOYED? a. Assess Patient understanding of simple medication adherence and symptom monitoring aids HCRN/CHPT a. If the patient does not know how to fill the pillbox and the caregiver is not present during the home visit, the pharmacy technician should demonstrate how to fill the example candy pillbox based on the candy patient friendly medication list alongside the patient as the patient fills their own pillbox with their patient friendly medication list and contact the patient s caregiver following the home visit. b. In addition if the caregiver is unable or unwilling to help fill the patient s pillbox, the pharmacy technician should find alternates (i.e., home health, Congregational Health Network volunteer, homemaker services) to assist the patient. c.. 23