This webinar investigated the ways that team members can contribute to the care of patients with complex medical and/or social needs. The focus was on developing the expanded care team and ensuring ready communication between the core and expanded care teams. Models for effective care management were presented. This webinar was presented May 5, 2016 3:00 p.m. Eastern Time

1. Welcome
The National Cooperative Agreement on
Advancing Team-Based Care
WEBINAR 6: Complex Care Management in Primary Care
May 5th, 2016
Presented by the
the Community Health Center, Inc.
& the MacColl Center for Health Care Innovation

2. Speakers
From MacColl Center for Health Care Innovation, Group Health Research Institute:
Ed Wagner, MD, MPH, Director Emeritus
Brian Austin, Deputy Director
Katie Coleman, MSPH, Research Associate
From Daughters of Charity Health Centers
Robert Post, MD. Chief Medical Officer
Roslyn Arnaud, RN, Chief Nursing Officer
Grace Mena, RN, RN Care Manager/QI Coordinator
From Community Health Center, Inc.:
Margaret Flinter, APRN, PhD, Senior Vice President & Clinical Director
Kerry Bamrick, MBA, Senior Program Manager

3. LEARNING COLLABORATIVE APPLICATIONS NOW
OPEN!
o Participation in the Learning Collaborative is FREE for health
centers.
o 9-month intensive learning collaborative provided by CHCI,
it’s Weitzman Institute and partners
o Team Based Care or Post-Graduate Residency Program
How to apply?
-Visit www.chc1.com/nca
-PDF of the application is available on our website
-Applications due May 20th

4. Learning Objectives:
1. Participants will be able to describe the features that distinguish effective
care management programs.
2. Participants will be able to describe ways that expanded care team members
can work with core team members to provide seamless, non-fragmented
care to patients.

5. Get the Most Out of Your Zoom Experience
• Send your questions using Q&A function in Zoom
• Look for our polling questions
• Live tweet us at @CHCworkforceNCA and #primarycareteams and #HRSAnca
• Recording and slides are available after the presentation on our website within one week
• CME approved activity; requires survey completion
• Upcoming webinars: Register at www.chc1.com/nca

6. A Team Approach to Complex Care
Management
Learning from Effective Ambulatory Practices
MacColl Center for Health Care Innovation
Group Health Research Institute
May 5th , 2016
Ed Wagner, Director Emeritus
Katie Coleman, Research Associate | Brian Austin, Deputy Director

7. The Key Functions Of Excellent Primary Care

8. What is a “complex” patient?
• American Geriatrics Society--Persons whose conditions
require complex continuous care and frequently require
services from different practitioners in multiple settings.
• Robert Wood Johnson Foundation--Patients … with multiple
chronic conditions, frequent hospitalizations, and limitations
on their ability to perform basic daily functions due to
physical, mental and psychosocial challenges.
8

9. The challenges of caring for the patient with multiple
chronic conditions
• Limited evidence base
– complex, older patients excluded from trials, growing
evidence of poorer outcomes when treated according to
disease-specific guidelines.
• Added care complexity
– multiple guidelines, multiple registries, difficult co-
morbidities such as psychiatric disorders and substance
abuse
• Polypharmacy
• Multiple physicians and a poor care coordination culture and
mechanisms.

10. Percent of patients reporting problems in care
by number of doctors seen
Base: Adults with any chronic condition
Percent reported any errors in past 2 years*
Data collection: Harris Interactive, Inc.
Source: 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.

11. What do Patients with Chronic Illness Need to
Optimize Outcomes
• Drug therapy and medication management that gets them
safely to therapeutic goals. MEDICATION MANAGEMENT
• Effective SELF-MANAGEMENT SUPPORT so that they can
manage their illness competently.
• Preventive interventions at recommended times. PLANNED
CARE/POPULATION MANAGEMENT
• Follow-up tailored to severity, and more intensive
management for those at high risk. CARE MANAGEMENT
• Timely, well-coordinated services from medical specialists and
other community resources. REFERRAL MANAGEMENT

12. But, the multi-problem problem patient likely
increases the need for:
• Full implementation of the patient-centered medical home.
• Primary care clinicians willing and able to be accountable for their
care.
• Greater sharing (interactive communication*) of care planning and
care management between primary and specialty care.
• Clinical care management services integrated with primary care
• More assertive and effective care coordination.
* Foy et al. Ann Int Med 2010; 152:247-258

13. Care for Patients with
Complex Health Care Needs
13
Care Management
Logistical
Logistical
Logistical Clinical Monitoring
Care Coordination
Clinical Follow-up Care
Medication management
Self-management Support
©MacColl Institute for Healthcare Innovation, Group Health Research Institute 2011
Clinical Monitoring
Complexity
Low High

14. Are care manager interventions effective for multi-
problem patients?
• Care manager interventions improve outcomes in diabetes,
depression, bipolar disorder, CHF, etc.
• TEAMcare study suggests effectiveness across conditions.
• But a recent meta-analysis* suggests that only patient
satisfaction is improved across studies—not health or costs.
But interventions are very different!
*Stokes et al. PLoS One. 2015; 10(7): e0132340. Published online 2015 Jul 17.

