Ambulatory Care Management An Enhanced Care Coordination Program Carol Ecklund, RN, MN, AOCN Director of Medical Management May 21, 2014 TMIP Office Manager Webinar
Objectives During this webinar you will learn: 1) National emphasis on care coordination 2) How ACM can assist your patients 3) Who and How to refer to case management 4) How case management will communicate with your office for patients in case management 5) Review of Case Studies 6) Q & A opportunity
How confusing is healthcare????? These pamphlets will explain the procedure and these leaflets will explain the pamphlets I hope I ve made that unclear enough.
Background: The push for Care Coordination 17% of GDP spent on National Health Expenditure,2010 Small % of Medicare population accounts for the vast majority of Medicare spending 20%- readmission rate for Medicare patients returning to the hospital within 30 days of their initial hospitalization Aging populations and increased longevity, coupled with chronic health problems Fragmented healthcare ; poor care coordination Goal: Increase Quality and Decrease Cost
An Enhanced Care Coordination Program
What is Ambulatory Care Management? Free of Charge 80% telephonic 20% Home visit RN, MSW, Care Coordination Program For those in need of Care Transitions Coordination between multiple doctors Medication Assessment Community Resources Health Teaching Higher Level of Care Advanced Care Planning
Who Are We? Nakaia Durr, RN SNP/Complex Case Management Nicole Ngayan, CM Assistant ACO and SNP Programs Sharon Harris, RN ACO Case Manager Branaka Jerkov, RN Lead Care Transitions Case Manager Nani Cardenas- CM Assistant All THIPA Programs Hang Le, MSW Care Transitions & Complex Case Management Helene Park- MSG, CPG SNP and Complex case Management Mary Collins, RN (not pictured)- ACO/THIPA SNF Case Manager
Who do we serve? ALL Torrance Hospital IPA Members ACO Members (TMIP ACO MDs) Medicare Fee For Service Anthem Blue Cross PPO
Who is a candidate for ACM? THIPA and ACO TMIP patients Complex Patients Multiple comorbidities Polypharmacy Depression Poor health literacy Palliative Care Multiple Care Transitions Multiple Hospitalizations Multiple ED visits Multiple MDs Community Resources Transportation In Home Caregivers Medication Assistance Programs Financial
Care Transitions Program 4 week telephonic care management program for members who are recently discharged from acute care (high risk), skilled nursing facility and/or post emergency room visit. The overall aim of the program is to improve the transition of care for recently discharged patients prevent re-hospitalization and/or hospitalization Initiate Advanced Care Planning when applicable. The program is based on the Coleman s Care Transitions Model.
Coleman s Care Transition: 4 Pillars Patient is knowledgeable about medications and has a medication management system Patient schedules and completes follow-up visit with the PCP or specialist Medication Management Medical Follow -Up Patient is knowledgeable about indications that their condition is worsening and how to respond. Red Flags Personal Health Record Patient understands and utilizes the Personal Health Record (PHR) to facilitate communication
CCC Data collected- 2013 Yes %Y No %N No data Kept Appt 45 76% 12 20% 2 Discharge summary available 40 68% 5 8% 14 Med Error IdenFfied during Visit 28 47% 18 31% 13 Agrees to ACM 10 17% 32 54% 17 POLST Form completed 19 32% 27 46% 13 PalliaFve care appropriate 17 29% 23 39% 19
Case Study #1: Avoided ED/Inpatient Case Study #2: Hospitalization 8/10 72 yo female ED visit for abdominal pain. Dx: Pyelonephritis PLAN: Oral abx; f/u PCP/Urology this week 8/13/13- CM CT call. Member had not scheduled PCP appt. Calling today. Unclear if needed to see Urology. Had not taken abx. Education given. 8/21/13 CM CT call- member still had not schedule appt. PCP CM called and scheduled appt 8/27/13. Last day abx tomorrow. 7/20 74 yo female ED visit for hip, knee, shoulder pain. No fx per CT PLAN: f/u with Ortho & PMD 1 week 7/23/13- CM CT call. Member requested to make own appt. 7/30/13 Ed visit for worsening pain. Did not f/u with MDs 7/30-8/4- Inpatient admission CT showed spinal stenosis L4-5 with disk bulging. Orhto c/s, Lumbar epidural-fluro, PT. D/C 8/4 8/27/13 Saw PCP. Took blood and urine. Do not need to see urology.
Case Study #3: Complicated Care Coordination 4/19/14 (Saturday) 66yo present to UC w/ neck pain and radiculopathy. PLAN: MRI Spine, neurosurgey referral asap 4/21/14- CM call. Member unable to get neurosugery appt x 2 weeks. CM expedited referral to alternate neurosurgeon, expedited MRI and f/u appt w/ PCP. 4/29/14 CM coordinated referrals for Oncology, Radiation Oncology, Pre-op, and additional MRI brain and PET eval 4/30/134 Dx with Lung CA. Multiple Mets including C- spine. Possible compression. On XRT for cord compression. f/u with Chemo. Outcome: prompt referrals and care coordination between 5 physicians & complex imaging; prompt dx and treatment of Lung Cancer; prompt tx of spinal cord compression Case Study #4: Complex Outpatient January 2013 Referral for member with high ED and inpatient utilization and non-compliance with plan of care. PMH: DM, CKD, COPD, Chronic BLE Cellulitis Social: Lives alone; family minimally involved Cognitive: Not cognitively impaired, but nonadherent with medical plan of care Plan: Indentified that member unable to be home alone. Needed placement Requires ongoing support and supervision for med & diet adherence, including ADLs Outcome: 2013 total of 4 ED and 12 inpatient admisisons Coordination between ACM/HH/SNF CM. November 2013 was successfully placed in Assisted Living Facility. Family now involved. Increased compliance with meds, diet and ADL therapy Since placement in ALF 1 Emergency room and 2 inpatient admissions
What ACM is NOT! ACM is NOT Home Health We DO arrange HH services We do NOT administer medications WE do NOT transport patients We do NOT provide assistance with ADL We DO ensure patients are taking medications We DO arrange transportation We DO arrange for the provision of these services
Who Can Refer? Do not need MD order Member self-refer ED census Inpatient Case Managers Home Health Physician Offices Suspicious high risk authorizations (THIPA) Health Plan(THIPA and Anthem PPO ACO)
Referrals to ACM How to Make a Referral: (Include : Name, DOB, Contact Number, Health plan information- (THIPA/TMIP), Name and contact number of person making the referral Phone: 310-257-7230,option 1 or 310-257-7250 (THIPA main line) Fax: 855-722-6229 Synermed Connect: Care Management (THIPA ONLY0 NextGen: Order Management
Communication with Ambulatory Case Managers The Case Managers will communicate with the primary/referring physician office in multiple ways: By phone for Immediate Follow-ups (transition appts, escalating home issues, urgent referrals) Faxed Letters and/or care plans on new, existing and closing cases Nextgen-communication notes HIE- coming soon The Case Management EMR will be integrated with the HIE. Connected offices will be able to view case status, care plan and possibly notes.
Program Measures Clinical/Quality Utilization Process Self Management ED Utilization Turnaround time MD follow up Admission rate Enrollment % Member Satisfaction Readmission rate Completion of AD
Contact Information Carol Ecklund, RN, MN, AOCN Director of Medical Management 310-257-7230 carol.ecklund@tmmc.com Nani Cardenas, CM Assistant 310-257-7282 (office) 855-771-6229 (fax) Nicole Ngayan, CM Assistant 310-257-7282 (office) 855-772-6229 (fax)
QUESTIONS?