Systematic Case Review- Stillwater Medical Group Prep Admin: 1-2 days prior to SCR, download the QI- CareMgrCntNotes and update our SCR tool Patients are organized by New pt- green COMPASS #- they are then color coded by update- blue, no update- yellow, or watch- orange Care Coor SBAR: Prior to SCR, patients are prepped with SBAR A SBAR note is made in the EMR under Patient Care Coor. o The dot SBAR phrase includes pre- populated data such as; diagnosis, questionnaires (PHQ- 9, GAD, AUDIT), last 3 BP, last A1c and LDL, last 3 Ht and Wt, medications, allergies The Recommendations section of SBAR is left blank and the encounter is left open so this can be filled in post SCR Day of SCR Make up of team Consulting Physician Consulting Psychiatrist HCH Care Coor- present patients and type consult note in CMTS during SCR Diamond Care Coor- present patients and type consult note in CMTS during SCR Diabetes Educator- discusses shared patients Panel Management/Registry Assist- drives the on screen computer and responsible for time o It is everyone s responsibility to keep us moving and on time with each patient Location We use a training room where each person has a computer and there is 1 computer on the large screen Process Patients are presented with New (green) patients first and then the rest of the patients follow in order of COMPASS # (this helps with the team remembering the patients better by staying in the same order each week) The driver of the big screen brings up the patient snapshot, reviews any new information or what is asked for by the team Staff each have their own computer to review the patient o They also in basket messages to providers/staff, if needed. The Care Coordinators present in SBAR format o New patients get a more in depth history
o Patients being updated on have a brief history, the last recommendation and what was completed, and any new issues The Care Coor. take turns typing in Consult Notes into the CMTS for each other so the note is complete with recommendations when the patient is done being discussed. The focus for the recommendations is what will be completed in the next week.
SYSTEMATIC CASE REVIEW TEMPLATE PATIENT NAME: PCP: Situation (2 sentences): Age/Sex: Race: Care Management start date: Car Management latest date: Pertinent Medical/Psychiatric Diagnoses: Individualized patient goals: Main Care concern(s) (behavioral/medical/physical): Length of time patient on current plan: Hospitalizations/ED encounters and risk: Background: Tobacco/Substance use: Diagnoses: Living situation/support system: Health Literacy: Adherence (?): Key leverage point: (values etc ) Labs and testing: PHQ- 9 Clinic- derived SBP Home SBP Latest Value and Date Baseline Value and Date Target HbA 1c LDL!
Other Provider specific information: Medications: Allergies and Medications tried: Problematic side effects of medications: Imaging: Consultants: Assessment: Successes: Challenges: Prioritize care issues: Recommendations: Behavioral: Medical:!
Patient Name: Date: PCP: Situation (2 sentences): Age Race Care Management start: Main Care concern(s) (behavioral/medical/physical: Background: Tobacco/Substance use: Diagnoses: Living situation/support system: Health Literacy: Adherence?: Key leverage point: (values etc ) PHQ( 9) latest: BP latest: A1c latest: LDL latest: HF Classification/EF: MMSE latest: egfr Other Provider specific information: Medications: PHQ(9) previous: BP previous: A1c previous: LDL previous: Allergies and Medications tried:
Imaging: Consultants: Assessment: Successes: Challenges: Prioritize care issues: Recommendations: Behavioral Medicine
Page 1 of 4 Patient Name: Age: Relationship status: Occupation: Race: Phone# PCP: Insurance: Situation: Why is pt. referred to COMPASS program? Pt is referred due to phq-9 >10, lab values not at target (A1c >8.5, Systolic BP >129 or LDL >99) and symptoms of depression affecting pt s quality of life DX: Patient diagnosed with Diabetes Mellitus or Cardiovascular disease Recent hospitalization: Background: Include contributing psychosocial factors e.g., financial problems, family issues, losses etc. Lab Values last OV visit: DATE TIME and DAY Phq-9: BP: A1c: LDL: BMI: Date of enrollment: DATE TIME and DAY 1 st phone Contact: scheduled 7/9/2013 Monday 3:00pm 2 nd Phone Contact : 3 rd Phone Contact 4 th Phone Contact Phq-9: BP: A1c: LDL: BMI: 5th Phone Contact : 6 th Phone Contact 7 th Phone Contact Phq-9: BP: A1c: LDL: BMI: 6/2013 Nasya S. Smith COMPASS Care Coordinator -MACIPA
Page 2 of 4 8 th Phone Contact : 9 th Phone Contact 10 th Phone Contact Phq-9: BP: A1c: LDL: BMI: Next Office Visit: Medications: Allergies: Medication Adherence: Does the patient feel comfortable with their medication routine? Supports: Recommendation: EXAMPLE Identify stressors and concerns discussed in most recent phone contact Medications consult: Identify any medication changes discussed in Systematic Case Review Behavioral Plan/Discussion: Identify plan to increase healthy behaviors and decrease maladaptive/unhealthy behaviors 6/2013 Nasya S. Smith COMPASS Care Coordinator -MACIPA
Page 3 of 4 6/2013 Nasya S. Smith COMPASS Care Coordinator -MACIPA
Page 4 of 4 6/2013 Nasya S. Smith COMPASS Care Coordinator -MACIPA