15. Care management is a function not a person
15
Providing follow up, clinical management, and self-
management support to patients outside of clinic visits.
Services and intensity
of services vary with
the severity of the
illness.
Some aspects
provided by a staff
person for lower risk
patients and by a
nurse or nurse-led
team for high-risk
patients.
Works best when the
care manager:
• Is an integral member of
the practice team
• Has social work support
• Can influence drugs
• Has a clinical support
structure.

16. How do effective practices provide follow-up and care
outside the office?
• Core teams, care managers, and referral coordinators
regularly monitor patients between visits.
• Follow-up can range in intensity from periodic status checks
by telephone or e-mail (MA) to active care management (RN).
• Higher risk patients (poor disease control, frailty, recent
hospitalization, etc.) receive regular follow-up (monitoring)
AND active care management from RN care manager and/or
social work. Referral coordinators and community workers
help patients get the services they need, and ensure that
providers get desired information.

17. One LEAP Clinic’s Approach to Hospitalized
Patients: Primary Care Assuming Accountability!
• Use risk stratification (Modified LACE* tool) to determine who makes the
Hospital F/U call.
– HIGH Risk-Call is made by RN, automatic referral to Care
Management, F/U visit with PCP in 2 to 3 days
– MODERATE Risk-Call is made by RN or MA Health Coach, automatic
referral to Care Management, F/U visit in clinic within 3 to 5 days
– LOW Risk-Call made by MA Health Coach, F/U visit in 7 days. MA
Health Coach makes a “touch base call” in a week after F/U

18. One LEAP clinic’s answer: The Expanded Team Huddle
• One hour once/week
• All clinic staff attend: front desk, pharmacy, MA, behavioral
health consultants, etc
• Clinician selects & presents patient (chart open on EMR
projected on screen)
• Front desk staff, health coach, and MA who live in community
asked what do they know?
What can be done if you don’t have a nurse?

19. Building a Care Management Capacity
1. Think about care management as a function or program, not
a person.
2. Shift RN roles toward care management.
3. Decide which patients to refer to CM.
4. Establish relationships with key hospitals to identify and co-
manage recently hospitalized patients.
5. Create protocols, standing orders, and standard workflows,
etc. to guide CM work.
6. Develop a support structure for care managers:
1. To discuss challenging problems.
2. To assist with psychosocial issues.

20. www.improvingprimarycare.org

21. Resource Spotlight #1

22. Resource Spotlight #2

23. Resource Spotlight #3
www.improvingprimarycare.org

24. Daughters of Charity Health Centers
Complex Care Management in
Marillac Community Health Centers
Roslyn Arnaud, Robert Post, Grace Mena

25. The Daughters of Charity have provided compassionate health care in
New Orleans for 180 years. After the sale of Hotel Dieu Hospital in
1992, the Daughters transitioned their efforts, establishing a
community health ministry known today as Daughters of Charity
Services of New Orleans.
The Transformation to Consumer-Driven Healthcare
Daughters of Charity Services of New Orleans offers primary and
preventive health services that address the needs of the total
individual – body, mind, and spirit.
Our nine health centers are conveniently located in various
geographic region of the greater New Orleans area. Most of
our health centers are located near bus lines. We provide
care for chronic illnesses such as asthma, cardiovascular
disease, diabetes, and depression. Women's health,
behavioral/mental health, dental, optometry, pharmacy,
podiatry and Women, Infants and Children (WIC) services
are also available at select health centers.

