COMPASS Workflow & Core Elements

Care of Mental, Physical, and Substance use Syndromes! The project described was supported by Grant Number 1C1CMS331048-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. 2

Objectives At the end of this session you will be able to: Describe the COMPASS model and workflow Understand and articulate key COMPASS concepts Identify COMPASS roles and need/opportunity for local adaptation 3

The COMPASS workflow was co-created & reviewed by representatives from all the consortium partners, drawing from several existing and proven models and the best practices discovered in their implementation. 4

COMPASS Intervention Guide Supporting annotations and appendices can be found in the COMPASS Intervention Guide at www.icsi.org. Based on local health care environments, care systems will need to identify necessary adaptations that still support the core model and overall goals. Includes more than 100 tools and resources

COMPASS Core Elements Population Focus Patient Engagement in Care Care Management Use of a Registry Systematic Case Review Team Treatment Intensification Includes more than 100 tools and resources

Foundational Approaches Chronic Care Model to lay the groundwork for organizing multiple levels of health systems needed to make this work possible. Practice Coaching to emphasize a systematic approach to supporting the transformation necessary in primary care. Patient Centered Medical Home principles to ensure consistency and continuity with NCQA accreditation standards. 7

Enrollment in COMPASS Care & Consent for Study Contact Population Management & Care Plan Development Outcome-Oriented Care Management Monitoring Transition to Routine Care 8

Enrollment in COMPASS Proactive patient identification and outreach Adult patients AND sub-optimally managed depression (PHQ-9 >9) AND sub-optimally managed diabetes or cardiovascular disease Recommended priority population:! Diagnosis of diabetes with A1c >8% OR SBP >145 mm Hg OR LDL > 100 mg/dl! Existing cardiovascular disease (e.g. history of ischemic heart disease diagnosis, coronary procedure, CHF or stroke) with SBP >145 OR LDL >100 mg/d! Patients 65 years and older with SBP > 160! Recent hospitalization or ED visit related to diabetes or cardiovascular disease 9

Example Enrollment Strategies Review daily appointment calendar Review hospital admission and discharge reports Administer PHQ-9 for patients with diabetes and CVD Run list of all MA/MC patients with eligible dx codes Claims review for patients on an antidepressant medication Staff talking points, written materials Lab database query for patients out of range Local media promotions/marketing Other ideas? 10

COMPASS Eligibility Patient Entry Point 1: EMR and/or claims review to identify patients with appropriate conditions Patient Entry Point 2: Office visit of patients with appropriate conditions Meets COMPASS care criteria? Yes No Noted. Usual care Register in COMPASS care and inform of care details 11

Population Management Care Plan Development Systematic Case Review Care manager, psychiatrist and IM/FM physician Weekly review of: Newly enrolled patients Patients with recent hospitalization/ed visit Those not improving as expected Severe/challenging patients Patients potentially ready for discharge Recommended treatment or changes Behavioral intervention strategies for self-care 12

Population Management Care Plan Development Primary Care Team Treatment Plan Targeted team communication Develop/revise personalized care plan Care manager follow-up & monitoring Patient is team member 13

Outcome-Oriented Care Management Implement Personalized Care Plan Care manager ongoing patient contacts Partnering & engagement Review of clinical targets, current readings/scores Behavioral activation & goal setting Education & support for treatment adherence, side effects Planned response to suicidal patients Coordinating transitions of care, hospitalizations & ED visits 14

Outcome-Oriented Care Management Patient at Goal? Care Plan Adjustment Needed? Based on personalized goals & targets Case review recommendations for changes Care team plan Prepare for transition to maintenance 15

Monitoring Transition to Routine Care Maintenance Plan & Routine Follow-up Target condition is at personalized goals Condition-specific maintenance plan Review progress & success factors Prevent exacerbations, risk for relapse Early warning signs Ongoing treatment needs Preventive & follow-up care schedule Transitions between care settings 16

New Role: Care Manager Dedicated clinic staff with background in nursing, psychology or social work, medical assistant or health education Does proactive outreach to identify potentially eligible patients Uses effective engagement strategies to build trusting relationship with patients for ongoing partnership Works a daily registry for population management including active follow-up for enrolled patients to monitor target conditions Provides education and self-management support to help patients reach healthy lifestyle goals and optimal treatment adherence Skills & knowledge of health literacy, motivational interviewing, community resources, treatment options and comorbidities Coordinates services such as PCP visits, preventive care schedules, specialty referrals and care transitions 17

New Role: Consulting Physician 1. IM/FM Physician with expertise in diabetes, hypertension, hyperlipidemia, cardiovascular disease 2. Psychiatrist with expertise in depression Population-based case review with shared accountability for outcomes Dedicated time each week (up to 2 hours) to review care manager caseload all new patients, patients not improving, complex cases Provide evidence-based treatment recommendations to the primary care physician who retains lead role for patient s care As much as possible, physician consultants and care manager meet as a team, including primary care physician as needed Provides resources, referrals, and links to specialty care services, e.g. cardiology, endocrinology, psychotherapy, in-patient care, etc. Provides additional training to care managers and other primary care staff on the target conditions, related conditions, medications, behaviors, etc. 18