26. We are a proud member of
Ascension Health, the nation’s
largest Catholic and non-profit
health care system. Our mission,
similar to that of other Ascension
Health ministries, is to improve the
health and well-being of our
community and to be a presence of
the Love of Jesus in the lives of all
we serve and with whom we
partner.
Our Mission

27. Integrated Team Care
Patient’s
Desires
& Needs
Patient
Panels
Outcome
and
Results
Measures
Population
Registries
Open
Access
Primary Care Team
Care Management
MD/MA
NP/MA
Care Coordinator
Nurse CM
BH CM
PharmD
PROACTIVE TREATMENT
Project
Collaboratives
PATIENT CENTRIC SERVICES
Continuous Quality
Improvement
Continuous Quality
Improvement
Adapted from David Dorr, MD, Care Management Plus

29. Complex Care Team
• Nurse Care Manager
– Intensive Case Management
– High Risk Patients
• Behavioral Health Consultants
– Immediate consultations
– Focused on outcomes
• Other Members of the Team
– Clinical Pharmacists – Established CHD

30. Complex Care Team
• Referrals
– Poor Control – Chronic Illness (Care Managers use
the Clinical Event Manager in the EMR)
– ED/IP Utilization
– Coordination of Care – home health, hospice
– CNS Barrier – Neurologic, Behavioral, Substance
– Perceived Risk by Primary Care Team

31. Other Responsibilities – Care Managers
• Abnormal Cancer Screen Tracking
• Hepatitis C Patients
• CMS Chronic Care Management
• NCQA – PCMH
• Clinical Resource to Medical Assistants
• Clinical Staff Training
• Quality Assurance
– Medical Assistant Chart Audits

32. Community Health Center, Inc.
Foundational Pillars
1. Clinical Excellence- fully Integrated teams, fully
integrated EMR, PCMH Level 3
2. Research & Development- CHC’s Weitzman Institute is
the home of formal research, quality improvement, and R&D
3. Training the Next Generation: Postgraduate training
programs for nurse practitioners and postdoctoral clinical
psychologists as well as training for all health professions
students
CHC Profile:
•Founding Year - 1972
•200+ delivery sites
•130k patients

33. What is Complex Care Management?
Complex Care Management is the deliberate organization of
patient care activities and sharing of information with the main
goal of meeting patients' needs and preferences in the delivery of
high-quality, high-value health care (AHRQ, 2015).
At CHC, Complex Care Management includes:
• CCM Tools: Dashboard, Scorecard, Structured Templates, Standing
Orders
• Project ECHO Complex Care Management
• Dedicated Education Unit
***CHC Ratios are 1 RN per 2 provider panels

34. • Goal: to improve the quality and coordination of care delivered to
our most complex patients
• Patients: identified through dashboards either by hospital
admissions, high ED utilization, chronic illness (uncontrolled or 4+)
or individually by a care team member
• Consent: patients consent to be enrolled in CCM
• Essential elements of the role:
• Transition Care (ie. hospital to home)
• Medication Reconciliation
• Having patients set their own goals and work with the
care team to meet them
• Individualized Care Plan
• Monitoring and adjustment of treatment regimens
• Discharge: once goals are met, transition is complete, care plan
is fully implemented, or patient opts out
34

35. Reason for Complex Care Management

36. • Basic Demographics (Age, Gender)
• Smoking status
• Clinical Markers (A1c, recent BP)
• Important Dates (CCM start/end date, last PCP visit, last BH visit)
• Self Management (last date self management goal set or MI done)
• Any Actions Due? (Subject of the action and due date)
• Patient Engagement (Portal Enabled?)
Scorecard Creation
• Enrollment Data (Ever & Current)
• HTN & DM Control Rates
• Transition Contact
• Coming Soon! Self-Management Goal Tracking
Additional Actionable Dashboard Data

37. Project ECHO Complex Care Management
 First session on 9/24/15
 Duration: 2 hours; 1 didactic and ~2 cases
 All 12 sites involved – Approx. 33 nurses
 Faculty consists of:
 Nurse Practitioner and Nurse Executive
 Homecare Nurse
 Medical Provider
 Pharmacist
 Behavioral Health Provider
 Complex Care Management Specialist and
Certified Diabetes Educator
 Registered Dietician and Certified Diabetes
Educator
 Access to Care Coordinators
37

38. - Support for further developing the role of the CCM
- Diverse Faculty Expertise
- Improve Nurse self-efficacy/
leadership
- Improve collaboration across
all disciplines and supporting
agencies
- Increase interactions with nursing colleagues
- Improve educational experience for students
8/25/2015
Goals of Project ECHO CCM

39. Q & A, Discussion

40. Reminders
Sign up for our next webinar in this series:
Achieving Full Integration of Behavioral Health and
Primary Care
Thursday, May 19th, 3–4 p.m. EST
Dissolving the Walls: Clinic Community Connections
Thursday, June 2nd, 3-4 p.m EST
Complete our survey!
Sign up at www.chc1.com/NCA